The Resourceful Patient

3.2 Skills to appraise knowledge

Providing knowledge to patients is necessary but not sufficient on its own.

Not all information is of equal quality, and although many patients are rightly willing to accept the clinician's assurance that his knowledge is good enough for the decision they face, the resourceful patient may wish to make his own assessment of the quality of the knowledge that he has been given.

3.2.1 Is the knowledge fit for the purpose?

The patient and the clinician have to decide if the knowledge is fit for the purpose. The quality of knowledge needed to decide whether or not to rub an aqueous cream or a proprietary, more expensive, skin lotion on a patch of dry skin on the dorsal surface of the left wrist is obviously lower than the quality of knowledge required by the patient facing a serious operation or intensive chemotherapy. Just how far a resourceful patient can go is elegantly described by Stephen Jay Gould, a noted palaeontologist, who gives a dramatic account of his appraisal not only of the knowledge he was given by the clinician but also of the quality of the knowledge he found in the literature.

3.2.2 Everyone is being taught to appraise sources of knowledge

1066, 1815, 664, 1314: the proportion of the population able to say what happened on those dates will diminish as the learning of dates is replaced by the appraisal of sources, even in primary school history. Thus the patient in future will have been taught to distinguish between primary and secondary sources and will also know the need to be suspicious of all sources, including primary sources. The attitude developed in history lessons will be relevant in the clinic.

At present, patients probably know to trust professional journals such as the British Medical Journal and The Lancet more than they would trust a newspaper. In future, as patients become better educated, they will learn to place more trust in systematic reviews of primary sources rather than the primary sources themselves.

3.2.3 Patients can appraise the knowledge itself

Hitherto patients have appraised the source of the knowledge, decided whether or not to trust the doctor or, if not, found another more trusted source of knowledge such as the BMJ or the British National Formulary, if available in the local library. However, patients will increasingly appraise knowledge itself, either choosing to do so, or being asked to do so, by clinicians wishing to share decision-making and responsibility. To do this they will need skills or access to the skills of others, for example by being able to use checklists for appraising knowledge such as those available on the Web from the Critical Appraisal Skills Programme in Oxford.

3.2.4 Training patients and their representatives

Three types of critical appraisal skills training are already emerging.

1. General training for all patients. This is poorly developed at present but will become part of the school curriculum. If pupils are taught to appraise sources in history, they should surely also be taught to appraise sources of knowledge in health and social education.

2. Training for representatives of patients and the public. Instead of public representatives on health service organisation boards accepting what the experts say, critical appraisal training is now regarded as necessary for any public or patient representative appointed to a health service board or working in a voluntary organisation.

3. Focused critical appraisal skills training. General training is useful, but people need it most urgently when they face serious decisions. One method of preparing a patient for serious decision-making is through coaching, to help him reflect on the consultation.