This interesting Open BMJ report from a team headed up by Prof Marianne Hester at the University of Bristol further validates the need for Carers to provide Patients with tools to share their important health information because it’s no longer possible to practice good medicine in 10 minute slots.
“During the same 12-month period, only two of 434 men (0.5%) had explicit partner victimisation or perpetration stated on their medical record, compared to 32 men (7.4%, 95% CI 4.6% to 10.3%) reporting this in the survey”
Although GP consultations still remain largely undocumented it’s rare for a week to pass without another highly regarded researcher or charity calling for Doctors to ask just one more routine question of their Patients and recently I’m noticing it’s even the Doctors encouraging their colleagues. Meanwhile at the coalface you have Patients queuing needlessly for hours and NHS GPs trying to be productive by seeing as many as 60 Patients a day in their clinic while others have posters informing Patients that they can only discuss one problem per consultation.
I think it’s easy to think of reasons why NHS Doctors aren’t going to be enthusiastic about asking sensitive questions about domestic violence/abuse (it’s probably the easiest way to get yourself reported to the Medical Council) but I see huge scope for interactive medical history questionnaires (like Instant Medical History the tool that is being used by us here at 3G Doctor and in the pioneering work of Dr Amir Hannan in the NHS) to contribute and help overcome the key challenges/barriers:
If this research is at all accurate and anything like 1 in 4 men presenting to GPs would report that they feel that they’ve been in a DVA relationship if they had the chance what hope have we of using this information to improve the quality of outcomes if we’re going to rely on the most overworked, qualified and expensive member of staff to ask and enter this information into the EHR?
“Participants: Male patients aged 18 or older, attending alone, who could read and write English”
I think the “could read and write English” requirement is interesting as there are lots of Doctors who are unknowingly consulting illiterate Patients and in a lot of cases it’s not being recorded in the Patients EHR. It’s also something that an online questionnaire can actually test for, assess and help initiate support for the Patient/Carers eg. to help the Doctor appreciate how literate the Patient is and refer them to adult education services etc.
“A total of 1403 of eligible patients (58%) participated in the survey and 1368 (56%) completed the questions relevant to this paper”
I think it’s very revealing that the researchers only approached “unaccompanied male patients” that didn’t appear to be “unwell” or “distressed” and yet half of the eligible Patients still declined the opportunity to participate. It would be fascinating to have more details on the Patients reasoning eg. Was it because it was a paper based questionnaire? Was it because the information was being shared with researchers and not just their trusted GP? Was it because the questionnaire seemed to be irrelevant to the reason they were waiting to see a Doctor? Was it because the content of the questionnaire wasn’t clear at the outset?, etc.
Need to personalise medical history taking questionnaires
As I explain in this talk I gave at Doctors 2.0 in Paris last year it’s important that we provide tools to Patients in advance of the consultation. We also need to appreciate that it’s impossible to know enough about the complex lives of our Patients before we consult with them so the whole idea of having Patients complete set questionnaires is a completely outdated approach that will invariably lead to really undesirable outcomes eg. uncompassionately designed experiences:
We need to be much more considerate of Patients needs because as we’ve seen with Patients refusing to complete “dementia questionnaires” many will have similar objections/resistance to completing “domestic violence/abuse” questionnaires honestly which will make them worse than useless.
Paper based questionnaires aren’t up to the task – history taking needs to be interactive
In the research paper it states that the surveyed men “did not know that the questionnaire would include questions on abuse“. I think this brings into play huge issues with trust and the researchers clearly appreciated these (the “questionnaire booklet contained a detachable information sheet with contact details of support services and national help lines. Respondents were also encouraged to talk to the researcher who recruited them if the survey raised issues that caused them concern“).
It doesn’t surprise me to read that the researchers found that only 56% of Participants completed the relevant questions as this is what happens when you’re not clear to Patients about why you’re asking things and what you’re doing with the personal information you’re gathering.
