Richard Smith on how to improve your interaction with patients by 50%

 Richard Smith
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

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.