Should Patients be asked about their habits every time they see NHS staff?

Denis Campbell in the Guardian has an excellent piece on the latest proposals from the NHS Future Forum:

There is of course a straightforward fix to this and Prof John Bachman MD, Professor of Primary Care at the Mayo Clinic, has already published a paper showing how it has transformed the care for his 5,000 patients:

My thoughts on the points brought up in the Guardian article:

Dr Clare Gerada, Chair, RCGP, “inadvertently frighten patients”

Dr Gerada makes a great point that some patients might be put off by what they saw as intrusive questioning from visiting family doctors:

“Young men pluck up the courage to go and see their GP, maybe about a sexually-transmitted infection, and would not want to be lectured by a middle-aged woman like me. So we have to be careful that we don’t impose our agenda on to the patients and don’t inadvertently frighten patients who are coming in to see the doctor and who fear that they might be preached at,” said Gerada.

I think the situation is more serious than this and opens up a host of new opportunities for avoidable Doctor/Patient friction and complaints.

It is obvious that in an ideal world patients should be asked about their diet, smoking and drinking habits every time they go to see a Doctor unfortunately with the time and volume pressures that exist this can introduce problems such as complaints about Doctors from patients who feel they’ve been hurriedly asked inappropriate questions for perhaps the wrong reasons. Here are a few of these to give you the idea:

An migrant male construction worker visiting a middle aged female Doctor who is asked how much he drinks when he’s visiting an emergency clinic about a workplace injury. “I don’t drink, but are you asking me this because of my nationality?”

An African patient visiting a white skinned GP with a dermatological complaint who is asked if they’ve ever used skin whitening treatments. It’s known by Doctors that they need to be more aware of this as a presenting problem (which is fuelled by racial prejudice) but why run the risk of introducing something like that in a 5 minute consultation?

A young female patient who is asked about her sexual health practices by a middle aged male GP. “Do you ask this to all the boys who come in here too?”

The fashion designer who comes in flamboyantly dressed who’s asked about psychological problems. “Are you asking me this because of the way I dress?”

The only solution to this is to have every patient offered access to the same interactive questionnaire prior to the consultation and let Doctors work from that starting point.

Documentation: “make every contact count”

The NHS Doctor is already bogged down with enough documentation that in some cases she’s rarely looking up from the computer screen at the patient. Asking more in-person questions would only magnify this. It would also encourage Doctors to skip on documentation and this introduces its own problems eg. the patient has told something to the Doctor but because the Doctor didn’t document everything this isn’t in the patients records. The patient never feels the need to mention it again because, “well, they’ve already told the Doctor that, haven’t they?”

Making every contact count starts with documenting the contact. As the work at the Mayo Clinic has shown the patient is not only the best person to do this but they are also the person who most wants to do this. In summary it’s obvious that it’s safer and with economic pressures faced by the NHS I think everyone has to begin to accept we can’t afford to do it any other way.

NB. If you’re a new reader of mHealthInsight the rights of a patient to access their health records and Doctor notes (with exceptions) are assumed here.

All Health Staff OR Doctors? How will we make them communicate?

I can see several issues arising from the NHS Future Forum’s intention to provide these survey tasks to a range of disciplines. Are the answers given going to be joined up with the medical records my GP has access to?

If you know about the elaborately difficult communication links between GP’s and Specialists you can’t even image the nightmare if every GP was being bombarded by EHR updates for their patients from every midwive, podiatrist and private sector optometrist, pharmacist etc. in the country.

Patient Association concern over uncomfortable questions

I think this is very valid concern but interactive digital questionnaires can manage this issue much better than can be achieved in an inperson history taking session. This is because (as patients see on the 3G Doctor patient history taking questionnaire) every question features “Skip” and “I don’t know” options.

Repeated “I don’t know” answers are linked to things like tests for reading/comprehension etc (a lot of GPs don’t know which of their patients are illiterate and asking them questions in person isn’t an effective way of learning this as a lot of patients won’t admit to it).

One off “I don’t know” responses are noted in the output of the questionnaire that the Doctor and Patient see before the consultation. This can help Doctors become aware of issues and better focus their efforts eg. a patient who selected “I don’t know” rather than selecting a yes/no answer to a question like “do you practice safe sex”, “have you been involved in a violent exchange in the last month”, “do you use recreational drugs” might benefit from a consultation focused on the trust they can expect from their Doctor and the reasons why they didn’t answer a particular question.

I think it’s obvious that these questionnaires need to be managed by family GPs as I’m not sure that patients will want to answer uncomfortable questions that will then be entered into a database at for example the pharmacy in their local supermarket.

“There are millions of opportunities every day for the NHS to help to improve people’s health and wellbeing”

I think that’s a low estimate but it should start with the patients who are wasting their time in waiting rooms watching TV or reading old well-thumbed magazines. Giving these individuals the tools to share their information with their carers is when all this is going to start for the NHS.

Dr Peter Carter, CEO, Royal College of Nursing

Peter makes a great point about patients tendency to conceal information they don’t think is linked to their reporting symptoms. But rather than his proposal for “renewed use of awareness-raising campaigns” I think we’ve got a big advantage to take from the greater honesty with which people answer questions online. I could give you a catalog of links to research on this but just go and look at Facebook if you want to see how openly people are sharing things online and ask yourself do you see this same behaviour in public places or physical encounters.

Katherine Murphy, CEO, Patients Association

I couldn’t agree more with Katherine’s point “It seems like overkill to ask every clinician to inappropriately badger and lecture patients each time that they see them”. However when we can utilize dead time normally spent in the waiting room OR while waiting for an available appointment (eg. on the GP clinics website) I think we have a very different situation.

Instead of asking a machine gun barrage of questions the Doctor can focus on the reporting problem efficiently before then saying “Before you go I see you’re having some stresses at home and you’ve started drinking a bit more than usual, here’s some flyers with information about things that can help with that but if you ever want to talk to me I’m here for that as well as the more medical fixes, ok?”

Tam Fry, Spokesman, National Obesity Forum

Tam nails it with regard to health professionals’ “reluctance in recent years to tell parents their child was overweight” and the contribution this has made to the rise in obesity:

“We welcome this plea from the NHS Future Forum. It’s a great beginning for 2012 that the medical profession is being advised to act in this way. It will do more good than harm. Health professionals have to change their mindset about approaching parents about their children’s weight”, he said.

I think that Tam should also change his mindset about who is telling their child is overweight. Parents can use a weigh scale in a waiting room and a ruler on the wall to add their childrens data in a preconsultation questionnaire. A consultation that begins with a report created by the mother that shows exactly where the childs weight falls on the BMI scale is going to be exactly the type of information that can open up a productive dialogue between a mother and her child “ok let’s measure your child again because it’s not me saying this it’s the National Obesity Forum and here’s all the literature and research that supports this”.

What do you think?

Ask patients their habits and deal with the data input tsunami OR give patients the tools they need to communicate effectively with their carers?

I’m of the feeling that in a highly regulated industry (like healthcare) documentation will improve quality and processes, so I wonder if rather than “make every encounter work” we’d be better to first focus on measuring what’s happening? Perhaps “Document every Encounter” would be safer and more effective?

About David Doherty
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