Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Social class, educational status and trust in doctors
- Peter Morrell (10 October 2000)
-
Some are more equal than others ?
- Rani Pal (12 October 2000)
-
Sharing decisions with patients involves more than being patient-centred
- Jill E Thistlethwaite (12 October 2000)
-
Re: Sharing decisions with patients involves more than being patient-centred
- Brian McKinstry (15 October 2000)
-
Preferences on participation in decision making in NICU.
- T H H G Koh, D Budge, L Collie, P Butow (16 October 2000)
-
Disempowerment
- Peter Morrell (17 October 2000)
-
Re Preferences on participation in decision making in NICU.
- Rani Pal (17 October 2000)
-
Re: Preferences on participation in decision making in NICU.
- Brian McKinstry (21 October 2000)
-
Unanswered points
- Gerard Foxley (23 October 2000)
-
Re: Unanswered points
- Joseph Watine (24 October 2000)
|
|
|||
|
Peter Morrell, Hon Research Associate, History of Medicine Staffordshire University
Send response to journal:
|
Sir, The McKinstry study might be summarised as follows: 1. at present relatively few patients would like to be involved in a decision-making dialogue with their GP [1]; 2. those who do show such an interest are mainly well-educated, higher-income earners; 3. no attempt is made to explain the low interest in collaborative decision-making amongst low-income poorly educated people, or the correspondingly higher interest in this among better educated, higher income earners; 4. low-income earners will probably not want this type of involvement, as their knowledge of medicine is very scant and their confidence in dealing with well-educated people like GPs is limited. Their ability to mount a credible critique of medicine or to articulate confidently any challenge to a medical decision are obviously limited. They are likewise limited in making any meaningful input to GP on a more collaborative basis. Being largely deferential and compliant people, they prefer to leave clinical decisions to their doctors and are confident and secure in doing so - most of the time. It is only when “things go wrong” for such patients, that their confidence in their doctor is thrown into question [2]. Thus, it is trust in one’s doctor that can be identified as the single most likely primary reason for their not wishing to be involved in the clinical decision-making process. 5. The higher income better educated people are members of the same general class as clinicians themselves, being better educated, more confident and generally articulate. Being more questioning, critical and assertive, they are therefore more likely to be able to present a convincing challenge to any medical position they disagree with, and express their views with some confidence and credibility. They are also a group of people, which studies have also shown may have some experience of alternative therapies [3], which may also derive from or give them a certain ambivalence towards orthodox medicine and hence possibly less trust in their doctor. They may have acquired a more critical or sceptical view of medicine than most lower class people may. On a more positive note, these people are also willing and able to make a viable input to the clinician by collaborating with him/her about the consultation process. Practitioners often label them as ‘difficult’ or ‘rebellious’, i.e. non- compliant with authoritarian clinicians; 6. in recent medical scandals [2], we have seen that it is only under duress, in extremis and when coming together into organised groups, with the assistance of legal and ethics experts, that low income and less educated people feel able or willing to make convincing challenges of, or inputs to, clinical decisions; 7. numerous studies have shown that smoking rates are always highest among low-income and less educated people than the reverse [4]. This is true not just in Scotland, but also in many other countries. On average and across all age groups, for both men and women, the commonest pattern is that members of social class 1 and 2 are about half as likely to smoke as people in social class 5 [5]. Smokers’ desire for greater collaboration with doctors, shown in this study, therefore seems surprising, if assessed purely on social class grounds, but it is understandable in terms of their awareness of the health effects of smoking, and this probably shows a greater willingness on smokers’ part to collaborate with their doctor, regardless of their social class, income group or educational status; 8. The article does not explore how or why future and more transparent collaborations between GP and patient might be (a) desirable or (b) established. It therefore appears to reinforce a complacent view of the clinician