Richard Smith on how to improve your interaction with patients by 50%
17 Jun, 09 | by BMJ Group
If there was a pill that would improve your interaction with patients by 50% would you take it? I imagine you would. Well, I don’t know of such pill and can’t think that there will ever be such a thing, but there is a non-pharmacological way to improve you consulting—it’s called “values based practice.” To be honest, I don’t know that it will improve your skills by 50%: it might be less or more, but I’m confident that it could help you.
Whether you recognise it or not (and often doctors don’t) you and the patient both bring values to a consultation. Sometimes, even often, those values will conflict, and if you don’t acknowledge and manage those conflicts then you, the patient, or both of you will be left dissatisfied. This, I believe, happens often, and because it’s usually the doctor’s values that dominate it’s the patient who is left most dissatisfied. Values are deep and complex. They are more than simply ethical values like justice and autonomy. They include wishes and desires, political and religious beliefs, likes and dislikes, and potentially rather ugly things like, in the case of myself, a tendency to iconoclasm and a love of argument for its own sake.
“Values based practice,” which has been developed by Bill Fulford, a professor of both philosophy and psychiatry in Oxford and Warwick, is “the theory and skills base for effective health care decision making where different (and hence potentially conflicting) values are in play.” It complements not conflicts with evidence based practice in that it says that both evidence and values are important in decision making. The founders of evidence based practice say the same, and we’ve made important progress in the past decade in bringing evidence into the consultation. Now we need to do the same for values.
The first step in values based practice is to be aware of values—both yours and the patients. This is not so easy, and just like the man who never knew he’d been speaking prose all this life you may not recognise some of your own values, particularly the less attractive ones. Next, you must learn to reason with values, then to know more about values through studying, and finally to communicate well, both to tease out the values in play and to negotiate and resolve conflict.
I’ve been learning about this in a two day conference at the University of Warwick, and I made some headway in a mock consultation with a student in social science who played an utterly convincing patient. I was playing a doctor who disliked drug companies and their products, disapproved of make up, and was wary of intervening in those with minor problems (not so hard). The patient presented with mild acne but wanted the spots gone at once so that she could confidently attend an interview to be a model in two weeks. She had tried various over the counter treatments, including toothpaste, and had read about an antibiotic cream in Hello magazine that had cleared up the spots of some people in a few days. She wanted a prescription for the antibiotic.
Let us suppose (and it’s not so far from the truth) that benzoyl peroxide, and both oral and locally applied antibiotics are unlikely to clear up the acne in days—but isotretinoin might at the risk of causing severe deformity in an unborn child. (You don’t need to email me that isotretinoin probably wouldn’t work that fast and that it is supposed to be prescribed only by “physicians with expertise in the use of systemic retinoids.” I know that now but didn’t at the time of the mock consultation.)
If I’d let my values dominate, perhaps without recognising them, then I might have sent her away with nothing or a prescription for one of the weak treatments, perhaps consoling her that the acne might soon be gone and she’d have other chance to become a model. If I’d simply allowed her values to dominate then I would have prescribed isotretinoin after convincing myself that it would be impossible for her to become pregnant in the next two weeks.
As it was, unskilled in values based practice and, come to that, consultation, I felt that I needed to tell her about isotretinoin but express my unhappiness with prescribing such a powerful and dangerous drug for something so minor. I overdid it, saying that prescribing the drug made me feel uncomfortable. Patients don’t want doctors, even pretend ones, telling them that they, the patients, have made the doctor uncomfortable. But better for the doctor in some more professional way to acknowledge his values—otherwise, he may feel used, dissatisfied.
This is clearly tricky territory, and I challenged the enthusiasts in Warwick to produce a video of a non-values based consultation and then a values based one, illustrating the expected superiority. I await that video. Meanwhile, you can learn more at http://www2.warwick.ac.uk/fac/med/study/cpd/subject_index/pemh/vbp_introduction/readguide/
Competing interest. RS is an honorary professor at the University of Warwick. He hopes to have his expenses paid for attending the meeting if he can ever get round to claiming them.
