It’s the little things

 

I was in a GP surgery recently when I saw something that made me think about the movement to ‘Rethink Medicine’. The surgery waiting room has a rolling screen, electronic pager that beeps and announces in a disembodied voice ‘Ann Smith to see Dr Jones in room 12’. All the doctors use it, and patients shuffle off to the appropriate consulting room as they are called. One young doctor had a different approach. He came into the waiting room and asked for Ann Smith. An elderly lady clutching two walking sticks identified herself as Ann Smith. He went over to her and introduced himself, helped her out of the chair and guided her by the elbow towards the corridor where the consulting rooms are located. As the pair left a conversation was beginning. Others in the waiting room smiled. Then the pager bleeped as another patient was summoned by the anonymous voice to attend Dr X in room 12. It made an uncomfortable contrast.

 

We hear a lot at a policy level about changing relationships and the need to become more patient centred and evidence-based. This young doctor seemed to me to address this agenda by making a relatively small change in his behaviour.

By coming out of his personal space to greet the patient, he signalled a relationship of equals. By helping her from the chair, he recognized her unique needs. The walk from the waiting room provided valuable evidence about her mobility and underlying wellbeing.

 

A few years back I listened to a presentation about a surgery that had persuaded its GPs to stop saying ‘I’m going to refer you…’ and instead say ‘How would you feel about a referral to…? . Doctors reported a sense of embarrassment at the pause that inevitably followed the question. But referrals dropped by over 50% and DNAs by a further 20%. It would be a bit simplistic to say that the surgery was over-referring by 70%, but, by substituting a question –‘how would you feel about?’- for a decision –‘I am going to’ – , patients were being invited to explore other options, which, after a little thinking time, they did – Shared Decision Making in action.

 

Little things can lead to negative consequences too. Recently, I applied to see part of my medical record in an attempt to gather information to self-manage an LTC. By way of response, I got a letter from the Trust’s legal department, laying out their responsibilities and the procedures they will be following to meet the legal requirement. I can’t say I found the letter encouraging. It wasn’t addressed to ‘Dear Troublemaker’, but it had that feel to it… paternalistic medicine in practice. What a difference it would have made to have my request dealt with by Patient Services instead.

 

In RTM there has been a focus on big ideas things such as a shift away from paternalistic, bio-clinical model of medicine to a shared psycho-social model of wellbeing. This shift seems to require doctors to embrace at least one change in the way they work or the service they provide. Social prescribing, shared digital records and health coaching are good examples of new ways of working which reflect the way we now think about medicine, but just as important as the big idea is the way it is reflected in behavior and supported by appropriate systems. Big ideas can drive change, but it’s behavior that delivers it.

 

It’s the little things…

 

AR 25 Nov 2019