as the dominant partner and offers nothing to those who would question this status quo. Sources [1] BMJ article 7 October 2000, Do patients wish to be involved in decision making in the consultation? A cross sectional survey with video vignettes, Brian McKinstry. [2] e.g. Griffiths Inquiry, Shipman murders, Neale case, etc [3] Vickers and Zollman series BMJ 1999 [4] some examples include: “The higher one's income, the less likely he or she will be to smoke...higher education in general is inversely related to smoking. There is a pattern of higher smoking prevalence among blue-collar workers than white-collar workers.” http://www.nicotrol.com/guide/profile.html Cigarette smoking by socioeconomic group, sex, and age: effects of price, income, and health publicity, J Townsend, P Roderick, J Cooper , BMJ 8 Oct 1994 http://www.bmj.com/cgi/content/full/309/6959/923 [5] Scottish smoking survey: Smoking and Income Since the 1960s smoking rates have declined more sharply in higher income groups. “In 1994 data from the General Household Survey shows a smoking rate that is more than twice as high among women in households with an unskilled manual head of household than women in social class I....Women in higher social groups have changed their smoking behaviour in line with health education advise earlier and in larger numbers than women in low income groups.” http://www.inwat.org/scotland.htm “smokers are twice as likely to be in social class V than I or II. 49% as opposed to 23%...” http://www.official-documents.co.uk/document/scottish/shealth/tab4-16.htm “As can be seen from Table 4.17, informants in manual social classes were not only more likely to smoke than those in non-manual social classes, their average consumption of cigarettes was also higher.” http://www.official-documents.co.uk/document/scottish/shealth/shch4a.htm |
|||
|
|
|||
|
Rani Pal, Consultant Paediatrician UK
Send response to journal:
|
Social class snobbery defined in this paper does not correlate with human emotion - are we not all equal in this factor, or are our emotions judged by the ladder of class status? Of course patients want to be involved in the decision making, and certainly need to! Without their informed consent you cannot advocate treatment, therapy or referral. The unhappy, uninformed develop misunderstanding of their condition, which later will lead to anger or even litigation. This will be misinterpreted as a severe reaction, psychological problems or a difficult and annoying patient. Has McKinstry looked at the outcome of involved and uninvolved decisions? Were the videos shown of the same style of language? Was that fair to all social classes? Consultations are to do with varying tone, manner, speed and words, enabling a dialogue (two-way affair) responsive to the needs of that individual patient. Of course a doctor needs to spend time, or give further opportunites later to discuss the medical condition and make a decision based on incorporating the patients' view. Involvement in decision-making, consent to decision-taking and choice at each step of the process - that breeds partnership and a mutual understanding. After all we, as doctors also learn from our patients at each consultation. Does the giver of news (the doctor) know that implications for the receiver's health (whatever intelligence or social class) will inevitably cause shock and inability to retain or understand what has been said. Naturally, going into the passive mode is the easiest way for many patients...you decide doctor....However, later reflections will cause disturbances, fears and a feeling of being out of control. Please give our patients a chance, a choice and a provide a clear path by empowering them to comprehend their health decisions. We all have a role in our class-given society, let us not forget that 'the doctor' should be there to provide impartial health information which should be distributed equally to all patients, in the manner they most easily understand to encourage them to partake in the decision process. |
|||
|
|
|||
|
Jill E Thistlethwaite, Senior lecturer in community-based teaching & general practitioner Academic Unit of Primary Care, University of Leeds
Send response to journal:
|
