The word ‘Doctor’ is the agentive noun of the Latin verb Docere which means ‘to teach’. The title ‘Doctor’ refers to a person who is recognised to have acquired sufficient knowledge in a subject to be a teacher of that subject. The role of the doctor as a teacher helps educate patients about their condition. A well-informed patient is crucial to the success of any treatment plan. In an era of increasing demands on the healthcare system coupled with changing patient expectations, the doctor’s role as a teacher has a unique significance.
The supreme court ruling in the Montgomery case (Montgomery v Lanarkshire Health Board, 2015) was a watershed moment from a medicolegal perspective. Mrs Montgomery, a small built diabetic patient had complications during a vaginal delivery which resulted in her son being born with severe disabilities. The case hinged on whether the health board had provided her with all the information which could have helped her make a decision between a normal delivery or a caesarean section. Her obstetrician felt that the risks of shoulder dystocia during normal labour was not significant enough to discuss with her thinking that this information may have resulted in the patient choosing a caesarean section which had its own risks. The supreme court felt that had the risks been explained fully to the patient, she would have opted for a caesarean section and the baby would have been born unharmed. This ruling established that a patient should be told whatever they want to know, not what the doctor thinks they should be told. Mrs Montgomery was awarded a compensation of £5.25 million and the ruling fundamentally changed the law on decision making with the transition from ‘medical paternalism’ to ‘patient autonomy’. The ruling makes it clear that any intervention must be based on a shared decision-making process ensuring the patient is aware of all options and supported in making an informed choice by their healthcare professional.
The General Medical Council (GMC) document on Good medical practice advises to work in partnership with patients:
- You must listen to patients, take account of their views, and respond honestly to their questions.
- You must give patients the information they want or need to know in a way they can understand. You should make sure that arrangements are made, wherever possible, to meet patients’ language and communication needs.
- You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.
The Realistic Medicine agenda led by the Chief Medical Officer (CMO) of Scotland makes shared decision making and a personalised approach to care its key themes. (https://www.gov.scot/publications/practising-realistic-medicine/)
‘The King’s Fund’ research recommends that patients should be given a chance to take an active role in decisions about their care and treatment by providing the right opportunities, information and support. Services should reflect the needs of patients by meaningfully involving patients and carers in service commissioning, planning, design and improvement. (https://www.kingsfund.org.uk/publications/shared-responsibility-health)
An informed patient can positively contribute to decision making regarding a personalised approach to his or her treatment. This would also mean that patients are more open to share the responsibility of these decisions and be prepared to live with the consequences of their choices thus reducing the risk of complaints and litigation. Patient decisions are not only influenced by medical considerations but also by non-clinical issues which are of relevance to that individual patient. Values, beliefs and life experiences that have a personal significance can influence choices. Our role as clinicians is to support the patient in the decision-making process by providing expert medical advice through a dialogue. Unlike emergency situations where decisions have to be made quickly to save the life or limb of a patient, the vast majority of treatment decisions are taken in primary care or in an elective setting in secondary care. Many conditions have a variety of treatment options, each with its own benefits and risks. In some situations, having ‘no treatment’ is also a reasonable option.
Many patients are well-researched about their condition having read various articles on ‘Google search’. However, for a non-medical lay person to comprehend the vast, often confusing and sometimes contradictory online information can be challenging. This may leave patients with incomplete and out of context information. Hence the information that the patient could assimilate online is quite different from the knowledge that he or she needs to make personalised treatment choices. The clinician has the unique role as a teacher to help transform the information the patient has into knowledge whereby safe personal choices on treatment could be made.
Discussion regarding the various methods of Patient education is a topic on its own and is beyond the scope of this blog. Though innovative ways to deliver succinct information using digital media seems to be the way forward, these would never replace the warmth and compassion of a caring competent clinician who would help patients make the right balanced choices. This would only be possible with the provision of time and resources to improve meaningful information sharing during consultations.
The CMO’s annual report (2016-17) acknowledges that the main barrier to healthcare professionals having more in-depth discussions with patients is the issue of time. “Simply offering the standard treatment or investigation may be quicker, but not necessarily what is in the patients’ individual best interests. It is essential that in order to provide high quality, personalised care clinicians are in a position to make the time to have these important discussions. If we are able to move towards engaging in these conversations as a part of routine practice, it is likely this will in some circumstances save time where patients decide against investigations or treatments that they do not feel are right for them.”
The second Citizens’ Panel Survey (August 2017) revealed that the behaviour/style of the doctor and how busy they are (or are perceived to be) had an impact on patients’ inclination to ask questions. The current legal and regulatory requirements make it the responsibility of the clinician to provide adequate time to the patient so that they are well informed prior to making a decision. However, the Scottish Public Service Ombudsman (SPSO) has commented in the CMO’s Annual report (2016-17) that this responsibility is not that of the clinician alone. This process would require policy changes within the organisation and a change in culture that encourages and fosters patient centric multi-disciplinary team working.
The GMC guidance, the Supreme court ruling, the concepts of Shared decision-making, Patient centric care and Realistic medicine all point to the pivotal role of patient education thus highlighting the importance of what it truly means to be a doctor : ‘A Teacher !’
Therefore, let us all remember to ‘teach before we treat !’ and support each other in patient education with the ultimate aim of delivering holistic patient care.
Dr. Sonia Cherian is a GP at NHS Dumfries and Galloway as well as a GP Appraiser and CPD Adviser at NHS Education for Scotland