A very interesting post! I think it gets to the heart of what a lot of talk about professionalism is about. Is it wrong to discuss our values with a patient if that makes them uncomfortable but we are still providing good care? Isn’t it better to be open and honest with a patient? Are their a set of values that we hold as a profession than always trump our own individual values?
Thank you,
Anne Marie
Anne Marie Cunningham
June 17th, 2009 at 5:57 pm
The elephant in the room.
Richard’s self-confessed over-exposure of his values was a refreshing change in a world which has seen doctors’ values as non-disclosed as MP’s expenses.
But like that famous marriage with 3 people in it, of whom only two were visible, so in values-basing our clinical practice we often have to consider a third party. The elephant in the room, whose values can intrude on the consultation is the ‘institution’. Here, for Richard and the others who tried their hand at consulting with the girl whose spots were going to impact on her chances to become a model, the NHS context implicates the values of resource allocation (aka rationing) which devolve to the GP. The institutional and contextual values at play include not only any relevant guidelines but also the potential reactions of colleagues in the practice who have worked so hard to achieve meritorious prescribing.
Values-based practice skills for this GP include not only getting in touch with his own values (the scenario specified that he should be anti-pharma and anti-cosmetic industry in his soul), the values of his patient (passionate about modelling and image) but also deciding at what point the ‘collective’ values of the NHS affect this individual consultation. Should he make that explicit?
Ed Peile
June 18th, 2009 at 5:42 am
Richard Smith had chosen a very good topic which is thought provoking.
Dr.N.P.Viswanathan
Dr.N.P.Viswanathan
June 18th, 2009 at 11:27 am
I confess I was also at the same event in Warwick and watch with interest the simulated consultation unfold in relation to acne and values. This adds another layer of rich complexity to consultation skills and complements the patient-centred approach and concordance as doctors strive to enter further into partnerships with patients. My concern is that we do not always mean the same thing by the word ‘values’ but then I suppose suggesting to a patient that we adopt a patient-centred approach in a consultation is not helpful to them - it is what we do rather than how we badge it that is important.
The VBP pill - we need to consider the possible adverse reactions, the potential allergies and the possible overdoses. As health professionals we may become comfortable with discussing certain values with patients (health beliefs, costs, rationing, attitudes to private mediciine, complementary therapies) but become breathless and anxious when discussing end of life decisions, lifestyle choices (including illicit drug use, risk behaviour) and religious and cultural practices. Novices often look for the hidden agenda and cannot accept that some consulations work well without too much introspection -but others fail spectacularly for want of common ground (or negotiated meaning).
One major learning point from the simulated patient exercise was the patient’s comment that she expected her doctor to be professional - and implied this meant not to admit to feeling uncomfortable - and this could mean not to bring his own values to the dialogue but to remain technical and impartial. Should we offer the patient the choice of whether values are considered and whose?
We want to avoid the tick box consultation map: ideas - yes; concerns - yes; expectation - yes; values - yes. Great you’ve passed. Is the patient satisfied? Maybe not. My problem is - the more I learn about communication, the more complex it becomes.
It would be fascinating to hear from non health professionals - we are making many assumptions.
Jill Thistlethwaite
June 18th, 2009 at 4:57 pm
It was fascinating watching the vignettes role played. It is more than decision analysis where the utilities or weight a patient places on a various outcome are multiplied by the probabilities, although that could be considered one aspect of value based practice. The implication is that this should be part of every consultation. It is not new. This was on the EBM cards in the Sackett handbook “what are the patient’s values and expectations for both the outcome we are trying to prevent and the treatment we are discussing”. Unlike the assessment of bias of evidence or calculating NNT there was no instruction kit for identifying values. So 10 years later we are trying to work out what are the tools we should be using for this during the 10 minute consultation and how do we help undergraduates learn this. Identifying ideas, concerns, and expectations has been part of the consultation process for nearly 40 years yet we still rarely achieve all three and as such, initiatives such as this are welcome.
