INTRODUCTION
General practice faces the challenges of an increase in the prevalence of long-term conditions (LTCs) and multimorbidity, coupled with increasing demand and the need for more collaborative partnerships with patients. To address these challenges, I believe we need a fundamental change in our definitions of health and health care, the way we ‘do’ general practice, and a transformation in our relationships with our patients.
THREE CHALLENGES FOR GENERAL PRACTICE IN THE 21st CENTURY
An increase in long-term conditions and multimorbidity
An LTC is generally defined as any medical condition that cannot currently be cured but can be managed with the use of medication and/or other therapies. More than 15 million people in England have LTCs: accounting for some 30% of the population and 70% of NHS spend.1 People with LTCs account for at least 50% of all GP appointments.
To address this challenge we need a new definition of health; one that includes the ability to ‘adapt and self-manage’,2 and which can provide a framework which focuses on the empowerment of patients and improves doctor and patient communication.
Increasing demands on GPs
Between 1995 and 2008 there was a 75% increase in the number of GP consultations, from 171 to >300 million consultations per year. The average number of consultations/person/year also increased from 3.9 to 5.5 and the length of consultations increased from a mean of 8.4 minutes to 11.7 minutes.3 There has also been a rise in the complexity of the problems that our patients present to us.
Patients want better partnerships with GPs
The evidence is unequivocal that our patients want improved collaborative partnerships with us: NHS patient surveys consistently show that 46–49% of patients want more involvement in treatment decisions.
Recent responses to this challenge include initiatives such as care planning,4 support for self-management,5 and shared decision-making initiatives.6
Care planning
Figure 1 shows the ‘House of Care’7 approach to care planning which has been pioneered by Diabetes UK and the RCGP as a way of improving the quality of care for people with diabetes by developing improved collaborative partnerships and resulting in improved health outcomes.
The House of Care (Coalition for Collaborative Care).8
Support for self-management
The Health Foundation, among others, has pioneered ‘support for self-management’.9 It has drawn attention to the fact that during the course of a year, a person with an LTC spends relatively little time with a health professional so that day-to-day management is self-management.
Shared decision-making
A third approach to improving patient partnerships is through shared decision- making (SDM). This is a process by which clinicians and patients work together to select tests, treatments, management, or support packages based on clinical evidence of the patient’s informed preferences.10
A recent trial of SDM in general practice showed that people with diabetes were able to make their own decisions about when to start treatment with insulin with support from their clinician and a personalised decision aid.11
Attitudinal change
Sue Roberts, leader of the ‘Year of Care Partnership’ has summarised the key areas of challenge in practitioner attitudes which need to be addressed if such innovations are to be embedded into usual NHS practice:
‘Where is the evidence?’
‘We are already doing it.’
‘I haven’t got time for all this.’
However, there is a wealth of evidence from the past 20 years which supports the improved health outcomes associated with initiatives such as care planning, support for self-management and shared decision making. It is also clear that almost half of our patients do not agree that we have fully developed partnerships with them. Finally, we must invest more time and energy into these initiatives if only because more and more people with LTCs are going to consult us, and our current practice is unsustainable.
HOW CAN THE TAO OF FAMILY MEDICINE HELP US TO ADDRESS THESE CHALLENGES?
What is the Tao?
Two fundamental concepts underpin the Tao Te Ching: the first, ‘Tao’, is literally a way or a pass, but in Taoist writings it has a far more comprehensive meaning. It teaches us that we must learn to sense its presence so that we can bring our own lives into harmony with it: we need to align ourselves with the ‘laws of heaven’.12
The second concept, the ‘Te’, denotes the moral power or virtue that a person acquires if they follow the Tao; that is, ‘Te’ is the virtue we can get from following the Tao.
I am going to examine four of the key principles of Taoism and interpret what they could mean for the consultation between GPs and people with LTCs. These are ‘do without doing’, ‘go with the flow’, ‘effortless being’, and Tz’u: ‘the first treasure’.
TAO OF THE CONSULTATION
‘Do without doing’
Clinical intuition
Clinical intuitions, by definition, appear quickly in our consciousness and we are not fully aware of the underlying reasons for them. However, they are generally strong enough to act on. A study examining the significance of ‘gut feelings’ about serious infection in children13 found that a ‘clinical intuition’ by the GP that something was wrong, despite the clinical assessment of non-severe illness, substantially increased the risk of serious illness (likelihood ratio 25.5).
Cognitive errors and clinical intuition
Only 4% of incorrect diagnoses are attributed to inadequate medical knowledge.14 Most of the mistakes we make regarding diagnosis are due to cognitive errors such as anchoring — sticking to a diagnosis in the face of disconfirming evidence — attribution biases (‘stereotyping’) and the ‘availability heuristic’, where we wrongly assume that the patient in front of us will turn out to have the same diagnosis as similar previous patients. We can harness our clinical intuition and avoid common cognitive errors by improving our patient partnerships. Groopman recommends that we invite our patients to ask us three questions when we are discussing a diagnosis:14
What else could it be?
Could two things be going on to explain my problem?
Is there anything in my history, examination, or lab results that does not fit with my diagnosis?
The Tao attitude of ‘do without doing’ can help us to use our clinical intuitions more effectively, develop our partnerships and reduce thinking errors in the consultation.
