Paper of the week: 20.06.18

Muir Gray’s paper of the week: Following the patient’s orders? Recommending vs. offering choice in neurology outpatient consultations 

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Reference: Paul Chappell, Merran Toerien, Clare Jackson, Markus Reuber, Following the patient’s orders? Recommending vs. offering choice in neurology outpatient consultations, Social Science & Medicine, Volume 205, 2018, Pages 8-16, ISSN 0277-9536

Bottom line, chosen by Muir from the paper

The UK’s Royal College of Surgeons (2016) has argued that health professionals must replace a ‘paternalistic’ approach to consent with ‘informed choice’. We engage with these guidelines through analysis of neurology consultations in two UK-based neuroscience centres, where informed choice has been advocated for over a decade. Based on 223 recorded consultations and related questionnaire data (collected in 2012), we used conversation analysis (CA) to identify two practices for offering choice: patient view elicitors (PVEs) and optionlists. 

This paper reports further, mixed-methods analyses, combining CA with statistical techniques to compare the ‘choice’ practices with recommendations. Recommendations were overwhelmingly more common. There was little evidence that patient demographics determined whether choice was offered. Instead, decisional practices were associated with a range of clinical considerations. There was also evidence that individual neurologists tended to have a ‘style’, making it partly a matter of chance which decisional practice(s) patients encountered. This variability matters for the perception of choice: neurologists and patients were more likely to agree a choice had been offered if a PVE or option-list was used. It also matters for the outcome of the decision making process: while recommendations nearly always ended in agreement to undertake the proffered course of action, option-lists and PVEs did so only about two-thirds of the time. While the direction of causality is unknown, this may indicate that patients are better enabled to refuse things they don’t want when neurologists avoid recommending. We argue that our findings imply that neurologists tend to view choice as risky – in that the patient might make the ‘wrong’ choice – but that the inter-individual variation indicates that greater use of the more participatory practices is possible. 

Implications for value improvement

The term patient is an old-fashioned term implying passive acceptance of not only the disease but also the process of care.  The process that developed was that the patient was expected and required to give informed consent before an operation was performed but this has become a routine and often unthinking process in which surgeons in training are expected to “get patients consented”, with the noun becoming the verb.

Legally this requires a different approach because, legally, the person  called the patient is the principal and the surgeon is the agent just as the surgeon is sometimes the principal when he or she is extending their house and dealing with an architect who is the agent.  We also need to take into account the evidence that we now have about the deficiencies in the traditional approach to “getting patients consented”

The right of the doctor to recommend a particular treatment is also questioned in this article which demonstrated that if choice was offered more than one quarter of the people said ‘no thank you” but when a recommendation was made almost every everyone accepts. To optimise patient value the concept of recommendation needs to be dropped.