Martin Dawes
June 18th, 2009 at 10:12 pm
What a brilliant metaphor of a pill for the ills of doctor-patient communication!
Richard is surely right that such a pill would be a world beater. But we need to be careful with new medications. Despite its encouraging take-up in mental health and primary care, we still don’t have the impact evidence that we need to tell us whether the ‘vbp pill’ will improve communication by Richard’s 50% (more or less), or whether indeed it might have at least in some areas, adverse side effects.
What would count as ‘evidence’ in this context is itself a challenge. There is no obvious equivalent of the RCT for good communication. And as far as we know, there have been no corresponding impact studies for related areas such as ethics or indeed evidence-based practice.
We welcome everyone’s help here.
VBP has been developed through strong partnerships between patients, carers and professionals. So, the first and vital step to relevant impact evidence is to start from your views as patients, or as carers, or as professionals, on what is important from our different perspectives in the consultation. Tell us your values!
Bill Fulford
June 19th, 2009 at 10:09 am
From ICE to V+ICE
Just as many of us define ourselves by the era in which we were born, “baby boomers”, “generation X” etc. I define myself as having been socialised into general practice in the era of “ideas concerns and expectations” or ICE. Having graduated with the idea that doctor knows best, it was revolutionary to learn that patients have their own ideas about what is wrong and expectations about what should be done. However, despite its importance in defining the nature of the doctor patient consultation and its influence on communication skills curricula, ICE may have become a rather jaded concept in need of revitalisation. It has become an approach to the consultation that is parroted by students and doctors in training not because they believe in it, but because it is a key factor in their assessments. The ICE approach was coined to counteract medical paternalism but its focus is outward, i.e. what the patient thinks rather than viewing the consultation as a meeting between two people who both have ideas, concerns and expectations. These ideas and concerns arise in turn from what we and those around us believe, know and value. Our beliefs and our values act like a lens or frame of reference through which we perceive the world and which shapes choices and our actions. As we listen to patients we are not aware of the lens as it limits and controls what we hear, how we interpret and how we choose to act. We need to become more aware of our personal frames of reference, our values and beliefs just as we need to get better at discovering the values that lie behind patients’ ideas, concerns and expectations. What is required is a new approach to communication skills training in which the requirements are not just to discover the patients’ agenda, make a diagnosis and agree a management plan, but also to understand how our own prejudices and values may be synergistic or conflicted with those of the patient. Despite the fact that the idea of values based practice has been round for a while there is still a lot to learn. How can we help doctors to become more self aware of their own values as well as the organisational and societal values that come into play when choices have to be made? How can we discover patient’s values during a consultation? How do we share our values with patients and manage conflict to achieve mutually agreeable solutions? These are all questions for another day, but for now we need to add some values to our ICE, yielding “VICE”, a brave new acronym for an increasingly complex world.
Peter Cantillon
June 21st, 2009 at 2:37 pm
There is certainly something intuitively right about Values-based Practice. Getting closer to what matters to an individual should produce decisions and behaviours he or she is happier with and more committed to, and at least in some cases this should lead to better clinical and wider well-being outcomes. There should be benefits to health professionals, too – from getting more positive feedback and more positive outcomes for their patients, or, for instance, from improved multidisciplinary team working.
The rationale is robust, but this will be of any importance (or at least greater importance) if some further conditions have been met:
- Values-based Practice should have clear advantages over existing alternatives (patient-centred approaches, communication skills approaches, health psychology-informed approaches, ICEs, FIFEs, narrative-based approaches …). And the onus of arguing for these clear advantages is still to be met.
- Values-based Practice should inspire confidence that it is able to overcome its intrinsic challenges – arising from the complexity of the focal concept of values, as well as its extrinsic challenges – what would happen if, for instance, the newly designed consultation models produce behaviours and consequences which patients, professionals, and society in general find too strange and uncomfortable to accept?
