Time for humanity from doctors towards patients.

I t would not be difficult to support the claim that medical achievements during the 20th century rank as high, if not higher, than those in any other field of human endeavour. Doctors have played a significant part in delivering the findings of science to patients in a variety of health care settings. Yet, the climate today in medicine and health care is not an optimistic one; indeed, it may never have been so gloomy. We are living in an era of frequent public inquiries into health professionals’ conduct, sensational headlines about failed, inadequate or unethical care, constant surveillance of performance and outcomes, concerns about NHS funding, and growing criticism from user groups and patients. Criticism of the effectiveness and cost of the biomedical model has been growing for at least three decades. Some would say that medicine’s efficacy has been overstated and that improvements in health have been largely due to improved nutrition and living conditions, hygiene, and changing patterns of reproduction. Illich argued that medicine has deskilled people in caring for themselves and their families, by ignoring the contribution they can make to their own care and recovery and encouraging dependency on medical ‘‘experts’’. Another criticism is that medicine now tends to focus solely on pathology and fails to locate the person within his or her socioenvironmental context. Patterns of morbidity and mortality are related to factors other than biology including, gender, class, race, education, income, and age. By looking only at the biological changes within the body, doctors fail to appreciate the links between people’s lifestyles, their domestic, cultural and social circumstances, and their illness. While never before has so much been on offer to so many patients by way of pharmacological, surgical and psychosocial interventions, patients appear to be more dissatisfied than ever with how services are provided. Dobson estimates that approximately a quarter of people who suffer from life diminishing neurotic disorders don’t seek medical help either because they feel that their doctor has nothing to offer them, or through fear of being reproved for taking up the doctor’s valuable time. A perceived lack of humanity on the part of doctors results in large numbers of people, especially those with the most pressing health problems, not having their health care needs met. Yet the evidence suggests that patients do not necessarily want more drugs or more interventions. What they do want is a partnership with their doctor in which they feel at ease to explain what their concerns are and discuss treatment options that fit into the context of their lives. In Beaver et al’s study of 1012 women with a confirmed diagnosis of breast cancer, 22% wanted to select their own treatment and 44% wanted to select their treatment collaboratively with their doctors. Fewer than half the women felt that they had achieved the level of control over decision making that they preferred. Patients’ preferences about choice of treatment were not well understood by doctors because doctors based their treatment decisions on intuitive rather than confirmed assumptions about patients’ intelligence, age, or quality of life. Sacks has said that patients need to tell their story in their own way in their own time, and that the doctor should seek to establish how the problems the patient has are affecting his/her life at that time. Yet in the general practitioner’s surgery, doctors may feel that allowing the patient time to talk may prolong the consultation to the detriment of effectively processing a waiting room full of other patients. It has been observed that the average time between the patient starting his opening statement and the doctor interrupting is 18 seconds and that 94% of all interruptions result in the doctor obtaining the floor. Use of closed questions and technical language, which the patient does not understand, are used to control the consultation, but will almost certainly guarantee that s/he will quickly return for a further consultation either with the same doctor or another in the practice. Use of open questions enables patients to reveal substantially more information than use of closed questions. More information enables the doctor to clarify the exact nature of the problem, to find out how the problem is affecting the patient’s daily life, and to understand the patient’s beliefs about his illness. He is also able to find out whether the problem first stated by the patient is the main problem or merely an introduction to something else that is in fact of greater importance to him. Allowing the patient to complete his opening statement provides the basis for a ‘‘patient centred’’ consultation. Broody stated that patients are more likely to improve when the meanings of their experiences are altered in positive directions, when things are explained to them, when they feel cared for, and when they feel they have an enhanced degree of control over their symptoms. Mutual discussion of treatment options and goals leads to fewer referrals and fewer investigations as the patient feels in control of the course of action being taken and more satisfied by his care. The doctor is more likely to prescribe drugs or treatment regimens to which the patient will adhere. Non-adherence is a major issue in the management of scarce resources, and understanding the reasons for this is a priority. We know that approximately 50% of patients do not take their medication correctly or at all. This wastage costs the NHS millions of pounds a year. Patients are more likely to comply when they have information about their condition, and understand what to expect in terms of both the positive and negative effects of their medication. Yet the study of Makoul et al showed that doctors spent just one minute in a 20 minute consultation giving information, although they believed that they had spent approximately half the interview giving information. In a recent study of patients with migraine, 88% of participants stated that their first requirement of their medical practitioners was a willingness to answer questions. Secondly, they wanted doctors to teach them about the causes of migraine attacks, how to treat them, and how to avoid them. The doctors, on the other hand, thought that patients wanted them to be ‘‘experts’’, demonstrating extensive and complex medical knowledge. Patients preferred to be able to talk to their doctors and trust that they were being given the whole story. While doctors may consider that patients primarily want information about treatment and drug therapy, it may be that patients are more interested in information about EDITORIAL 667