Me and mine all like Claire. She’s talented, works hard, and recently took a big chance going self-employed. It seems to be paying off. We chatted about her imminent holiday, and I was more interested in the plane she was going on than the exotic destination. The latest Boeing 787 is “The Dreamliner.” Carbon fibre construction and all the latest kit means it’s quieter, is more fuel efficient, has more space per passenger, and with better pressurisation and ambient lighting the promise of reduced jet lag.
“So, how was the plane?” says I when we meet on her return. She wrinkled her nose. “It was fine, quiet, and comfortable, just as promised…….but the cabin crew…….they were chatting to each other instead of focussing on us, and even being horrible about some other passengers down the plane in our hearing.” Then she used an interesting phrase. “They were unprofessional.”
If you haven’t yet caught up with Atul Gawande’s 2014 BBC Reith lectures do it, and do it soon. I especially commend the third—”The Problem of Hubris”—and I have no doubt you will be enthralled by the story of Peg who has reached a critical decision in her life. Her cancer has returned and her chemotherapy has induced a haematological malignancy on top. Recognised treatment options are exhausted, and words now matter more.
Such situations are the combined World Championships and Olympic Games of consultation skills. In such moments we’d better have our A-game up and running. Gawande, having talked to hundreds of patients and their families about serious illness, frailty, and other unsolvable problems has some salutary lessons for us. People in such situations do of course have priorities and goals, and if we want to find out what those are we need to listen more. We should talk less than half of the time in such consultations; Gawande found his default was to talk for 90% of the time. Facts and figures, risks and benefits, values and preferences. All in transmission mode. We’ve all done it. Mea culpa.
There’s more important stuff. He concludes there are four questions—just four—which really help people to voice how we can best help them, and importantly to speak the truth for themselves at such dark moments:-
“What is your understanding of where you are with your illness?”
“What are your fears and worries for the future?”
“What are your goals if time is short?”
“What outcomes would be unacceptable to you?”
The doctor-as-the-drug isn’t a new concept. And of course it isn’t just doctors; one of the many heroes in Peg’s story is the nurse from the hospice at home scheme. But when such forces are mobilised for populations amazing things happen. In this study in people with Stage 4 lung cancer the intervention was a consultation early on after diagnosis about the aims of care. Everybody got advanced technical care but the control group just had that and no conversation focussed ahead of time about those tough places for which many were heading.
The startling results were that the group that had the planning conversation had fewer urgent admissions to hospital or hospice care during their illness, had fewer courses of chemo, they lived 25% longer, their care cost less and of those who died, their relatives were in better shape psychologically 6 months after their death. Words matter.
Then there’s this equally jaw-dropping study from primary care. We’ve spent three decades working on how to uncover the patient’s “hidden agendas”—which will often only be truly disclosed if we are skilled at verbal and non-verbal communication. So in this simple randomised controlled trial the test was to say at the end of the consultation either “Is there anything else you want to address in the visit today” or “Is there something else you want to address in the visit today.” Does it matter? It can’t, can it? Surely they’re both fine, well-constructed, open questions, exactly in line with traditional communication skills teaching?
Well, saying “something” enabled disclosure of 78% of hidden agendas. Saying “anything” was indistinguishable from control. “Something” seems to be an enabling word, “anything” induces a let’s-stop-right-there response. The work needs replicating in different settings and cultures, but when I look at the magical world of linguistics which picks apart our interactions millisecond by millisecond, firstly I start to believe it really might be true, and secondly I fear we’ve only scratched the surface of the infinite complexity and therapeutic potential of our interactions.
And surely, just as we now recognise that hospice care is for people without a cancer diagnosis as well as those with, the four questions—the “What’s your understanding of where you are with your illness” et seq questions—may have a utility that goes beyond cancer. Let’s not lock them away, preventing people with non-cancer diagnoses from benefiting.
For example, I don’t see technical approaches fixing multi-morbidity decision making anytime soon. There just isn’t any scientific data which guides—never mind tells us—what the optimum management of atrial fibrillation is in an 84 year old who also has chronic renal failure, osteoporosis, gout, and iron deficiency anaemia of unknown cause. There simply isn’t any direct evidence. So the words matter. As we truly start to grapple with such problems the four questions are just the sorts of words we need to be trying out in those less dramatic, but still critically important conversations too. In these situations the technical stuff just doesn’t tell us what is the correct course of action at that time for that individual—beyond avoiding the barn-door drug interactions and contraindications of course.
Claire’s plane was about as technically advanced as it’s possible to be in commercial aviation, but because of the human to human interactions her experience was degraded, and it did nothing for the reputation of the plane or the airline. Stephen Hawking writes about a Universe that has no boundaries. The same is true of each and every consultation; we are all unique and when two or more people interact over a health problem and its management, then there is no single optimal treatment, only the uniqueness of the human interactions and their consequences.
The inevitable conclusion is not merely that consultation skills teaching is important; it is that consultation skills teaching needs to expand from eliciting the patients’ needs, wishes, and preferences into understanding of how and why humans make their decisions, and then deploying that deeper insight skilfully as meaningful conversations—about how to live, and yes sometimes about when to stop striving, and when and how to die.
In the end much of what we do comes down to decision making. I have come all-too-belatedly to recognise that the important ingredient of care that has become diminished in our understandable 20th century drive for science, evidence, and technology is one simple word, and that word is kindness. Of course, like Claire’s plane, technological advances are to be welcomed, and in healthcare we can and should strive to be as technically advanced and scientifically correct as we humanly can. Yet in the 21st century we also need to work more on the words that convey kindness and service. After all, we really are the professionals. Aren’t we?
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.