Catherine Calderwood: champion of “realistic medicine”BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i5455 (Published 11 October 2016) Cite this as: BMJ 2016;355:i5455
- Bryan Christie, freelance medical journalist, Edinburgh, UK
When Catherine Calderwood was appointed as Scotland’s chief medical officer in March 2015, she toured the country for six months and then decided to take a risk. She wanted to challenge the country’s doctors to change their relationship with patients and bury the notion that the “doctor knows best.”
In January, she published an annual report that asked doctors to take a fresh look at their practice and consider if patients are being harmed by overmedicalisation.1 The report suggested care could be improved by practising what Calderwood described as “realistic medicine,” an approach based on doctors spending more time listening to what patients want in order to avoid unnecessary treatment.
The report was a big success. NHS England’s former chief knowledge officer, Muir Gray, described it as one of the best he has read in 44 years. It has generated over five million Twitter impressions (a measure of social media activity) around the world, with hardly a dissenting voice.
“The risky part was that this was a concept that would fall flat, that people would say— what you are talking about is something we do not recognise,” Calderwood tells me at her office in Edinburgh’s art deco St Andrew’s House, the administrative heart of the Scottish government. “The opposite has happened, which I’ll admit was much to my surprise.”
She accepts that the idea behind realistic medicine is not new. It has been called various things elsewhere, such as Choosing Wisely in the United States and Slow Medicine in Italy. They all grow from the same root—reduce unnecessary treatment, address unacceptable variation, and deliver more appropriate, personalised care.
Calderwood’s conversion to this idea has been strongly influenced by data showing that doctors choose less invasive treatments for themselves, particularly at the end of life, than those they prescribe for patients.2 “I have always felt that people we are looking after should have the same information we have—why should it be different?”
Calderwood qualified from Cambridge and Glasgow universities and worked as a junior doctor in both Glasgow and Edinburgh before completing her specialist training in obstetrics and gynaecology and maternal medicine in Scotland and at St Thomas' Hospital London. She went on to be national clinical director for maternity and women’s health at NHS England and is the first Scottish chief medical officer to continue practising after being appointed; she still runs a fortnightly maternity clinic at the Royal Infirmary of Edinburgh.
Her obstetric background has also left her comfortable with the idea of choice and people’s close involvement in their care. “Doctors are fixers by nature, and they don’t like to say they’ll not fix things, but my experience is that patients and the public are already realistic to some extent.”
The positive response to the report has opened the way for its adoption across the health service in Scotland. She is working on ideas for embedding it in the national clinical strategy and also discussing radically changing the patient consent process with the royal colleges. Instead of a patient consenting to treatment, the idea is for patients to request treatment. “This would put the patient in the driving seat.”
Poor communication is the biggest source of complaints in the NHS, and she says there are too many examples of families being distraught at the overtreatment of loved ones at the end of life when they would have preferred less to be done.
She also highlights an unpublished audit carried out for the Scottish government into why people did not attend for elective surgery. The most common reason (26%) was that they had decided they did not want the operation. That, to Calderwood is a clear sign that the health service has to do better. “Why did these individuals agree to a procedure and to be put on a list but never wanted it?” Discussions have already been held with the main patient support groups in Scotland, which have been supportive, and a series of public events starting in November will gather wider views on what people think realistic medicine will mean for them.
Many doctors, says Calderwood, have already expressed their support for this shift. “Lots of people have told me they have been practising medicine in this way for years, but now they have been given permission to admit it.”
“There is a risk that this can be seen as being about cuts,” says Calderwood. “People might think this is about less medicine because it saves the NHS money but that is wrong— it’s about doing the right thing.”
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.