- Values-based Practice should be demonstrably teachable, and teachable not only to those who are wise, psychologically mature, open, and good communicators anyway.
As somebody who too has attended the above event and has also worked on identifying empirical research on health-related values, I find the intrinsic challenges – those arising from the broad understanding of the concept of values underlying the framework – the hardest. How do we jointly deal with issues that are so different in magnitude, nature and presentation, but are all clearly value laden, such as moral values, cultural values, attitudes, preferences, perceptions, meanings, prejudices, stereotypes, satisfaction, different models of diseases, cognitive framing, defences masking as values, generally health-benefiting values, generally health-damaging values, values we can articulate, values we cannot articulate … How do we channel these into a 10-minute consultation? Which of these phenomena are ‘noise’ rather than ‘signal’? The research literature seems to be there, but lacking a common plane to allow for it to be brought together. Maybe not a particularly popular route in current healthcare research, but conceptual work on the basis of empirical studies on values appears crucial.
Mila Petrova
July 1st, 2009 at 2:49 pm
Here at Warwick we’ve been steeped in the idea of “values-based” practice for a while now - its the natural counter-balance to evidence-based practice - the way forward for flipping (sorry to use that word) from the broad brush epidemiological population level evidence to something that can be useful for an individual - however we have been challenged to show that this “intervention” or health technology (in the broadest sense of the word) is beneficial to patients and improves health - has anyone got any ideas how we can measure the improvements that incorporating values might bring???
Aileen Clarke
July 1st, 2009 at 3:08 pm
Values Based Medicine?
I too attended the conference on Value Based Medicine. The issue we were attempting to begin to wrestle with is a thorny one: - Medicine and the delivery of health care is not a value-neutral pursuit and mechanisms need to be put in place in medical education to address this. So instead of teaching in this case, medics, to be “value-neutral or non-judgmental” we need to teach medics to be “value-sensitive” to primarily, their clients/patients concerns and world view but also insightful to their own value system and its impact on their professional conduct.
I am personally and professionally passionate in creating internal mechanisms for cognitive & effective integrity as well as strengthening teaching methods for the further development of professional probity. It seems to me though we have both a very worthy endeavour but also a struggle on our hands.
Our critics may say we could be creating more work for an already overstretched NHS. Opening up the NHS to being value-sensitive may create more demand for meaningful complaint mechanisms and/or systems for greater dialogue between patient and doctor, as disputes and conflict become explicit and articulated.
There is an argument to say that keeping the messy business of “values” suppressed in clinical interactions is an interpersonally dysfunctional but organisationally efficient way of dealing with the business of government provided health care. The problem is that patients suffer in many different ways because of the value neutral or more apt the consciously “value-blind” approach to health care delivery. Practitioners at the conference and others know this to be the case from their years of experience and collaboration in the mental health field, primary and acute care respectfully.
Value based medicine or VBM is a new and innovative way forward in health care education & delivery but we must be prepared to understand and acknowledge our detractors. We must enter into professional and interpersonal dialogue with both advocates and critics of Value Based Medicine, to strengthen, our rationale for it. To create a health service that is truly respectful of people’s desires and values, whilst also balancing the “company books” requires serious and rigorous debate and commitment.
Although I have been working in and involved with the NHS in various capacities for over 20 years, I feel somewhat of a youngster and “innovator” in terms of how we begin to develop this dialogue & debate around VBM. I live in the virtual world of academic “open access resources, guerrilla marketing, blogging, twittering and virtual marketisation of self. I have many meaningful relationships with people I may never meet, but with whom I share intimacies of professional & personal thought and experience.
I would say that we need to create, and facilitate the debate on Values Based Medicine; what it is? how people understand it? their hopes, their fears, and we can do this not simply through academic papers, but through online, virtual debate. The world is changing and the professional world of medicine and academia is changing also, we may find the virtual platform we inhabit just may be the mechanism that allows us to more easily open up and begin to articulate our value-laden perspectives and help achieve consensus on what VBM may look like and how it should shape future provision in the NHS in the coming years.
