Tag Archives: BMJ

You’re the Doctor

Adam Staten

Adam Staten

Adam Staten trained at Cambridge University and Kings’s College London School of Medicine. After serving a short service commission in the Royal Army Medical Corps he returned to the NHS and is now a salaried GP. He lives in Surrey with his wife and children and likes to bang on about general practice, the future of medicine, and saving the NHS.
Adam Staten

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When a patient says ‘you’re the doctor’ it can mean several things. Sometimes it means ‘I trust you and the advice you’ve given me’, sometimes it means ‘I don’t like what you’re saying but I don’t feel like I’m in a position to argue’, and sometimes it means ‘just get on with it and do what you’ve got to do’.

Whatever it means when a patient says this, it always feels like a kick in the teeth to me. Since my first day at medical school, the day on which I underwent my Balint lobotomy, I’ve been told to be patient centred. I’ve been taught that there really are no doctors and patients just symbiotic, therapeutic alliances from which mutually agreed treatment plans will emerge.

So when a patient tells me that I’m the doctor I feel like they’re not playing the game. When a patient says this, my inner consulter screams, ‘No! I’ve handed over to you now, just like Roger Neighbour told me to, we need to share this decision like Pendleton suggested, and then we’re going to modify your health seeking behaviours like Stott and Davies wanted’. But an astonishing number of my patients haven’t read any of Neighbour’s work. Even fewer seem to be familiar with the Cambridge-Calgary model, which may explain why some of them don’t seem to get in when I’m ‘closing the session’ and seem instead to want to talk about more problems.

A recent BMJ article, written by a patient, talked about this experience from the other side. The author spoke of feeling bemused and uncomfortable when her GP asked her questions like ‘what do you think is wrong?’ or ‘what do you think we should do about this?. Interestingly, the author found the relentless pursuit of her ‘ideas, concerns, and expectations’ was actually damaging to the therapeutic relationship as it resulted in her losing faith in her doctor.

This is unsettling but not surprising news. The fact that a number of patients simply want to be treated as a patient is obvious to us all from everyday practice. Many people simply want to be told what’s wrong with them and what to do to make it better.

There is an assumption in medical education that this dynamic, the one in which the doctor is in control, comes naturally to all doctors and so doesn’t need to be taught. But even if this type of consultation does come naturally to many doctors, we spend years of training disempowering doctors from taking on an authoritative role in a consultation by punishing them every time they do so in an exam situation.

The current paradigm for the medical consultation is heavily weighted towards eliciting ideas, concerns and expectations, and the MRCGP clinical skills assessment mark scheme reflects this. This encourages rigid adherence to consultation models so that the appropriate boxes can be ticked on the mark scheme. And this can be really detrimental to the natural communication skills that many doctors already possess, turning them from instinctive consulters to consulting play actors.

Articles such as that in the BMJ are evidence that we need to ensure that our doctors can consult flexibly, are able to recognise different consultation dynamics, and are able to be the doctor when that is what the patient wants them to be.

Next GP Journal Club is Sunday 3rd July at 8pm: migraine and CV disease in women

image1The next GP Journal Club will be discussing the BMJ paper:

Migraine and risk of cardiovascular disease in women: prospective cohort study by Kurth et al. 

You can download it here.

Migraine occurs in 15% of the UK adult population and is three times more common in women. This large cohort study from the US suggests that female migraine sufferers are at increased risk of experiencing cardiovascular events. What will this mean for those of us in primary care who have responsibility for managing cardiovascular risk? Should we be advising all female migraine sufferers to take a statin, for instance?

Please read the article and consider your response to the following questions, which will form the basis of our discussion:

  1. Was their PPI strategy appropriate? Would the study have benefited from more patient involvement?
  2. Elevated cholesterol and hypertension were treated as binary variables, is this acceptable
  3. 15.2% of the women reported a diagnosis of migraine at baseline. Is this what you would expect if the cohort was representative?
  4. Does it surprise you that the effects of migraine weren’t modified by other factors such as hypertension and smoking?
  5. Based on this study, should we be paying more attention to assessment of migraine sufferers’ CV risk?

Hope to see you all on Twitter next Sunday at 8pm.

Lucy Pocock

Qualitative research and the BJGP

Kath photo

Kath Checkland (@khcheck) is a GP and a Professor at the University of Manchester. She is a passionate advocate of the value of qualitative research, and is a member of the BJGP editorial board.

On Saturday, the British Medical Journal published an open letter, signed by 75 senior academics (of which I was one), calling for the journal to rethink its current stance on the publication of qualitative research. The letter was prompted by the publication on Twitter of an extract from a rejection letter stating: ‘I am sorry to say that qualitative studies are an extremely low priority for The BMJ. Our research shows that they are not as widely accessed, downloaded, or cited as other research.’