McKinstry (McKinstry B. Do patients wish to be involved in decision making in the consultation? A cross sectional survey with video vignettes. BMJ 2000; 321: 867-71) suggests that patients vary in their desire for involvement in decision making in consultations, a conclusion based on their responses to case vignettes. I would hesitate to label the consultations included in the paper as examples of a shared approach. True the doctor is attempting to be patient-centred and to elicit the patients' expectations and ideas but there is little attempt to share information and evidence and to help the patients weigh up their options. Towle & Godolphin (Towle A, Godolphin W. Framework for teaching and learning informed shared decision making. BMJ 1999; 319: 766-71) have defined a set of competencies required for informed shared decision making which include identifying choices and evaluating research, and helping patients to reflect on and assess the impact of alternative decisions on their condition or lifestyle. Charles et al (Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? ((or it takes at elast two to tango)) Social Science and Medicine 1997; 44: 681-92) stipulate that both parties should take steps to build a consensus about the preferred treatment. In the vignette concerning the patient with rheumatoid arthritis the doctor does not go through the options with the patient, neither presenting concrete evidence nor commenting on its lack with regards to drug treatment versus none, nor does he/she explore the reasons for the patient's reluctance to carry on with treatment. Similarly relating to the runner, no evidence is given as to why the patient should rest or alternatives suggested. At a time when informed shared decision making is being promoted, doctors and patients need to be aware of exactly what this means, an awareness that is unlikely from such consultation strategies as these. |
|||
|
|
|||
|
Brian McKinstry, general practitioner Ashgrove HC Blackburn W Lothian
Send response to journal:
|
I have a great deal of sympathy for Dr. Thistlethwaite's points. I was surprised by the results of my research. I had expected to show that patients generally wanted a more sharing approach. A small qualitative research project, not reported in this paper, carried out with focus groups using the videos as a trigger showed a consensus among different social groups in their attitude towards explanation and the presentation of treatment options to patients. Generally patients wanted explanation and treatment options, but also wanted the doctor to choose one of the options presented. They did not like the idea of being presented with an unfamiliar smorgasbord of treatments and being invited to choose. I certainly do not believe my research is the last word on this subject, but it does suggest that the easy consensus, that decision sharing is unreservedly good, to which I, along with many of the medical profession, had come to subscribe may be flawed. Patients I interviewed were very vocal about the reasons for choosing one or other of the consultations. It was clear that many wanted the doctor to be 'decisive' and had no truck with what they saw as 'modern' consultation technique. Many were appalled that the doctor should ask a patient what they ought to do with a serious illness suggesting that such an action was 'unprofessional'. It would be interesting to create a set of video vignettes which included explanations and treatment options, understandable at the many different levels to suit the needs of those watching, which offered patients a choice of a doctor selecting the treatment against one where the patient was asked to choose. If these could be made suitable to be shown in a brief period to large numbers of patients it would be ideal. This would not, however, be an easy task. Brian McKinstry |
|||
|
|
|||
|
T H H G Koh, Senior staff specialist in neonatal paediatrics NICU, Kirwan Hospital, Townsville, Great Barrier Reef, QLD 4817, AUSTRALIA, D Budge, L Collie, P Butow
Send response to journal:
|
Dear Editor, We read with interest the findings by McKinstry on patients’ preferences for participation in decision making in general practice consultations for different medical problems (1). Our group has been evaluating different ways of promoting family centred care (2) and fostering partnership (3) with parents of sick babies in the intensive care situation. An important but difficult role for the neonatal team is to tailor information provision and decision making to the individual preferences of parents in Neonatal Intensive Care. It is always a challenge to both ensure accessibility to people with limited literacy and to inform adequately those who desired detailed information and involvement. At the beginning of the neonatal journey it is important and useful to know the parents' preferences. As part of a project on improving parental experiences in NICU we have been seeking the views of parents of NICU babies regarding information and involvement in decision making (2). Thus far 104 parents of babies newly admitted to our NICU have completed a questionnaire and the percentages endorsing each response option are: A The doctor should make the decisions using all that's known
about the treatments (26%).