The conference at Warwick was a foundational step in the journey that will hopefully lead to a more “sensitive” NHS. But what we need to do now is “talk” and creates broadly agreed narratives across the health spectrum in regards to the nature, function and benefits of exposing “values” in healthcare interactions in the contemporary NHS.
Giselle Corincigh
July 2nd, 2009 at 10:46 am
What does values-based practice mean to me? I think it has the potential to improve patient choice and improve the quality of care as defined by patients.
Values are at play in the decisions we make, bringing them more into the open by increasing our own self awareness of what they are for me is a positive step.
Evidence based medicine on its own does not inform decision making. One simple example is breastfeeding, the evidence states ‘breast is best’ but it is values that influence the rest, reflecting our culture, social class and personal preferences.
We cannot assume that patients will go away and accept a decision based on evidence if it conflicts with their values. Discussing values as well as evidence brings both sets of issues out into the open. Why do we have such a large proportion of patients who do not take their medication? Is that about differences in preferences and values? How much does this wastage cost? Bringing values and evidence into the discussion before arriving at an agreed management plan is a step towards a solution the patient is more likely to co-operate with.
We cannot assume that asking about values will change the consultation time or change the cost of healthcare, but can we afford to not to ask about values? We are after all in a time of quality.
“Throughout this Review, I have heard clearly and consistently that people want a greater degree of control and influence over their health and healthcare.”
Lord Darzi 2008
Jan Illing
July 2nd, 2009 at 3:51 pm
It is with regret that I was unable to attend the conference at Warwick. The many correspondences presented in this blog clearly illustrate the wealth of interest related to this fascinating and important area.
I thought I would raise a question related to how we might proceed with researching values-based practice. As a starting point, if one performs a search for the current literature, it is apparent that values in medicine and healthcare are receiving more attention than ever before. The range of values associated with health, illness and healthcare is considerable. Values represent an integral part of any health-related decision in healthcare. Yet, in trying to search for relevant publications on values you are likely to come across a few difficulties. For example, the word “values” is likely to capture publications discussing laboratory test values or even statistical significance values. So it is essential to determine appropriate terminology and what keywords should be used when attempting to retrieve the evidence-base related to values.
To follow-on from Prof. Fulford’s comments about “What would count as ‘evidence’ in this context”, this is a challenge and urgently needs researching. It is not clear what types of study design will provide the most appropriate means of investigating values-based practice. As a systematic reviewer, one might also consider what are the most appropriate criteria or tools for quality assessing and critically appraising the values-based literature.
This is an opportunity for researchers to collaborate, share ideas and methodological expertise to establish which avenues of values-based research might be explored. We should be encouraging the involvement of different disciplines. Furthermore, there is scope to work closely with PCTs, commissioners, health professionals and patients. This is an exciting time for novel collaborative research and I hope people will maintain the momentum and enthusiasm generated by the recent conference.
Paul Sutcliffe
July 2nd, 2009 at 4:17 pm
Why moving from ICE to V+ICE may be useful to NICE
Richard highlights the importance of “values” in the doctor patient interaction and discusses the implications if they are not recognised. In his response Peter Cantillon suggests adding “values” (V) to what he suggests may be a slightly jaded “ideas, concerns and expectations” (ICE) concept, that may not only revitalise it, but will lead to another new (but quite interesting) acronym in health care.
At the National Institute for Health and Clinical Excellence (NICE) we are not involved in individual doctor patient interactions but we do make national prioritisation decisions that influence many thousands of doctor and patient decisions.
Already we expect our advisory bodies http://www.nice.org.uk/aboutnice/howwework/socialvaluejudgements/socialvaluejudgements.jsp to apply social values as well as scientific values when making their decisions. The methodology underpinning the latter is complex but relatively well understood. However, while the former is equally complex, we are only just feeling our way in how to apply and (more importantly)to be seen to apply social values in our decisions in a way that professionals, patients and the public understand.
