4.3 The 21st century clinician - the complementary clinician

'The key question to ask is what is the function of the human being in the digital age?'

Bill Gates

Bill Gates' question was posed for people who manage service industries such as banks or travel agents, but it is equally relevant for those who run health services and for clinicians themselves. The question could also be posed by asking, 'what is the function of the clinician in the consumer age?' but these two questions are inter-related because the Internet gives consumers new and unprecedented powers, and consumerism gives the patient the confidence to expect a service that meets their individual needs. The clinician in the 21st century therefore has to complement the skills and resources of each patient and be different things to different patients, supporting decision-making for the patient who wants to make all the decisions herself but taking decisions when the patient has made it clear that she wants the clinician to take the final decision and organise care appropriately. The clinician of the 21st century will also have to be:

• a good mechanic, and
• a sensitive human being

4.3.1 The clinician must be a master mechanic

The statement that 'no patient should be treated by a below average clinician' epitomises a problem for both clinician and patient. Below average sounds unacceptable but being below average is for a proportion of clinicians or any other group, inevitable and inescapable, and 50% of clinicians will always be 'below average'. There is, however, increasing concern among patients about below average services, which may be confused with low levels of quality. The latter are unacceptable, the former are inevitable, but patients are, understandably, less tolerant of errors in healthcare and below average clinical practice.

Two official reports of medical errors in the United States and the United Kingdom (9,10) revealed just how common such errors are. Furthermore, it is clear that some of these errors are not preventable but are inherent in the process of complex decision-making and the delivery of technologically sophisticated healthcare. However, this is not an argument for complacency, and errors can and must be reduced in both incidence and severity. Similarly, all clinicians must be helped to become better at practising their calling, and the profession as a whole is keen to do this, although it is sometimes felt that both the public and politicians overlook the barriers that clinicians have to face and overcome if they are to deliver acceptable, or excellent, quality care. To improve mutual understanding, the General Medical Council, the medical profession's ruling body, has set up a Patient Reference Group to allow patients a greater say in the evolution of the profession.

One barrier is the fact that the clinician is faced with a huge amount of knowledge which changes and increases remorselessly. A study of general practitioners showed that by the end of 1998, each had been sent 22 kg of guidelines; it is estimated that to keep up with developments in medicine as a general practitioner or physician, it would be necessary to read twenty scientific papers every day. The only option for the 21st century physician is to recognise the truth of a proposition by Dr David Pencheon, cited in the British Medical Journal, that 'the three most important words for the clinician of the future are 'I don't know.' Instead of using the clinician as a repository of the knowledge, the clinician should be a knowledge manager, that is someone who can:

• ask the right question and find the best answer
• help the patient interpret the knowledge he has been given or has found for himself

To be a knowledge manager, the clinician has to have easy access to best current knowledge, and this is sadly lacking at the moment. The young mechanic at a Ford garage is provided with the knowledge he needs, available within seconds. If something needs attention on a Boeing aircraft engine, every mechanic who requires it will be given the knowledge to repair it that same day. In the middle of the night the young clinician on a hospital ward may have no access to the Internet or any other easily accessible source of best current knowledge. Equally, if knowledge has to be distributed to increase the safety of healthcare, it can take months or years to arrive, or may never arrive in the form most likely to be helpful. This makes the job of the clinician even more difficult because the clinician has to be much more than a mechanic: she has to complement the resources of the patient.

4.3.1.1. Master mechanics need decent workshops

Clinicians need access to best current knowledge, whenever and wherever they see patients. The National electronic Library for Health now offers easy access but only if clinicians can get their hands on a keyboard and their eyes on a screen, and for many clinicians, this is impossible. The NHS Information Authority is now taking steps to get the infrastructure in place, in partnership with the big players in the computer industry such as Cisco, Oracle, and Microsoft, but massive changes are needed to transform health services, and the Department of Health has set up a Modernisation Agency to accelerate change. Highly trained mechanics cannot do their job if they are given no more than a hammer.

