My Twitter timeline today included a tweet from Richard Lehman, who suggested that Healthwatch’s BRAN ‘model’ of talking to a doctor could be turned upside down. In this post, I would like to suggest that whether it’s BRAN or NARB, the ordinary conversation beats it hands down.
The BRAN model is a suggestion how to “get the most out of conversations with your Doctor” (I’m not certain why doctors must be capitalised, hey, let’s not fuss). The way is to ask the following four questions:
- What are the benefits?
- What are the risks?
- What are the alternatives?
- What if I do nothing?
Is it cool or is it cool, you might want to ask. My response is – not it’s not. And for two – interrelated – reasons.
First, I hope that you will have seen how general those questions are. You ask about benefits, risks and alternatives, as if they were obvious, clearly defined both for you and your GP. But, in fact, nothing can be further from truth. So, when you ask such questions, and they are very explicitly positioned as questions you should ask, you leave it to the doctor to tell you what he or she things the benefits or risks are. And what if this is not what you actually want to find out?
I really would like someone to stop and consider the issue from my point of view. Things like, will I put on weight, will I fart (e.g. statins are known to produce this unfortunate side effect, and yet, no one has ever discussed it with me), will I be inconvenienced by precise times of taking the medication? Do these things qualify as risks? Is feeling bloated and distention risk enough for you to mention it, doctor?
The second, and related aspect of this is that Healthwatch seems to suggest that the questions you ask may only concern the medical aspect of your treatment, and the relationship between your farting and your social life hardly features on their or the doctor’s agenda. But it is really worth considering that treatments do not only have medical contexts. Treatments are social and have social consequences. And I am yet to be told that taking some medication might mean something, might, for example, be stigmatising, might be difficult, might be something yet different.
The first time I was made painfully aware of it was when, about 10+ years ago, I was prescribed medication for hypertension. I started taking it, but I thought I should take a second opinion and went to see a specialist in my native Poland. During the interview, the doctor asked me about the medication I had and was surprised to see my tablets. She said that in Poland that particular medication had not been prescribed for some time and medication X (which she described as latest-generation) was now standard.
She started me on X and when I came back to the UK, I visited my GP with a request to prescribe me more of X. The GP said he couldn’t as X was too expensive, but the medication I was on, he said, was almost as good. I was shocked, I assumed I was getting the state-of-the-art stuff. The GP was not even apologetic. That’s the stuff, I wasn’t even supposed to know there was an option.
Interestingly, after the conversation which ensued, I was prescribed medication X. Why? Well, you could say it was because I had side effects of the medication I was on, which qualified me to be put on something different. But really, it was because I am highly educated and highly gobby patient who is not that afraid to challenge.
But the question I have is different. When I ask you about the alternatives, do you tell me that there is medication you’re not allowed to prescribe me? Will you explore the possibilities?
Now, Prof. Lehman changes the perspective. He prefers to start with doing nothing:
- How about doing Nothing (waiting – what’s the worst that could happen?)
- What are the Alternatives?
- Is it more Risky to wait or to act?
- Which action is most likely to be Beneficial?
I do understand why Lehman has changed the order. He wants to make sure that I don’t get too much medicine. But then, I still hate watchful waiting. I would never ask the questions he suggests, as I want medicine to help me and not to simply leave me to my own devices (this is, to a considerable extent, how I see watchful waiting). And I don’t care whether all other patients prefer the NARB order. I will never start with nothing, because if I thought nothing was on the cards, I would not have come to see you, doctor, in the first place. And while I appreciate Dr Lehman’s intentions, what he proposes goes right against my action!
So, my main point is that helpful as Healthwatch and Prof. Lehman are hoping to be, the former promotes the medical perspective, the latter undermines mine. But there is one last comment I want to make about the drill of four questions. It suggests that I, the patient, should come well-prepared. The idea puts responsibility onto me to “get the most out of conversations with my Doctor”. But what happens, if I don’t have the internet, if I forget, if I am not confident enough to ask all those questions? Do I not get the conversation I need? Or do I just tell myself that it serves me right? I should be a modern, proactive and empowered patient (bloody hell, how I hate talking about empowered patients), going actively about my health, not a nitwit of a chump who can’t even ask the right question.
Probably because I know how much it costs me emotionally to challenge my doctors (they’re unlikely to understand this), I do dislike this pressure to get the best out of the conversation. No, it’s you, doctor, who should make sure that I don’t have to come with the wonder of four questions, ready to fire them. No, I should be reassured that you will care for me even if I don’t open my mouth out fear. In fact, I would like to think that it is particularly then that you will be take care of me.
And so, let’s come to the solution. Surprisingly, the solution is not the four questions, in whatever order, the solution is the ability to talk to you doctor. And it does behove you to make me comfortable to talk, and to make me feel that I can forget, because you will remind me. And if we have this kind of relationship, we’ll be fine. And the ordinary conversation between you and me will be just fine. But yes, we need the time, the space, and the willingness to talk. Both yours and mine.
And this is, finally, why I particularly dislike the BRAN and its counterpoint. I dislike it because it wants to take a shortcut. I come prepared, you don’t have to tell, we don’t have to have a relationship. And I’d rather I didn’t have to take shortcuts.