How to understand medical decisions

Traditional and written explanations

Traditionally, doctors and other health professionals have given verbal explanations alone.  It has not been common practice to provide patients with a written summary of each decision with its diagnosis and related findings as a memory aid.  This means that many patients who are on a number of treatments may not remember why each decision to treat was made.  Also, it may be unclear to other doctors what the doctor who made each original decision was thinking and the facts on which each diagnosis were based.

 

Few, if any, doctors will have the time to sit and answer all the questions about a detailed treatment plan in one go, in order that the patient or supporter can write everything down.  It might be easier for a patient to begin the process and for the doctor to make corrections and insert more information.  This might involve the doctor going through the records before completing the 'self-explanatory summary' for the patient (but most will be too over-stretched to do this). It would be better if such a summary were created or updated after each visit to a doctor or nurse in primary or secondary care.

 

Nevertheless, it is important that any new medical decision is made in the full and clear knowledge of existing diagnoses and treatments, otherwise serious mistakes can happen.  It is also important that all treatments are kept under review and stopped or modified if necessary.  A self-explanatory summary is therefore invaluable for doctors and the patients who have to understand and agree to decisions.

 

The General Medical Council (GMC) which regulates doctors expects them to involve patients in all decisions about their care.  This applies to doctors working in England, Wales, Scotland and Northen Ireland (something similar applies in all countries of the world).  This existing regulation has been re-inforced in the NHS of England by the Goverment highlighting that there should be "no decision about me without me".  

 

All doctors know how to describe the symptoms, (i.e. what the patients experienced), examination findings and test results that were used to arrive at each diagnosis and  decision.  Their ability to do this is tested verbally in every professional exam from their time as students to their advanced professional diplomas.  However, they are rarely expected to provide this explanation in writing, especially for patients.

 

Patients should be able to retain and repeat an explanation to the doctor to show that they have understood it.  If they cannot do this, then they may not be regarded as having the mental capacity to agree legally to the advice!  Doctors have a responsibility to check that patients are in a position to consent properly.  One way to ensure this is to provide a written self-explanatory summary of the kind described here.

 

The actions and decisions in a current ‘Plan’ is often built up over years (or hours in a fast moving hospital setting).  Most patients will accept each decision with its explanation at the time. However, patients, their relatives and other supporters may be not be able to concentrate because of anxiety and other preoccupations.  Because of this, they may not be able to recall the explanation within minutes let alone years later.  Such inability to retain an explanation raises questions about valid consent, especially for subsequent long term treatments.

 

If the plan is made up of a large number of actions, it will be a lot of work for one doctor to provide a self-explanatory summary covering each item with a diagnosis and its related symptoms, examination findings and test results so that the patient or supporter can write everything down.  Traditional medical records do not show these relationships (in the way that the ‘Examples’ show the relationships) so a reviewing doctor may have to work out what was in the mind of the doctor who made the original decision.

 

Until self-explanatory summaries are created automatically, the work could be delegated to panels of doctors and nurses trained to draft such self-explanatory summaries for patients and their doctors to check and agree.  There is no provision for such a service yet.

 

© Huw Llewelyn 2016