It’s important to appreciate that the type of questions that are valuable if you were consulting with a Patient who is reporting that they have been abused are very different to those you would ask someone who hasn’t been. With Interactive questionnaires Patients don’t have to waste their time or be distracted by having to flick through pages of detailed questions that are irrelevant to them and can be very distracting (eg. after a branched question about domestic abuse a parent might think ‘I wonder what I’d of been asked if I had actually told the truth and let the Doctor know I did smack my child just once when they were naughty’).
The report suggests that “While nearly a third of the men had experienced or perpetrated a negative behaviour from or towards a partner (or both), about two-thirds of these men did not think their relationships had ever been characterised by DVA“. Clearly the detection of such subtle differences isn’t going to ever be achievable if the Patient is completing paper based questionnaires unaided (eg. without a researcher with a clipboard) as it’s easy to imagine they might try and game their answers eg. skipping forward a few answers to see what else they would get asked if they gave a certain answer etc.
Crime & Punishment or Crime Prevention
As soon as Doctors start asking sensitive questions and recording answers about what might be illegal activities it’s important that they are doing it in ways that make it admissible to courts. To ensure that Doctors asking domestic abuse questions don’t end up spending long periods away from their Patients having ‘he said she said’ discussions in court rooms it might be an idea to have the questionnaires approved in advance by court/defence authorities so that they’re accepted, can be used and don’t require Doctors to be involved in yet more administrative work.
The paper links to lots of evidence linking post-traumatic syndrome, depression, substance misuse, etc with domestic violence. Clearly these are things that GPs see day in day out so I think it’s obvious that we need more support for the use of interactive medical history taking questionnaires from proponents of crime prevention initiatives eg. by getting adults to share earlier with their GPs in more honest and open ways we stand a good chance of helping Patients identify problem behaviour before it escalates into abuse/violence.
Questionnaires need to be made available to Patients before the waiting room
In 2015 Patients shouldn’t be required to sit in a waiting room to access the attention of a Doctor (something that should be incredibly obvious following annual flu seasons, etc) but it’s also interesting to note that the researchers also discovered another flaw with having Patients complete surveys in the waiting room.
“Men completed the survey while waiting to be called for their appointment and thus, had limited time to complete the survey and some were interrupted before completing it. All the data missing for this reason are, therefore, missing at random, justifying to some extent our imputation method”
With >95% of NHS Patients waiting to see a GP having access to the internet themselves or via a carer so there’s simply no reason we can’t use the tools of our time because it should be obvious that the waiting room isn’t the ideal place/time for medical history sharing. It’s also important to appreciate that Patients are much more likely to share sensitive information (on issues like domestic abuse) when they can do it at a time and place that they choose.
Another related issue I noticed with the design of this research is that it only surveyed “unaccompanied male patients” and they didn’t approach any that appeared to be “unwell” or “distressed“. If you can walk into a NHS GP waiting room and at first glance tell me who’s unwell or distressed you’re wasting your time holding a clipboard – you have a unique talent for people reading, give me a call and we’ll go bankrupt a Las Vegas casino…
Does my Doctor know something I shared in their waiting room?
“Data were entered from the paper questionnaire into an Access database. Only individuals who responded to all four questions on negative behaviours were included; two respondents were excluded because they were younger than 18… …Consent was sought from participants for access to their medical records”
No mention is made as to how personal medical information that was revealed by Patients in their GPs waiting room was shared with their GP. I can see we need to be very careful with this because for example if a Patient reveals they’re abusing alcohol (or worse still their partner) to the researcher and the GP says nothing about this during the consultation might the Patient leave with the impression that their behaviour is acceptable/tolerated?
It’s unsurprising that a “strong association between negative behaviours consistent with DVA and mental health problems” was found in the research. I think this really highlights the compulsory need to incorporate clinically validated mental health questionnaires within any questionnaires that we put to Patients about Domestic Violence and Abuse (and vice versa).
What thoughts did you have on reading the paper?