‘Go with the flow’
On average, the first interruption by a doctor is between 18–20 seconds after the start of the consultation.15 The Tao teaches us to ‘go with the flow’ with the interaction between ourselves and the person sitting in front of us. We teach our registrars to ‘elicit the patient’s ideas, concerns, and expectations’ in the vain hope that this will somehow translate into ‘patient-centredness’. However, this reduces the consultation to a series of tasks: a series of things that we do.
Patient-centredness, however, is a way of ‘being not doing’.16 If we are to be more patient-centred and follow the patient’s agenda, we also need to develop our ability to be quiet and fully engaged listeners so that we can truly hear the patient’s story.
‘Effortless being’
The Tao teaches us ‘to be’ rather than ‘to do’. This idea is similar to the practice of ‘mindfulness’ for which there is good evidence for its effectiveness: its essence is a focus on attention and awareness.17 Mindfulness teaches us that thoughts and feelings are transient; that they come and they go and ultimately one has a choice of whether to act on them or not. Like the Tao it distinguishes between ‘doing’ and ‘being’. When we are in our ‘doing’ mode, we’re very good at solving problems and making sure that things get done. ‘Doing’ however becomes a problem when it is used inappropriately for a task such as addressing a troubling emotion either in ourselves or in a patient. In this situation, it is necessary to shift into ‘being’ mode and this is what mindfulness provides — the ability to change gear from doing to being and to distinguish what is important and what is not — developing an awareness that transcends thinking.
Anxiety and the consultation
Both doctors and patients experience anxiety during the course of a consultation.18 Patients worry about whether they will be heard by the doctor, whether or not they have a serious diagnosis or whether they might be humiliated by being shown up as either ignorant or troubling the doctor unnecessarily.
In parallel, our main anxieties as GPs tend to focus on whether a patient could become ‘insatiable’ and whether or not they follow any agreed management plan, the risk that we will get the diagnosis wrong and whether or not we are practising good evidence-based medicine. Becoming aware of these often unconscious anxieties can help us address them and use them to build better partnerships with patients.
The optimal experience
Those of us who have run marathons will recognise the experience of being ‘in the zone’. This feeling of being able to run ‘without effort’, has been described as ‘the optimal experience’,19 whereby one can make considerable effort for long periods of time without exerting willpower. The people who experience such flow describe it as a ‘state of effortless concentration so deep that they lose their sense of time, of themselves and of their problems’. This experience of flow is perhaps what the ancient Chinese wisdom of the Tao describes as ‘do without doing’, ‘going with the flow’, and ‘effortless attending’. We do not need to invoke the laws of heaven to account for it; it describes our experience when the two systems of our minds, identified by modern neuroscience and psychology, function optimally during the consultation.
Tz’u ‘the first treasure’ (compassion)
Lao Tz’u describes compassion in the ancient Tao as the ‘first treasure’ because from compassion comes wisdom, and wisdom should be one of the main goals of life. Our RCGP motto ‘Cum Scientia Caritas’ (with science, compassion) recognises that compassion is as important as science in the delivery of our care. However, we don’t always recognise that such an attitude of ‘open-heartedness’ is also essential for our own emotional and mental health.20
Professional artistry
In essence, ‘do without doing’ means we should develop our clinical intuition and use our patient partnerships to reduce our cognitive errors. ‘Going with the flow’ implies that we shouldn’t interrupt, we should listen quietly and follow our patients agenda and develop our partnership in terms of care planning, support for self-management, and shared decision making. ‘Effortless being’ teaches us to relax, to develop our own mindfulness, express our natural compassion, but always remain modest about what we know. The Tao teaches us to try and get into the zone of ‘effortless attending’. [Box 1).
The Tao of the consultation: professional artistry
Do without doing: Use your clinical intuition, develop your patient partnerships, and reduce your cognitive errors.
Go with the flow: Don’t interrupt, listen quietly, follow your patient’s agenda, and develop the partnership [share decisions].
Effortless being: Relax, become mindful, express your natural compassion but remain modest about what you know.
The Tao: Get into ‘the zone’ of ‘effortless attending’
A Cultural Revolution
Chairman Mao launched his Cultural Revolution in 1966. He called for the smashing of the ‘Four Olds’: old customs, old culture, old habits, and old ideas. It is now time for our own cultural revolution; a revolution which addresses our own ‘Four Olds’:
old definitions of health;
old ‘doctor-centred’ care;
old way we ‘do’ general practice; and
old QOF driven consultations.
If we are to achieve fundamental change in the way we deliver health care in general practice and transform our patient partnerships, not only do we need to address our knowledge and skills gap but we also need to transform our own attitudes towards our patients. The beauty of the Tao is that it speaks to us in the universal language of humanity. The axioms are capable of multiple interpretations and application in many different cultures. They are timeless and can provide us with great insights into the professional artistry required to care for people with LTCs. People with such conditions should expect their GPs to be thinking and feeling doctors who use their intuition and compassion, based on good medical knowledge, critical reasoning, and communication skills.
The Tao teaches us a way to do this.
Notes
Provenance
Freely submitted; not externally peer reviewed.
Footnotes
This text is based on the James Mackenzie Lecture given at the RCGP in London, 30 Euston Square on the 15 November 2013. Copies of the full text of this Lecture are available to download: http://www.sheffield.ac.uk/polopoly_fs/1.403203!/file/The_James_Mackenzie_Lecture_2014_by_Professor_Nigel_Mathers.pdf
- © British Journal of General Practice 2014
In this issue
Jump to section
More in this TOC Section
Related Articles
Cited By...