It is time for a debate on the interaction between VBM and EBM
Peter Littlejohns
July 2nd, 2009 at 5:01 pm
One of the key aspects of VBP that interests me is the contrast with a principles-based medical ethics. VBP is different in two respects: the values considered are wider in range; and there is no suggestion that their normative force can be codified in a set of principles. Thus sensitivity to the potentially conflicting demands of the values in play in a situation requires a capacity to make uncodified judgements. In other words, VBP reminds us of the importance of clinical judgement.
But the idea that good medical practice depends on skilled judgements that cannot be given an algorithmic codification is broader even than this broad picture. It is implicit in any account of understanding the meaning or significance of patients’ (or service users’) experiences that rejects a theoretically mediated view of interpersonal understanding. (In other words: any account which rejects ‘theory theory’.) Such opposing views include so called ‘simulation theory’, models of empathy or idiographic understanding and the idea that we can simply directly experience at least the expression of others’ mental states.
It is also a part of models of medical practice that stress a role for tacit, or situation-specific practical knowledge. And there is good reason to think that a tacit dimension is of particular importance in medicine given that it aims to intervene as well as describe.
But there is a deeper reason for thinking that a notion of judgement plays a key role in medicine. Consider the distinction Kant draws between determinate and reflective judgement:
If the universal (the rule, principle, law) is given, then judgment, which subsumes the particular under it, is determinate… But if only the particular is given and judgment has to find the universal for it, then this power is merely reflective. [Kant 1987: 18]
The idea is that determinate judgement is unproblematic. It is like deduction. If you know that:
1: All men are mortal; and
2: Socrates is a man.
Then you can infer that:
3: Socrates is mortal.
If you have accepted 1 and 2 then you have accepted 3 already. To accept that all men are mortal is to accept that Tom, Dick, Harry and Socrates are mortal. So given 1 and 2, then 3 is no step at all.
By contrast, there is another kind of judgement which Kant calls ‘reflective’ where the problem is how to get from the level of individuals to the level of generalities. That isn’t a matter of deduction. To move from the particular to the general is somehow to gain information not to deploy it. But that is the key requirement of diagnosis: to see in the person before one that he or she is describable using a general concept. It is no use invoking further general concepts to help to explain how this is possible. Instead, in the ubiquitous phenomenon of observation, there is a key role for clinical judgement.
Values Based Practice is just the start of it!
Tim Thornton
July 3rd, 2009 at 2:58 pm
Being also a participant at the Warwick conference, and looking at the comments above, I want to higlight that i) the relevant values extend beyond personal values (whether of the patient or the physician)or institutional values, and ii)that values permeate clinical practice at its core rather than peripherally (meaning that the importance of dealing with values in clinical practice extend beyond improving interaction with patients).
Regarding the kinds of values in clinical practice, the values of the patient have been mentioned above and they may be subset of cultural, societal, familial, and other kinds of values. The personal values of the doctor have also been mentioned and again are shared to some extent with those of his/her culture, society, institution etc. Other kinds of values relevant to clinical practice include prudential values, aesthetic values, religious values, obligations, duties, responsibilities, virtues, ideals, norms, principles, legal values, values about right and wrong, values about good and bad, better and worse, etc.
Most strikingly, the values that are brought to the clinical practice by the physician, and legitimately so, are the professional/medical/scientific values. These are the values that guide the medical opinions. After-all, the physician is expert on what is BAD for the person’s health, what will be the BETTER intervention (diagnostically or therapeutically), what the patient SHOULD do for the sake of his/her health, what the patient NEEDS to do (e.g. adhere to treatment), notably also on what the physiological NORMS are. (Note the VALUE words in capitals)
Becoming aware that these are indeed values (hopefully supported by evidence), changes substantively the ball came in the communication between patient and physician, for then the communication may be explicitly about the relevant and legitimate values and their appropriate domains. For example, in the communication it matters substantively that something being GOOD for the patient’s health, let’s say going on a sugar free diet, may nonetheless not be GOOD for the person/patient (from his/her point of view).
