{"id":32194,"date":"2014-08-21T16:54:50","date_gmt":"2014-08-21T15:54:50","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=32194"},"modified":"2014-08-21T16:54:50","modified_gmt":"2014-08-21T15:54:50","slug":"neal-maskrey-tipping-the-balance-towards-individualised-care","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2014\/08\/21\/neal-maskrey-tipping-the-balance-towards-individualised-care\/","title":{"rendered":"Neal Maskrey: Tipping the balance towards individualised care"},"content":{"rendered":"

\"neal_maskrey\"<\/a>I don\u2019t 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\u2019s white hot technological revolution<\/a> had more credence than Mary Shelley\u2019s\u00a0Frankenstein<\/em>.<\/p>\n

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.<\/p>\n

Emulating James Herriot<\/a> on his way to a cow\u2019s bottom, I drove for miles across Yorkshire in the pouring rain one Saturday to David\u2019s workshop. His white hot technology filled a small van, and the tapes might have been Betamax<\/a>. It was fascinating, pioneering work. We GP trainers should have offered a standing ovation and a brass band\u2014or at least hearty congratulations, a pint of Tetley\u2019s, and a pork pie. What he got was: \u201cWe haven\u2019t got the time for this,\u201d \u201cThe patients will never consent to being videoed,\u201d and \u201cYou can\u2019t really teach consultation skills.\u201d What we meant was: \u201cThis is new, it exposes our consultation skills in ways we\u2019ve never seen before, and we need time to get used to the idea.\u201d A few years ago we had a beer and I got the chance to apologise in person. Mea culpa.<\/p>\n

Fast forward the Betamax to the present . . . and I\u2019m worried about consultation skills. Their presence on the undergraduate curriculum is ubiquitous,\u00a0but I don\u2019t 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\u2014notably UK general practice\u2014but looks patchier in others. And after training is finished, how much continuing professional development is devoted to consultation skills? Very little.<\/p>\n

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\u00a0patients 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\u2014even though clinicians see just that every day in their practice.<\/p>\n

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 \u201cidentify the patient\u2019s ideas, concerns, and expectations\u201d 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?<\/p>\n

A decade after David\u2019s 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.<\/p>\n

Fast forward 20 years, and there\u2019s a general acknowledgement that few people go searching PubMed after\u00a0constructing an answerable clinical question. There are excellent guidelines on how to construct guidelines, and if they are followed\u2014and often they aren\u2019t\u2014there\u2019s a robust summary of the available evidence in the end product. But even if guidelines are well\u00a0constructed, 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\u2014containing scores of recommendations for practice\u2014can be part of the problem, rather than a contributor towards the Holy Grail of individualised, optimal care.<\/p>\n

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<\/a> 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\u2019s definitely a different process from the R to N translation<\/a>.<\/p>\n

And when we come to translate from the local policy (L) in individual (I) consultations that\u2019s a different process yet again, and we\u2019re back round to dealing with consultations skills and (especially) shared decision making. There\u2019s a bunch of dedicated shared decision making researchers and teachers, but it\u2019s clear that their work hasn\u2019t penetrated mainstream, day to day clinical encounters.<\/p>\n

I\u2019ve found that the RNLI model helps shape more constructive discussions when we are investigating why the\u00a0use 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\u2019s no contest. Well constructed guidance and systematic reviews are of course essential, but they\u2019re a point in the journey and not the destination.<\/p>\n

In the famous 1931 film adaptation of Mary Shelley\u2019s Frankenstein<\/em>, Dr Waldman, as played by Edward van Sloan, tells his colleague\u00a0and friend Dr Frankenstein: \u201cYou have created a Monster and he will destroy you<\/a>.\u201d It would be unfair to call the industrial scale production of guidelines and the teaching of communication skills \u201cmonsters.\u201d But, arguably, we\u2019re 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\u00a0domination of\u00a0R to N translation in EBP.<\/p>\n

One definition of a revolution is \u201ca complete change in the way people work.\u201d I don\u2019t hear voices talking revolution and passion anymore for either EBP or consultation skills teaching. The music has died\u2014drowned out by production, process, and assessment. We\u2019ve somehow got stuck with the science and the fine detail, when we\u2014as well as our patients\u2014need 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?<\/p>\n

Neal Maskrey’s<\/strong>\u00a0early 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.<\/em><\/p>\n

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.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

I don\u2019t 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 […]<\/p>\n

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