Real world partnership with patients

Abstract

In my former role as an NHS Prescribing Adviser, I advised GPs about cost-effective prescribing. Evidence-based considerations went hand in hand with an eye on the drug budget. We routinely performed drug switches with only a passing regard for patients’ wishes. Until one day, during a visit to a GP practice, I informed the GP partners that their prescribing for benzodiazepines was considerably higher than the national average. They explained that they had tried to wean their patients off benzodiazepines, in line with local guidelines, but one of their patients reacted badly to the news of his coping strategy being threatened, and committed suicide. Naturally, this had made them somewhat cautious. Therein lies the problem, our expectations of how things ‘should’ be, are revealed to us in carefully considered evidence-based guidelines. Meanwhile, our perception of what reality ‘is’ confronts us through our lived experience (Box 1). The often opposing demands of following evidence-based guidelines and acting in partnership with patients can leave GPs with the stark choice of either following guidelines or not.1 This is likely to result in patients receiving inferior care and GPs feeling legally vulnerable. Is there a way of pragmatically empowering GPs to make the best decisions in complex circumstances in partnership with their patients, and for these decisions to be systematic, transparent, and defendable? | | ‘Is’ — lived experience | ‘Should’ — clinical evidence | ‘Could’ — management plan | |:--------- | --------------------------------------------------------------------------------------------------------------- | ----------------------------------------------------------------------------------------------------- | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | Clinician | Clinical diagnosis and prognosis; clinical experience; available resources; and, logistics of healthcare system | Evidence-based guidelines; application of probabilities of risks; and, benefits to individual patient | A realistic and mutually owned management plan, developed through conversation between the patient and clinician, in the context of an empathetic and therapeutic consultation, that is reviewed as appropriate. | | Patient | Patient’s lived experience of: | Patient’s understanding of condition, and risks and benefits of treatments options | Box 1. A mapping of the highest scoring topics from Wentink et al12 on to the dimensions of the Triangle of Reality The original intention of evidence-based medicine was to provide a tool for that purpose.2 A new way of thinking was proposed in which clinical decisions would be based on scientific evidence.3 At first sight this may appear as though evidence dominates other factors in …