http://bmj.com/cgi/content/full/324/7338/0/h
Why is it so difficult for doctors to put patients at the centre of their own care?
Doctors of course intend to, and think that they do, put patients at the
centre of things. That's one reason why they go the extra mile for
them
as Roger Jones
describes in his editorial on altruism (p
624). It's why they feel shame when they have to admit that
things could be done betteras
Frank Davidoff explains in his editorial on the powerful effects of
shame in stopping improvement efforts (p
623). And it's why doctors care strongly about their professional
values and want to protect them against what Dennis Pereria Gray
describes as a three pronged attack from the British government (p
627).
Yet several papers in this week's issue show pretty convincingly that patients don't feel part of the decision making about their care. Mavis Kirkham and her colleagues in Wales conducted a cluster randomised trial of the effectiveness of evidence based leaflets in promoting informed choice in maternity care (p 643). No more women said that they exercised informed choice in the units that used leaflets than in the control group.
A qualitative study performed alongside the trial helps explain this failure
(p
639). The researchers observed over 800 antenatal consultations
and conducted over 300 interviews with pregnant women and their
health professionalsand
found "informed compliance" rather than informed care. Sometimes
midwives withheld the leaflets because they discussed options not
available locally; they made wrong assumptions about women's ability
and willingness to use the information; and the availability of
technology and fear of litigation led to women being "bullied" into
accepting interventions. The hierarchy in maternity services meant
that in practice obstetricians defined the choices on offer. The
authors conclude that evidence based leaflets are unlikely to promote
informed choice unless they are introduced as a part of a wider
strategy that addresses power imbalances.
Angela Coulter would probably agree. Her article takes as its starting point the British government's intent to improve patients' experiences of their health care (p 648) and her argument is that much is to be gained from involving patients more. Paternalism tends to foster demand rather than inducing self reliance; the gains from greater responsiveness to patients include more appropriate health care, better outcomes, and greater patient safety. "If we want to centre quality improvement efforts on the needs and wishes of patients we must first understand how things look through their eyes and those of their carers," she says.
Our two personal views offer rather contrasting perspectives on that
understanding. Philip Smith describes how a thoughtless remark in a
letter to a general practitioner led to his copying all his letters
to patients, having discussed the contents with them (p
685). While Jacqueline Maxmin's description of her dying partner
shows how patients and their carers need more than just "impressive
informative behaviour" (p
686).
Footnotes
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