Neal Maskrey: Tipping the balance towards individualised care

neal_maskreyI don’t really get the horror genre. Even as a young boy, the flaky plots and a world working to different rules than the one I was becoming more familiar with every day all seemed laughably improbable. Science takes us incrementally and logically from one discovery to another, building on the shoulders of giants. In the 1960s, in a North Staffordshire mining village existing on the dying embers of the industrial revolution, it seemed to me that Harold Wilson’s white hot technological revolution had more credence than Mary Shelley’s Frankenstein.

Talking of revolutions, two of the great potential revolutions in medicine in the last 30 years have been the formalised teaching of consultation skills and the development of evidence based practice (EBP). I was lucky enough to be a young GP trainer when David Pendleton brought us the first videos of real, live consultations. The memory remains vivid so many years later.

Emulating James Herriot on his way to a cow’s bottom, I drove for miles across Yorkshire in the pouring rain one Saturday to David’s workshop. His white hot technology filled a small van, and the tapes might have been Betamax. It was fascinating, pioneering work. We GP trainers should have offered a standing ovation and a brass band—or at least hearty congratulations, a pint of Tetley’s, and a pork pie. What he got was: “We haven’t got the time for this,” “The patients will never consent to being videoed,” and “You can’t really teach consultation skills.” What we meant was: “This is new, it exposes our consultation skills in ways we’ve never seen before, and we need time to get used to the idea.” A few years ago we had a beer and I got the chance to apologise in person. Mea culpa.

Fast forward the Betamax to the present . . . and I’m worried about consultation skills. Their presence on the undergraduate curriculum is ubiquitous, but I don’t hear the students enthusing about the importance of the subject. Quite the opposite. In postgraduate training, the focus on the topic is strong in some specialties and settings—notably UK general practice—but looks patchier in others. And after training is finished, how much continuing professional development is devoted to consultation skills? Very little.

One of my things is shared decision making and patient decision aids. But teaching and learning the technical skills for communicating risks and benefits in terms patients can understand often pales into educational insignificance, as I meet clinician after clinician with embedded views about what treatment they prefer to give patients for a given condition. Of course, different clinicians have different embedded views, and (before I start on these views) they are largely blind to the fact that patients often have very different values and preferences from them and from each other—even though clinicians see just that every day in their practice.

More than ever we need less dogma, and more clinicians who are fantastic at supporting patients with multiple long term conditions, being interested in them and their lives, offering advice where it seems appropriate, witnessing, showing kindness. Are we teaching “identify the patient’s ideas, concerns, and expectations” mechanistically, and then letting those basic skills atrophy as soon as the postgraduate exam is passed? Do we teach decision making with (and for) patients as an integral part of communication skills? Would that make the topic more vibrant and relevant for learners?

A decade after David’s videos, evidence based practice (EBP) came along; systematic reviews and guidelines were all the rage. Optimism was unbounded as we worshipped at the altar of the PICO, learnt basic clinical epidemiology and critical appraisal, and longed for the day when a Cochrane review or a guideline was available for all common conditions.

Fast forward 20 years, and there’s a general acknowledgement that few people go searching PubMed after constructing an answerable clinical question. There are excellent guidelines on how to construct guidelines, and if they are followed—and often they aren’t—there’s a robust summary of the available evidence in the end product. But even if guidelines are well constructed, they may not be based on all of the evidence, and their volume has created information overload for generalists. I find it difficult to write this, but multiple finely grained guidelines—containing scores of recommendations for practice—can be part of the problem, rather than a contributor towards the Holy Grail of individualised, optimal care.

Somehow, EBP has become a systematic review and guidance production line. We spend lots of time and money translating research (R) into national guidance (N) around the globe. But we know that clinicians rely on mindlines rather than guidelines in their consultations; local (L) policies, pathways, and formularies abound but guidance on how to optimally translate from the N to the L is thin or absent. It’s definitely a different process from the R to N translation.

And when we come to translate from the local policy (L) in individual (I) consultations that’s a different process yet again, and we’re back round to dealing with consultations skills and (especially) shared decision making. There’s a bunch of dedicated shared decision making researchers and teachers, but it’s clear that their work hasn’t penetrated mainstream, day to day clinical encounters.

I’ve found that the RNLI model helps shape more constructive discussions when we are investigating why the use of high quality evidence to guide clinical practice is patchy, and slower to catch on than perhaps patients and payers would like. If we compare the public resources devoted to optimising the R to N translation, to those available for the N to L, and the L to I translations, it’s no contest. Well constructed guidance and systematic reviews are of course essential, but they’re a point in the journey and not the destination.

In the famous 1931 film adaptation of Mary Shelley’s Frankenstein, Dr Waldman, as played by Edward van Sloan, tells his colleague and friend Dr Frankenstein: “You have created a Monster and he will destroy you.” It would be unfair to call the industrial scale production of guidelines and the teaching of communication skills “monsters.” But, arguably, we’re missing the greater good from both sets of endeavours, both by focusing overly on communication processes and not enough on individualised decision making, and by the domination of R to N translation in EBP.

One definition of a revolution is “a complete change in the way people work.” I don’t hear voices talking revolution and passion anymore for either EBP or consultation skills teaching. The music has died—drowned out by production, process, and assessment. We’ve somehow got stuck with the science and the fine detail, when we—as well as our patients—need the traditional, core endeavour of our great profession: the love of humankind we offer, and which we should be supported to offer, unselfishly many times every day. Can we find ways to get the balance tipped back towards the I of RNLI, and quickly?

Neal Maskrey’s early career was as a GP before spending seven years as a medical manager and part time GP. After 12 years as a director of the National Prescribing Centre and programme director at NICE, he is now honorary professor of evidence-informed decision making at Keele University, and consultant clinical adviser in the Medicines and Prescribing Centre, NICE.

Competing interests: I declare that I have read and understood the BMJ policy on declaration of interests and I hereby declare the following interest: Employed part time by the National Institute for Health and Care Excellence.

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