Why won’t my patients listen to me?

Dr David Paynton, RCGP Clinical Champion for Person-centred care

04 January 2019

Around the country, clinicians, especially general practitioners, are increasingly frustrated that despite ever increasing workload, efforts go unrewarded.

There is a feeling that although we face a faster treadmill of consultations, blood tests, referrals, QOF targets, contract indicators and regulatory requirements, the law of diminishing returns still applies.

The population is getting older with increased psycho-social complexity. Poor mental health, often compounded by adverse social circumstances, adds to the picture which modern medicine, despite huge advances, cannot solve. People with multiple problems have too many priorities in their lives to always follow medical advice even if it is right. The burden of complying with best practice becomes overwhelming even for the most organised and capable.

Hospital doctors, especially those working with people with long-term conditions, sometimes feel the same: “I tell my patients about the importance of losing weight, reducing alcohol and increasing exercise etc. but if falls on deaf ears”

So faced by this conundrum, is it time to rebalance the role of medicine in modern society?

Is it time to take a long term view on how clinicians can be more effective in improving both the health and well-being of the person in front of them? An increasing number of clinicians are beginning to ask those questions. They come together under different buzz words: Overdiagnosis, Person-centred care , Shared Decision Making, GP online services, Choosing Rightly and Right Care, to name a few. Different names and slightly different objectives but all driven by a sense of unease that the traditional biomedical model is not as comprehensive we may have once thought. Across the UK, there are movements working under different systems all starting to think the unthinkable – Is the biomedical model enough in the modern world? 

What do our population say? 

This is part of the conundrum in that while many patient groups and charities such as National Voices argue strongly (and rightly) for a change in the relationship and consultations with health professionals “a meeting of two experts”. This can however conflict however, as every day in our surgeries we are faced with people who superficially accept the medical model “well you are the doctor”

Does that invalidate the biomedical model? 

It is tempting sometimes to forget some of the major advances in modern medicine. Modern drugs such as ACE inhibitors, statins, Proton Pump Inhibitors together with new surgical techniques such as endoscopic surgery and diagnostic such as MRI means people with acute and long-term conditions are enjoying a good quality of life who would have died fifty or even five years ago. Advances in genomics also have the potential to take medicine another step forward.

The answer is that the biomedical model we all learnt at medical school, is still absolutely valid but perhaps its limitations need to be recognised and addressed.

What is the solution?

Perhaps the start of this journey of rebalancing the medical model is thinking about the relationship between us as clinicians and the person in front of us. 

It really should be a meeting between two equals “the expert in me, the person with diabetes and you as the health professional”. Behind this radical shift in thinking, off course, would need to be a change in processes with preparation, proactive multidisciplinary team meetings, care planning, health coaching and social prescribing, underpinned by shared decision - very different from the reactive medical model of today.

So what next?

Rebalancing medicine requires us to consider the persons own priorities in the context of their own non-biomedical context and realities “what matters to me” and how this translates into what they are doing themselves to maintain good health. Equally giving the same thought and scientific rigor in how we develop, support, apply and evaluate a different approach as we have in the past.

There would have to be a wide and inclusive debate with the profession and public about what we all want from modern medicine without making it is an either/or exercise.

This is one of these occasions when the journey is more important than the destination because in reality the destination is never reached.

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