One crucial pointer to good process in VBP is that communication plays a substantive, rather than merely executive role in dealing with conflicts between values. This means communication is not merely a means to an end, does not merely serve a purpose in pursuit of particular values (e.g. what would be good medically), but a shared engagement about the relevant values whereby the eminent decisions of patient and physician, in partnership, may be guided. For example, telling a patient to be treatment adherent may be considered executive communication. Substantive communication is about how and what the patient and I are going to decide in partnership considering the various values including the medical value that treatment adherence will be good for his/her health, as well as the other relevant values of the patient, the institution, the society, the culture, the family, other health professions, etc.
Substantive communication in VBP defies, furthermore, that way of interacting about treatment whereby the physician merely tells about treatment options (thus prodominantly driven by medical values) and the patient is left to make the decision (that is, the patient is left to consider the former with his/her values).
Considering the variety of values including medical/scientific/professional values, values are not peripheral to clinical practice, not merely an appendix to it, not merely a matter of professional prudence or finesse, but at the core of all clinical decision making and communication.
Werdie van Staden
July 3rd, 2009 at 3:05 pm
Having also been at the conference and “lurked” around the blog on and off for the last couple of weeks I am intrigued at how intuitive values based practice seems, yet how slippery the concept is when one tries to define it. I do like Peter Cantillon’s (wonderfully subversive)acronym “VICE” and I think Werdie’s submission that values are at the core of all decision making and communication is really helpful. In fact values are perhaps a shorthand for all that is deeply held and which permeates all our beliefs, thoughts, preferences, ideas(concerns and expectations). Perhaps values are to life as salt is to the sea.
Maybe we could rearrange the VICE equation to ICE/V where ICE is what is what we can discover relatively easily if we ask and listen but V underpins it all and is that which is only discoverable through reflection - and even then we find it difficult to express verbally.
The debate around how to demonstrate the effectiveness of VBP reminds me of that around continuity of care. It is difficult to define what the important aspects of continue are and how it influences outcomes. But I think the two are also linked in that the reflection needed to discover values takes time and ongoing relationship, absorbing what is said, what is written and what is seen out of the corner of the eye in the waiting room. Is it possible for values to really be discovered in any meaningful way in the ten minute polyclinic consultation with robodoc?
Dan Munday
July 3rd, 2009 at 10:16 pm
Since the Warwick conference, I have been considering what would need to happen for values-based
practice to be effectively incorporated into our educational programs. It seems that we would have to think more broadly than the consultation, and the skills the learner needed to acquire to use within it. The professional context would also have to be addressed. We have quite a lot of information, from studies in several countries, about what medical students learn in the ‘informal curriculum’ of medical education. Repeatedly we hear that medical education actually distances learners from their values, at least in the short term, and can lead to detachment, which learners come to believe is ultimately good for their patients.This effect seems to be directly opposite to what authentic engagement in values-based practice would require. To effectively embed values-based practice in education, the informal curriculum would have to be explored and made explicit, so that both learners and teachers could be aware of and address its messages.
Karen Mann
July 4th, 2009 at 9:38 pm
Recognising that what is communicated in a consultation is predicated on a set of values mediated by expectations and constrained by a range of diverse targets embedded in the local culture of the clinic or health economy is important. In that sense thinking of doctor-patient interaction as solely about the flow of information is overly simplistic. Similarly, imagining that decision-making about treatment options is solely a product of this dyadic interaction is also unhelpful. Treatment is a product of multi-disciplinary teams often split across organisations and a doctor in a consultation is hard-pressed to speak on behalf of all those producing the intervention. Similarly, patients rarely make decisions about a medical intervention or follow advice without discussions with carers, friends, family and exploring ‘evidence from a range of sources.