Interestingly, these percentages tend towards greater doctor responsibility than those reported in adult medicine settings. For example, more cancer patients prefer to make the decisions themselves (5). It takes the parents 2 minutes to fill in this one- side A4 questionnaire. This is clearly a worthwhile addition to clinical practice. These "decision" profiles may change at different stages of the baby's stay. It is possible that there may be differences between father and mother. The impact of such interventions deserves further study. Yours sincerely, THHG Koh FRCPCH FRACP Budge D RN Collie L RN Kirwan Hospital
Townsville,
Great Barrier Reef, QLD 4817 AUSTRALIA
Assoc Prof P Butow PhD MPH,
This is part of the T.A.P.E. project, funded by The Royal Children's Hospital Foundation, Brisbane. 1) Brian McKinstry.Do patients wish to be involved in decision making in the consultation? A cross sectional survey with video vignettes. BMJ 2000;321:867-871 ( 7 October ) 2)Harrison H. The principles of family-centered neonatal care. Pediatrics 1993;92: 643-650. 3) Richards T. Partnership with patients. BMJ 1998; 316: 85-8 4) Koh THHG, Casey A Budge D, Collie L, Bolisetty S, Whitehall J, Dunn S, Patole S, Tattersall M, Butow P. Parental preferences for information and role in decision making in NICU. Proceedings of the Perinatal Society of Australia and New Zealand 7th Annual Congress, Brisbane March 2000. 5) Butow PN, Maclean M, Dunn SM, Tattersall MHN, Boyer MJ. (1997) The dynamics of change: cancer patients’ preferences for information, involvement and support. Annals of Oncology, 8, 857-863. |
|||
|
|
|||
|
Peter Morrell, Hon Research Associate, History of Medicine Staffordshire University
Send response to journal:
|
Sir, There are some further and important aspects to the McKinstry study [1] which need to be delineated. Rather like the submissive figures in Millet's famous painting ‘The Angelus’ [2], most patients are disempowered as the real negotiators and hermeneuticists [text interpreters] they could be [3]. They are disempowered by a range of potent forces. These include: 1. fear of disease and death in society; 2. lack of confidence in dealing with high class, intellectual, assertive, high status, highly qualified people that most doctors are; 3. real or presumed lack of medical knowledge on their own part; 4. lack of realisation that their views and perceptions are useful to the clinician and which are plus/minus sought after; 5. disempowered by social conformity to a stereotype of the deferential and compliant 'preferred patient', who is rewarded by society more than the non-deferential 'troublemaker' or 'difficult patient'; 6. they do not regard themselves as experts on their own body, symptoms or feelings or that such information is or could be of much use to the clinician; 7. they invest in clinicians the power, authority and responsibility over their own bodies [and minds] to make whatever decisions pertain to their medical condition; 8. and thereby absolve themselves of such power, authority and responsibility. From the viewpoint of the clinician, and somewhat perversely or worryingly, by absolving themselves of this power, authority and responsibility and investing it in the clinician, patients are then able to blame the clinician for any consequences that might flow from any clinical decision they make on their behalf. However, when viewed from the patient's side, it must be said that this absolvement is a product of coercion upon the patient of strong social forces [conformity with the behaviour of the preferred patient model], with which clinicians also collude to rob them of the power they could choose to assert in consultation, to which they are entitled, but which they are denied [a] by their own timidity and [b] by the assertiveness of clinicians. In which case, on balance, the clinician is the more powerful partner in collaboration and is thus ultimately more responsible for the decisions they make on the patient's behalf. Hence in summary, it is hardly likely that patients opt for greater willingness to be a more assertive partner in consultation. Sources [1] BMJ 2000; 321: 867-871 (7 October), GENERAL PRACTICE, Do patients wish to be involved in decision making in the consultation? A cross sectional survey with video vignettes, Brian McKinstry, BMJ 2000; 321: 867 -871 http://www.bmj.com/cgi/content/full/321/7265/867 [2] http://192.41.13.240/artchive/m/millet/angelus.jpg [3] see BMJ 1995; 310: 985-987 (15 April), Education and debate, The rhetoric of research, Richard Horton http://www.bmj.com/cgi/content/full/310/6985/985 |
|||
|
|
|||
|
Rani Pal, Consultant Neonatal Paediatrician UK
Send response to journal:
|
