Patient centred, patient focused, patient oriented, co-design, co-production, co-creation, and so on…
The medical world is abuzz with the desire to make patients the central focus of all of our efforts. It is almost so blindingly obvious that patients should be at the centre of everything that we do that very often clinicians feel somewhat startled or amazed if challenged about the lack of focus on the actual wants or needs of the patient they are seeing at any particular time.
I think that physicians are carrying a few centuries of baggage when it comes to truly making the patient the centre of their business. When we look at medical practice over the years, and see how we have morphed from the days of Hippocrates, where he lived amongst his patients, understood their cultural connections, their livelihoods and social context, to the situation where we have constructed huge systems to convey patients to a highly qualified and skilled clinician to pronounce their fate after looking at the evidence of illness contained within their history, test results and imaging reports. As Foucault suggested, the patient was almost a secondary consideration, when coming under the ‘clinical gaze.’
However, these days the concept of the physician as owner, and keeper of medical knowledge – ready for dispensing at the appropriate time and place is being challenged by the democratisation of knowledge through the internet, and the empowerment this gives patients to seek alternatives, challenge received wisdom, and be so much more engaged in their own health decisions than ever before.
A paper in this month’s issue has also got me thinking a bit about the sociological factors that influence what we as physicians think is important when we give advice or news to patients.
The paper in question examined the advice given to patients who suffered a stroke or TIA. Now, the DVLA issues guidance on driving restrictions for many many conditions, and for category 1 drivers, it recommends 1 month off driving, and for category 2 (HGV / public service vehicles) it recommends a year off driving.
But how good are doctors, and allied health professionals at giving this advice?
Sadly it turns out we aren’t great at it.
The knowledge of the correct duration of restrictions varied dramatically with only 28% of physicians giving the correct information, and 11% of AHPs reporting accurate information regarding driving after a TIA. A lack of education may explain some of this poor performance – 53% of doctors, and only 18% of the AHPs had had any teaching specifically on fitness to drive after TIA or stroke.
As I was reading the paper though, I wondered if the lack of knowledge of how restrictive a condition could or should be for patients reveals a little about how patient centred we really are as a profession. I suspect that the same group of doctors and AHPs – if asked about the correct antiplatelet regime, or the correct diagnostic workup to assess for further interventions, and how to calculate ongoing risk of stroke would have scored far higher than their knowledge about fitness to drive. Is this truly just a lack of education? or is it that the truly patient centred stuff is sometime left till last. We think that by knowing the very latest science revealing a marginal gain with a new medication is patient centred, as it will translate to better outcomes for the people we treat. And by ensuring that each and every patient is offered the latest imaging or potential for surgical intervention is patient centred for the same reasons.
But what happens when a patient having had a TIA gets home, and only discovers by themselves that they have invalidated their insurance by not informing the DVLA of their condition, or suddenly discovers they can’t drive to the social club or shops any more – but weren’t prepared for this whilst at the hospital undergoing scans and treatments? It may not seem very cutting edge or advanced in terms of medical practice, but actually understanding the impact of an illness on the social and spiritual as well as the physical being before us will make us truly patient centred.
So yes, keeping up to date with the latest advances in medical technology are a vital part of lifelong learning, but ensuring that we pay attention to what is important to our patients is also key to being a truly patient-centred clinician.