Values-Based Medicine provides an opportunity for greater transparency in the dealings between doctors and those they treat and the explicit recognition of the often hidden assumptions that are part of the expectations, cultures and practices of medicine. As others have noted, such transparency carries with it the risk of changing the image of the physician and exposing some of the uncertainty and disquiet often obscured by the professional roles and the social distance that they require.
What are the implications for how we prepare medical students for practice? This is the issue that our working group at the conference wrestled with. We are seeking to understand better whether student doctors trained in VBP manage and experience consultations differently and whether any difference is apparent to patients. Such proposed research will help to reveal the extent to which VBP training shifts not only the cognitive approach to doctor-patient interaction but also the lived experience of the consultation.
Jonathan Tritter
July 6th, 2009 at 10:10 am
I think this conversation sheds light on an important ommission. It is very difficult to apportion equal weight and respect to the values of both doctor and patient, not least because one of the parties is put in the position of tending to “know better”.
I think that in being open about his or her own values the practitioner shows her own vulnerabilities and limitations but I would be concerned about the real possibility of the professional ceding to patient demands against her own better judgemnt.
It seems to me that value-based practice poses a very real challenge to both doctor and patient but one that does need to be negotiated with great sensitivity and emotional sophistication.Each adult is called upon to take the weight of what can be enormously stressful decisions. Both are called upon therefore to bear the weight of the ensuing outcomes.
The reason one is called the patient is that he or she comes to the doctor in distress. This may affect the patient’s capacity to judge well and this, too, must be put into the equation.
In following this desirable, if not utopian path, we are requiring a high standard of emotional maturity in our physicains.
How are they to acquire this?
Kate Gilbert
July 7th, 2009 at 12:12 pm
I was sent the link to this article & commentary by someone who felt that the patient perspective had not really yet been heard. It is interesting to me that we knew little about the patient with spots. Had she seen the doctor before about this problem? Had she any choice in who she saw at the practice? Would a female doctor had values which would be more or less sympathetic? I am just trying to point out that values have to be put in context, this has been refered to but needs in this choice, personalisation times to be far more explicit. I have a mental illness diagnosis and the values that come into play when I interact with the health service are more about risk, control and compulsion so are ’society’ rather than individual values but as everything is open to interpretation an open dialogue with someone with what I consider sympathtic values would make us all feel better.
Mary Nettle
July 8th, 2009 at 2:52 pm
I think the development of the values-side of medical practice articulated by the evidence-based medicine theorists has not received proportionate attention and development compared to the evidence side. Therefore,I was very pleased to see this blog entry from Dr. Smith and am delighted with the progress and foresight of the Warwick group.
In my view what the next step is, in terms of developing empirical evidence for the efficacy and humanity of VBP, is educational materials for training medical students, residents, and other clinicians, thus setting the stage for comparative trials for VBP and medicine as usual.
John Z Sadler
July 15th, 2009 at 3:27 pm
Apologies for arriving so late to this blog!
I was also at the conference and I have found it really interesting to read the posts and to consider further some of the issues around values based practice. It is clear that, whatever the evidence, values undoubtedly influence the way that professionals and patients behave and that this has a considerable impact on care – although researching this and identifying outcomes of a more values based approach clearly remains problematic.
However, the patient/professional interaction is not the only situation where values can conflict and dissonance between professional values can also lead to problems in clinical practice. This can occur when one professional is more in ‘tune’ with the patients values or believes that his/her own values are more important than other professionals or the patient and should, therefore, drive care. One possible way to address this is to encourage professionals to adopt a more open approach with each other about their values and consider how these may lead to conflict in clinical practice. Unfortunately, what sometimes happens when care becomes complex is that staff resort to ‘professional tribalism’ with each profession, extolling the values of their own practice rather than working in a more creative way to address the issue. Perhaps more reflection and self awareness about how and why professional values conflict could lead to improved teamwork and patient care.
Jan Cooper
August 2nd, 2009 at 12:21 am