This stance represents a change in policy for the BMJ. Not only has the journal published some important and influential qualitative papers (for example see Gabbay et al 2004), but it was also at the forefront of promoting the use of qualitative methods in health research, publishing a number of highly-regarded series of ‘education and debate’ papers exploring the value of qualitative methods and providing a superb introduction to a variety of methods for the novice researcher (Pope and Mays 1995, Pope et al 2000, Pope and Mays 2009). In what would seem to represent a significant change in policy, an editorial accompanying the letter argues that: ‘qualitative studies are usually exploratory by their very nature and do not provide generalisable answers’, and puts them together with case reports, surveys of self-reported practice etc as studies less likely to ‘change clinical practice and help doctors make better decisions’.

The ‘rapid responses’ to the letter indicate the depth of support for the stance taken by the signatories. Qualitative and quantitative researchers have added their voices, highlighting the absurdity of an editorial position which selects articles by study design rather than by quality, importance of the topic or relevance of the findings. In their original claims and in their response to the letter the BMJ editorial board demonstrate a number of misunderstandings about the nature of research more generally, not only about that done using qualitative methods. These include:

  1. An apparent belief that quantitative studies can provide definitive answers to healthcare problems that will straightforwardly ‘change practice’. Some of those responding to the BMJ article have pointed out the weakness of this position. All scientific results are provisional, and clinicians changing their practice on the basis of a single randomised trial would be rightly accused of being reckless. Furthermore, the approach espoused would seem to equate statistical generalisability with real world generalisability.
  2. A failure to appreciate the complexity of service delivery. Recent MRC guidance re-emphasises the fact that even when a trial result is confirmed and replicated, many important questions still remain (Moore et al 2015). To what extent was the study population highly selected? How might the findings translate in the real world? For other study designs such as quantitative observational studies, further research is needed to explore causation and to try to delineate the relevant contexts in which particular effects might occur. Implementation research is a huge field, and it is rarely the case that the most important studies use quantitative methods. Understanding how human beings behave within healthcare organisations is vital if clinical services are to be improved, and understanding how patients appreciate and value treatments and types of services, as well as different aspects of their lives is essential if overall care is to be improved. Such research topics are not trivial or minor, and it simply is not the case that research which explores these issues can never be generalisable, of high impact or change practice. It is also not the case that BMJ readers are unlikely to find such research interesting to read or valuable in shaping their practice.
  3. A misunderstanding of the nature of qualitative evidence, confusing a method with methodology. While there is undoubtedly a place, as many responses to the letter have highlighted, for qualitative elements exploring aspects of trials of complex interventions, such research represents a tiny proportion of the possible applications of qualitative techniques. Not only does qualitative research answer different types of questions (‘how, why and in what circumstances?’ rather than ‘what?’), but it also embodies a wide range of philosophical approaches and theoretical perspectives. Just because research is not statistically generalisable does not mean that its findings cannot have wider relevance. Theoretical generalisation means that research speaks to a wider body of theory which applies beyond the immediate context, and research using qualitative methods may use theory to generate findings which are highly generalisable. For example, the work done by May and colleagues on Normalisation Process Theory (May 2009) provides a well-researched and widely applicable framework within which to think about how change occurs and how it can be supported in clinical practice. One could argue that such work is more likely to generate sustained and embedded change in clinical practice than any meta-analysis or trial.

In the 1970s and 1980s social scientists engaged in the so-called ‘paradigm wars’ in which those of different theoretical persuasions debated (sometimes hotly) their different approaches, beliefs and assumptions. In general, within social science such wars have long been over, with scholars embracing different paradigms and world views respecting one another’s work and working together without rancour. It is sad to see the BMJ apparently reopening those debates.

To suggest, as the BMJ editorial does, that qualitative work can rarely be of interest to a general medical audience, and that it represents a niche approach which should be published in ‘more specialised’ journals does a disservice to the journal’s many readers who understand and value the diverse contributions which research using qualitative methods may offer, as well as to its own honourable history.

Here at the BJGP we take a different view, and would encourage readers of the BMJ to diversify their reading to explore some of the challenging, highly pertinent and practice-changing research that we publish. In the last 6 months alone we have reported: useful evidence for GPs trying to support those bereaved by suicide ( et al 2016); recommendations as to how practices should support patients to self-monitor their anti-coagulation therapy (Tompson et al 2015); and evidence from a realist review delineating when and how digital communication methods might support access to care for marginalised patients (Huxley et al 2015). For readers, these three examples — selected at random — all address significant clinical issues, and have the potential to change important aspects of clinical care. For researchers, we offer the opportunity to have your study tested and commented on by knowledgeable reviewers skilled in a wide variety of social science disciplines and approaches, providing an invaluable service for those we reject as well as those we publish.