Five-point plan to increase the value of clinical practice

Jordi Varela
Editor

In an article recently published in Clinical Medicine, Five recommendations to increase the value of clinical practice, I proposed a plan with a view to a more valuable clinical practice and, given the timely topic, I allow myself to partly reproduce in this post. You should note that this plan does not support pilot tests or halftones, but should be implemented with a perspective of in-depth organizational change, aiming to generate an institutional profile of value and excellence.

1. Improve skills in the clinical interview

The training of physicians in the clinical interview is below the rigour required in other disciplines considered basic such as statistics, anatomy or physiology. This is a difficult training gap to understand since it’s obvious that if a doctor does not listen properly to the patient (see the post by Danielle Ofri), the clinical process will probably be biased, leading to misdiagnosis and out-of-focus therapeutic decisions. As the problem is known, there are many initiatives to improve the quality of clinical interviews. However,  improving communication skills in graduate programs is not easy, hence medical students should understand that every minute invested in listening, asking (openly) and dialogue is a time saved to achieve a valuable clinical practice.

2. Go in search of lost clinical reasoning

In 1991, Kassirer, Wong, and Kopelman published "Learning Clinical Reasoning," a work that laid the groundwork for clinical reasoning. In 2011, twenty years after the first edition, the same authors republished the book, warning that they had to update it because they saw that clinical practice was undergoing a rampant dehumanization. It seems, says the author, that today's doctors have forgotten that no evidence exceeds the sensitivity and specificity of a good medical history (see post on the subject). The point is that the current impoverishment of the diagnostic process is a powerful fact. According to a report by the National Academy of Medicine, diagnostic errors are responsible for 10% of deaths and 6-7% of adverse effects in US hospitals.

To improve the clinical reasoning situation, at Massachusetts General Hospital, Simpkin and colleagues have a plan that could be summarized as follows: a) discussion of complex cases with a tutor, b) periodic analysis of the causes of readmissions, c) promotion of clinical-pathological sessions, d) discussions on the causes of diagnostic errors and strategies to avoid them, and e) specific clinical reasoning seminars for residents.

3. Encourage shared clinical decisions making

In a systematic review, Cochrane has found that shared decisions improve patients' knowledge and perception of their clinical situation, and also help reduce traditional communication conflicts, but their progress is being very slow, if not zero (in this sense, I recommend visiting the label "shared clinical decision" in this same blog). Many physicians believe that the mere fact of maintaining an honest and open relationship with their patients is enough, but they should be aware that to reduce the inevitable superiority, certain relational skills that are not always recognizable in physicians are needed.

Given the contradictions between discourses in favour of patient-centred care and the difficulties in advancing them, many health systems propose specific plans for their development (MAGIC of the British NHS, Massachusetts General Hospital and Kaiser Permanente would be three examples). All indications are that each health care institution should develop a specific strategy to train physicians in a motivational interview and a shared decision methodology, for the sake of a clinical practice adapted to each person's way of life.

4. Reverse low-value clinical practices

A medical reversal is the need to stop performing a clinical activity because a consistent study shows that the desired results are unmet, or that adverse effects don’t outweigh the benefits (recommended to visit two posts by Vinay Prasad in this blog: 1 and 2). Through the website "dianahealth.com" you can consult 28 sources of "right care" that report on more than 5,500 recommendations of low-value clinical practices. Therefore, health care organizations now have tools to create working groups that work internally to enhance valuable activities and reverse those that don’t add value. On the other hand, when it comes to the value of clinical practices, one of the most difficult problems is the fight against routines (see two posts by Nacho Vallejo on the things we do for no reason: 1 and 2). The point is that in clinical settings we often have an attachment to traditions and many practices are performed over and over again without the necessary contrast.

At this point, it's essential to talk about the excess of bureaucracy, because, in itself, it has a negative influence on the value of clinical work. Several studies indicate that doctors are devoting more than half of their time to computer screens or to bureaucratic work of various kinds, which is proving to be one of the big burdens of medicine and a factor in generating burnout among clinicians. Melinda Ashton, an American paediatrician, recommends that each institution and each unit develop their plan to avoid useless activities, so they can focus on the clinic and, by the way, increase physicians' satisfaction with their work.

5. Encourage multidisciplinary teamwork

A clinical micro-system is a unit of work in which its professionals share values and goals, everyone believes that the activities they undertake make sense to their patients, multidisciplinary team meetings are promoted and all clinicians (doctors, nurses or other related professionals) perform their functions according to their capabilities and competencies. In hospitals it’s not difficult to observe some well-performing clinical micro-systems, despite this, two major areas resist multidisciplinary teamwork: primary care and wards. The promotion of clinical micro-systems in all areas is a Bohmer-based proposal (see Bohmer R. label in this same blog), which care managers and clinicians should prioritize, if they want to leave behind the current fragmented model.

Medicine is becoming more technical, but this would not be a problem if it were not for the fact that this industrializing dynamic is sweeping the humanistic foundations of clinical practice, which in turn takes it away from its ends and worsens its results. It will therefore be necessary to draw up plans to reverse this negative dynamic.