4.3.2 Complementing the patient's resources

In the 20th century, the clinician's task was determined by a number of variables such as:

• the state of knowledge about a health problem
• the health service
• resources available
• the patient's diagnosis and clinical condition
• the clinician's training and expertise

All these are still relevant to 21st century clinical practice, but the focus in the 21st century, and the clinician's approach to a patient, are now influenced by other factors, notably:

• the value patients attribute to health improvement and the adverse effects that might occur as a result of treatment
• the resources that the patient has available to participate in decision-making about management and care, for example whether or not the patient has access to the World Wide Web
• the style of decision-making desired by the patient
• the experience and skill of the patient in decision-making and care management
• the clinician's skill in, and attitude towards, shared decision making

Attitudes influence professional behaviour, and not all professionals are equally committed to making resources available to patients. Pregnant women, one expects, would be a group that clinicians would want to see well informed because they are healthy people being helped on a journey which is usually safe, with a pleasant outcome. Excellent information is available for pregnant women, in the form of leaflets based on best current knowledge, specifically designed to promote informed choice by the Midwives Information and Resource Service. A study of professional reactions to the leaflets found that although midwives thought them helpful, the clinicians who carried out the ultrasound examination were concerned that the message was too negative and would create unnecessary anxiety. Furthermore, they feared that the provision of too much information might have an adverse affect on the relationship between clinician and patient. (11) The changes taking place within professions are not always welcome, and the President of the General Medical Council, Sir Donald Irvine, was frequently criticised for the introduction of changes essential for the continuing independence of the medical profession.

Hostile attitudes to change are becoming less common, partly because clinicians now know that for medico-legal reasons they must offer all the information about the risks and limitations of the services they provide. They are also in decline because of a genuine commitment to patient centred consultations, which focus on high quality communication and a sense of partnership, as well as the traditional function of the consultation, as a means of finding and solving problems.

4.3.2.1 Patient preferences for consulting style

It is important to remember that not all patients want the same style of consultation. Furthermore, the evidence is that clinicians, not surprisingly, do not always identify the style of decision making that patients want. In one study of women with breast cancer, showing a range of preferences for different types of decision making:

• 42% of women achieved their preferred level of control
• 14.9% of women believed they had been pushed to take more control than they wanted
• 21% of the women who wanted the most active level of responsibility for decision making - 22% of all women - achieved it. (12)

Direct observation of 1057 consultations in the United States found that only 9.0% of consultations had completely satisfactory communication and decision-making. Even more worryingly, it found that only 1.5% of consultations were deemed to have assessed the level of the patient's understanding, (13) leading the author of an editorial accompanying the article to state that, if the profession is to achieve shared decision making 'we, as physicians, must do a better job of practising what we preach.' (14)

4.3.2.2. The end of 'compliance'

Analogous to the term 'consent' is the term 'compliance' which is used to describe the degree to which the patient conforms with the therapeutic 'regime', another term with connotations of control and power. The term 'compliance' is usually employed when describing the taking of prescribed medication - good compliance means the patient takes the drugs as prescribed, poor compliance means they don't. In an attempt to reframe the relationship, the Royal Pharmaceutical Society of Great Britain, which governs the practice of pharmacists, has proposed the use of the term 'concordance' and has defined this term.

Concordance has also been called partnership in medicine taking; it has been defined as building a therapeutic alliance. It's a complex recipe, but here are three crucial ingredients:

Concordance includes an explicit agreement between two people - even if the two agree to differ. One person's impression that an agreement has been reached is not enough.

Concordance is based on respect for each other's beliefs. We reject the idea that one group of people (health care professionals) is objective, expert and rational, while another (patients) is subjective, ignorant and irrational. Patients are often experts on their own condition. We all (patients and professionals) need to respect the right of others to think differently - and take strength from embracing the opposing view.

Concordance gives the patient the casting vote. If the patient wants the professional to rake all the decisions, that's fine. But if the patient and prescriber agree to differ, we recognise that the patient's view comes first. Taking medicines is a kind of experiment, which can only take place if the patient wants it to.

Many of the examples in this book describe the interaction between doctor and patient, but the issues are equally relevant for all clinicians, dentists, nurses, and therapists. Some of these groups, notably nurses, have been quicker to appreciate the need to take the patient's perspective, and as these other professions are given more power and more direct responsibility for decision-making and support, these principles and practices will become even more relevant and important.

