When I was a lad, if you were ill you tried homemade remedies first – mostly pretty horrible. When I had a cold with a cough and green “snot” the doctor gave me antibiotics. I didn’t question it.
When I trained to be a doctor I was given lots of technical knowledge and excellent diagnostic skills and I learnt which treatment went with which diagnosis.
As a GP I used to ask patients what they thought the matter was. Most replied that it was up to me to tell them and then prescribe the right pill. Sometimes I told patients about side effects and sometimes they listened but were often surprised when they got them.
I used to decide what tests were needed and patients usually turned up for the test. Sometimes tests cause more uncertainties rather than produce answers.
So “doctor knows best”. I don’t think so. And Choosing Wisely Wales doesn’t think so and nor do many others.
The clinician (not just the doctor) is an expert in diagnosis and knowing what tests and treatments may help. The patient (or individual with the health problem) is the expert about their body, their life and their community.
Both can access information about health, disease, tests and treatment from the internet, books, magazines and friends. The clinician has the expertise in assessing how good or relevant that information is and the patient is best able to apply that to their own circumstances providing they understand the words and messages.
How about if clinicians and patients had more equal conversations more often? Ones perhaps more open and honest where the patient gets the opportunity to explain how they feel, how their problem impacts on their life, what they are worried about, what is important to them and what they expect or hope will (or will not) happen.
The clinician explains what the likely problem is and what evidence (research) suggests should be done. They also explain what improvement to expect but also what risks there may be and how easy it will be to provide the care.
The patient asks for more information. What else could we do? What harm might happen? How likely am I to get better? Will I be able to do what I need to do next week or the week after? What will happen if we do nothing? What can I do to help myself?
There won’t always be definite answers and sometimes there just won’t be enough time but this conversation will help make a shared decision more common. It means both patient and clinician are taking responsibility for the choices made both appreciating that whilst a good outcome is likely there is a risk something unintended might happen.
We know many treatments in the NHS can cause harm. That isn’t the intention but it happens. We know which treatments or tests are more likely to cause new problems than solve current ones. It makes sense to avoid those most of the time.
Choosing Wisely Wales is part of an international movement led by clinicians in partnership with patients. It aims to change or rebalance clinical conversations recognising patient and clinician as near equal partners bringing different knowledge and skills to reach an agreed plan to improve the wellbeing of one of them.
It is recommending that patients be more confident in asking four questions about suggested tests and treatment. It encourages clinicians to explain the options or choices for patients based on appropriate evidence, which is shared in the conversation.
Choosing Wisely Wales suggests several tests and treatments that should normally be avoided as of low benefit but which may occasionally be of value. It suggests alternatives to be discussed and recognises that the final choice rests with the clinician and patient together.
Dr Paul Myres is the programme lead for Choosing Wisely Wales and Chair of the Academy of Medical Royal Colleges Wales. He is also a GP in Wrexham.
Choosing Wisely Wales was launched in September and is part of an international movement. It is led in Wales through a partnership of the Academy of Medical Royal Colleges in Wales, Board of Community Health Councils and Public Health Wales and supported by Welsh Government.