Koh and colleagues demonstrate that the majority of their parents do want to be partly involved in the decision-making process. Does this not depend on pre-existing antenatal information, opportunity to visit NICU or discuss the whole process of intensive care stay in anticipation of baby admission ? Did the responses of parents armoured with knowledge pre-admission differ from those whose babies were admitted without warning ? Beginning the neonatal journey and the roller-coaster stay in NICU is complex. Decision-making ranges from initial resuscitation, placing invasive catheters with risks, starting treatment with drugs, fearful or pleasing day to day events and life-death ethical decisions. Do parents really have a choice in being involved in the decision- making at any stage or are we just presenting a single-track path for our goals, because we know best? If we ask parents about their preferences, and know they do want invlovement, then how do we ensure that they are any more involved than the usual information-sharing given to all parents. As the medical/nursing team in NICU we either recognise that there is no choice in decision-making despite parent preference and continue improving our 'information-giving.' Or consider concepts in our style of care to incorporate parent preferences in decisions - integrated available records for all, family- medical ward rounds and pre-strategy joint decision meetings. |
|||
|
|
|||
|
Brian McKinstry, general practitioner Ashgrove HC Balckburn W Lothian
Send response to journal:
|
Sir, Dr. Koh and colleagues have performed an excellent study. The parents whose views they sought were actually faced with serious illness rather than guessing what it might be like. One of the reasons patients may not wish to take part in decision making is the fear of responsibility for a wrong decision. This must be much worse when that decision affects another life (your child's). Patients faced with cancer may not all be desperately ill. Seeking the views of those who are might give a similar result to that which Dr. Koh and colleagues found. The anthropologist Susan DiGiacomo (1987) who in a moving account, describes in her essay ‘An Anthropologist in the Kingdom of the Sick’ how, faced with cancer, she made the decision to ‘take control’ of her illness. She encountered resistance from the medical profession who advised her of the psychological difficulties of doing this. Whilst she resented such advice, she found it uncomfortable to be sharing the medical practitioner’s worries and concluded that there was sometimes a need for the doctor to hold power over the patient. The corollary of this, she found, was that patients who have transferred power and control to their doctor also transfer responsibility. They come to see the doctor as omniscient and omnipotent and, faced with a less than perfect outcome, are able to hold the doctor to account. Brian McKinstry DiGiacomo SM. (1987) Biomedicine as cultural system: an anthropologist in the kingdom of the sick. In Baer HA (ed.), Encounters with Biomedicine: Case Studies in Medical Anthropology. New York: Gordon and Breach, 315-46. |
|||
|
|
|||
|
Gerard Foxley, retired
Send response to journal:
|
Editor, McKinstry’s study has failed to show that patients generally crave greater collaboration with their doctor in making decisions. Call me old- fashioned, but this is hardly surprising! As Morrell has pointed out, power, authority and responsibility are invested in the doctor by patients [and society and the law] because they believe that the expensive training these intelligent people have received equips them, by and large, to do the job competently on the patient’s behalf, and shoulder any credit or blame, that might arise therefrom. Such is the nature of doctoring, like it or lump it. What can patients realistically contribute to these decisions, anyway? They do not know which antibiotic or tranquilliser to prescribe, they cannot be expected to make a diagnosis and cannot understand the meaning of lab tests. What is the point of a decent medical training, if decisions in consultation are going to be part-done by the patient? It seems absurd if not incredible to even suggest that their involvement should be increased. It smacks of trendy tokenism and is probably highly dangerous too. Doctors alone are responsible and culpable in law for the decisions they make - how can patients be? As soon as you increase the patient’s role, you automatically dilute and diminish the power, authority and prestige of the clinician. It is inevitable. I therefore seriously question the basis for the idea of greater patient involvement. Even in the case of social and financial factors contingent upon the patient’s problems, how can such matters qualitatively, not to say quantitatively, impinge upon the actualities of diagnosis and treatment? McKinstry dismally fails to tell us. If McKinstry is so convinced that inputs from patients are so valuable, which is an idea that seems implicit to his study, then he should give some good examples of how such inputs are useful, then readers can assess more fully for themselves what precisely he is talking about. And he must also indicate, and justify, the extent to which such involvements would dilute the authority, prestige and responsibility of the clinician. sincerely, G Foxley (retired) |
|||
|
|
|||
|
Joseph Watine, Eur Clin Chem Hôpital de Rodez, France
Send response to journal:
|
“Authority, prestige (…) of the clinician” … [1] Are these “qualities” those of the “perfect feudal type” clinician [2] ? [1] http://www.bmj.com/cgi/eletters?lookup=by_date&days=1#321/7265/867/EL10 [2] Doctors' attitudes resemble those of the old aristocracy. BMJ 2000; 321:447. |
|||