4.3.3 The clinician as human being

In response to Mr Gates' challenge, the clinician has to focus on the human side of clinical practice in the 21st century. Some of the techniques that clinicians have formerly used unaided can now be supported by computing and the World Wide Web, such as:

• taking a comprehensive and complete history
• finding best current knowledge
• choosing the most appropriate tests
• relating research knowledge and test results to the individual patient

No clinician is now in a position to know everything or be absolutely sure they are up to date, and why should they be? These are tasks which human beings can do if they super-specialise and spend their life in study. In the 21st century, knowledge management is dramatically facilitated by the World Wide Web and human beings may concentrate on tasks that computers and the Web cannot do.

It is important, however, that clinicians are not complacent about their human powers. Many clinicians, for example, claim that they are able to offer empathy to patients, but interviews demonstrate that some patients have found that Internet chat rooms offer better support than clinicians. The personality of the clinician may give the impression that the clinician either has the empathic sensitivity or that he does not, but what has been revealed is that many physicians are predisposed to provide empathy and support for patients but that their behaviour does not always indicate this. Increasingly, clinical students are increasingly taught not only to be clear in the consultation but also to give the right leads to patients. For example, interviews with patients and the observations of consultations have allowed guidelines for clinical empathy to be developed (Table 13) and statements that facilitate empathy to be identified and taught (Table 14). (15) Despite this, human sensitivity, if well developed, still offers receptivity far beyond that of the computer.

Human sensitivity is particularly important where subtle influences are crucial. When a patient is incompetent, or unconscious, or a minor, his ability to be resourceful is obviously impaired, and special arrangements are in place to ensure good decision making. When, however, the patient is competent, but is poorer and much older than the clinician, or less well-educated, or of a different race, class or gender, decision making can be compromised. There is evidence that people who differ from clinicians in these ways have different experiences, often with different outcomes, than patients of the same class, age, race and educational level as the clinician. For example, one study of patients in the US who were elderly, poor and black, found them to have higher rates of feeding through a tube placed through the skin into the stomach - a gastrostomy tube - even though this procedure had a substantial mortality rate of 15.3%. (16) Another study, of patients over 65 with heart disease in Liverpool, found that 'patients from deprived areas may be less confident in dealing with doctors than their more affluent neighbours' and concluded that cultural barriers reduced the probability of elderly poor patients being referred for effective treatment despite 'all but one patient having English as their first language.' (17)

Prejudice, conscious or unconscious, is one explanation for such differences. However, the explanation may be more subtle, with even the least prejudiced clinician having problems with communication. Clinicians need practical advice about the best way to seek consent.

4.3.4 A practical guide to obtaining consent for treatment

The Christmas edition of the British Medical Journal is always a joy. Many of the articles
are tongue-in-cheek, but the court jester style allows things to be said which never could be said in the serious editions of the journal on the other fifty weeks of the year (the bumper Christmas edition covers two weeks).

In a paper in the Christmas 2001 edition, three of the leaders of the evidence-based medicine initiative gave 'a practical guide to informed consent to treatment'.

Interactive, personalised approach to informed consent:

'Good morning, Mrs Jones. My name is Dr Smith. Please sit down and make yourself comfortable. Your GP has probably explained to you that he has asked me to see you because your breathlessness doesn't seem to be getting any better, and he wondered whether I might be able to suggest ways of helping. I hope I will be able to do so, but this may well mean seeing you on several occasions over the next few months and working together to find the best treatment for your condition.

'I'm more likely to be able to help if I can get to know more about you and your priorities and preferences. As this is the first time we've met, I thought it might be helpful to mention briefly how I will try to do this. Patients vary in the amount of information that they want to give to and receive from their doctors. Most patients seem to get less information from their doctors than they want, but others would rather not be told some of the things that doctors assume they must want to know. Because you and I don't know each other yet, I'm going to need your help in learning how much information you want about your problem, and about the possible treatment options. I'm going to depend on you to prompt me to give you more information if you think I'm not being sufficiently forthcoming, or to tell me that you've heard enough if you think I'm overdoing it. You also need to know that I will never lie in response to a straight question from you, and if I don't know the answer I will do my best to find it for you. Does that seem to you to be an acceptable way of proceeding?' (18)

4.3.4 Partnerships between resourceful patients and complementary clinicians

The most important principle for the future is that of partnership.

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