This is my last blogpost about the change from being in the care of the British NHS to the (mostly private) care of Polish doctors. Although the coronavirus dominates medical news, I want to end my triptych on switching between British and Polish medicine. Today, I want to write about shared decision-making SDM).
Shared decision-making is in. It’s so in that just about every visit with an NHS doctor will involve questions about what exactly you want, what your preferences are. You will be asked about your ideas and expectations. Needless to say, at least if you go by my experience, those will mostly be ignored, but at least you will go shared decision-making. Go SDM!
I’ve written time and again that I really don’t want to be asked questions about which medication I would like to be prescribed. This is because more often than not I have no view! And, in fact, I want to rely on your judgement. Yes, not only on guidelines and research results, I also want your judgement. That’s why, as much as it is possible, I tend to choose doctors I see. This is because want a relationship with them, I want to be able to trust their judgement. I also really don’t want the pretence of a doctor-patient partnership. In my view, the power imbalance is so great that such a partnership is just about an impossibility. But a decent doctor-patient relationship is not.
For me there are all too many questions you can ask of SDM to make at the very least very problematic. When do doctors do SDM, both globally (what kind of decisions) and locally (when in interaction)? Who opens SDM and who closes it? How is it done? What’s the process like (how about transcripts!). What kind of evidence is discussed and, crucially, who makes a decision about that? And all that is just for starters.
Now, having moved to the (mostly private) care of Polish doctors, SDM seems just funny. SDM birds don’t really fly so far east. Yes, (half-)celebrity doctors will tell you all about partnerships and joint decisions, but when you see them, you know it’s not much more than lip service. Over the years, I am yet to engage in anything that could be sensibly referred to as shared decision-making with a Polish doctor. Well, at least shared decision-making as it is described in the literature. Except one thing – medication.
Time and again, when I am prescribed medication, I am told to see how it works. In other words, my prescription, which is given with instructions how to take the medication, can in fact be re-negotiated by me. The doctor only offers me parameters within which I can move, how I move within them is up to my (somewhat informed) decision. For example, as I take my blood pressure at home (I continue to be amazed how it changes from one reading to another), I can be told what my goal is and I can then adjust my medication accordingly. And, surprisingly, it works.
There are couple of comments I would like to make on this. What is quite fascinating is that the conversation about this has nothing to do with decision-making, shared or otherwise. If anything, it’s anything but. The conversation is very powerful – the doctor basically tells me what to do. There is no discussion here. But, somewhat surprisingly, the command-like instructions from the doctor lead to space for my decision. It is then for me to decide how I feel, to take my BP, to make sure that I take my medication. And, shockingly, my compliance is higher, because I cannot make an informed decision (which is my decision) if I don’t collect the evidence, so to say.
But to all those who would like to think about empowerment in this context, I’d like to say that I don’t. If anything, I think that the doctor treats me like a responsible adult. I can simply be trusted to act responsibly in my own interest.
There are at least two interesting consequences of such a practice. First, I don’t need to see a doctor (which means I don’t need to pay again) when I need to adjust the dosage. I can, if things don’t go as expected, but I don’t need to. Second, and probably more important, I am considerably more diligent with regard to taking the medication, taking my blood pressure and so on and so forth. After all, I am in charge, I want to do things right. I am no longer reduced to following the instructions of my doctor, having to run for permission for every tweak. I am also no longer only collecting data for the doctor to peruse and make decisions on. I am collecting data for myself.
But the main point I want to make here is it’s not anything remotely akin to SDM. The doctor didn’t discuss the medication with me. I should add: I am delighted to say for there would be nothing to discuss? I must and want to defer to the medic. Yes, of course, after experiencing it, I will have a view about how I feel about it. Do I have headaches, muscle pains, distensions…? Yet, at the end of the day, if this is the treatment that will keep me in shape, I will fart my way through it because for me this is being adult.
And so, I wonder whether this should be the new in-thing – adult medicine. No, I am not just a container for pills, but no, I am no medic either. I am a sensible person who wants to get better and I will act in my best interest. And, maybe, if we treat each other like adults, we might get somewhere.
There are quite a number of buts here, obviously. I am probably a particular kind of patient (my GP has said on a number of occasions that I challenged him and I do get this), taking blood pressure is relatively easy, it’s most certainly not going to work for everybody. But I somehow think that treating people like adults will get them to behave like adults. And if they don’t, well, it’s also a choice we should be allowed to make.
Of course, my reference to ‘adult medicine’ is a provocation. You can call it collaborative medicine, you can call it, patient-inclusive medicine. You can call it whatever you want. And, in fact, when you google such names, you will find literature on them, sometimes written a few months ago, always with an air of wonder underpinning them. Look, doctors, you can collaborate with your patients. Alleluia!
I had a look at a few of them and none seems to realise that what I want is to be treated like a person who, outside the doctor’s surgery, leads a complicated life, taking complicated decisions, sometimes very significant decisions, impacting on people’s lives. And it would be good, if doctors actually understood and acknowledged this, and acted accordingly. Needless to say, I am not holding my breath, but it would be nice….
PS. I am writing this blogpost in the midst of feeling like being under the coronavirus siege. The education system in Poland has been shut down, Polish borders have all but been shut down. Cinemas, museums, concerts, all shut down, with shopping malls following shortly. Today I heard and read that it’s all exaggerated, all too panicky, stupid, nothing will happen, sometimes said by celebrities, including people wanting to be serious journalists. And yet, I am mostly pleased that such measures are being taken. Daily I read that because of my condition, I am in a high-risk group. And it’s the first time in my life, I think, I have apparently joined the group of vulnerable people. It’s not a pleasant feeling at all. And if those social distancing measures are a bit (or more than a bit) of an exaggeration, well, so bloody be it. As a member of the vulnerable, I don’t care. I really prefer to err on the safe side. I so would not like to hear (and in particular, no longer be able to hear) a societal ‘oops’.