B.A.R.D. in the Practice

A Guide for Family Doctors to Consult Efficiently, Effectively and Happily

Ed Warren

• Publisher: CRC Press
• Year: 2018
• ISBN:
  9781315345291
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Forewords by Mayur Lakhani, Mike Pringle and Philip R Evans Respectively Chairman of Communications and Publishing, Royal College of General Practitioners, London; Head of School and Professor of General Practice, University of Nottingham; Former President of WONCA Region Europe. This groundbreaking book describes a completely new approach to the medical consultation, focusing on four key points: Behaviour, Aims, Room and Dialogue (B.A.R.D.). This practical approach has gained support from the Royal College of General Practitioners and reflects the way real family doctors consult in the real world, to the benefit of both the practitioner and the patient. Practical suggestions are made throughout the guide, with training exercises to aid in application. B.A.R.D in the Practice provides important reading for all general practitioners and general practitioner registrars.

Chapter 1

An introduction to BARD

We’ve come a long way

Family doctors should really feel very proud of themselves. The rate of improvement in the standard of primary care consulting is nothing short of remarkable. A patient of the 1950s would scarcely recognise what goes on today. The science has changed – there are now many more treatments available from primary care for more conditions, and also more reasons to refer patients to hospital for increasingly sophisticated investigations and procedures. There is more emphasis on prevention and chronic disease monitoring than ever before. Patients spend more time in each visit to their family doctor in order to accommodate the extra things that now go on in a normal primary care consultation.

Another change that the patient of the 1950s would notice is the increasing trend for family doctors to work in teams, and the organisational changes that this has required. In the past, where a family doctor worked at all with non-medical people, it was on the assumption that the family doctor was in charge and told the others what to do. Now, in contrast, family practice could not survive without teamworking, and nearly all family doctors accept that in many instances a nonmedical team member is the best person to provide the service. In the UK, most out-of-hours care is delivered by workers who have nothing to do with the patient’s family doctor practice. Most preventive work and an increasing amount of urgent work is dealt with by nursing colleagues, and more consulting is going on over the telephone and the Internet.

Yet despite these considerable structural alterations, the major change that the patient of the 1950s would notice is in the attitude and behaviour of their family doctor.

• Fifty years ago, medical paternalism was considered to be a legitimate consultation strategy. Patients had a duty to do as they were told by their family doctor, and nearly everyone was familiar with phrases like ‘doctor’s orders’ and ‘doctor knows best’. ‘Poor compliance’ was the phrase used for patients who would not do as they were told and did not take their medicines properly. The case is now firmly established for patient empowerment – many (but not all) patients are most content when they are active and informed participants in the planning and progress of their care.¹
• In 1976, Byrne and Long found that many consultations never got to first base – the family doctor never found out why the patient had come – and showed how inflexible most family doctors were in using their consultation skills.² A mere three decades later, all family doctors in training in the UK have their communication techniques subjected (on video) to the closest external scrutiny. The major UK postgraduate family doctor qualifications all require candidates to be assessed on their consulting skills.
• The currently established ideas about what constitutes a good consultation have almost all been developed in the last 30 years or so. Considering the antiquity of the medical profession, this represents a staggering effort by family doctors to learn new skills (and discard old ones) in order to improve the quality of their performance.

Changes of such speed and magnitude might be expected to have a distressing effect on primary care patients, especially on those who use the services a lot and who have memories of how things used to be. However, this has not happened. Taking the UK as an example, a MORI survey in 2004 reported that 92% of the public trusted doctors to tell the truth and were satisfied with the way that doctors do their job. These figures were higher than for any other professional group, and higher than they were in the previous survey in 1983.³ Further evidence comes from the data on complaints. In the UK the number of complaints about doctors has certainly risen in recent years,⁴ but still only a tiny minority of family doctor consultations result in a patient complaint. It is a tribute to the skills of workers in primary care that they have been able to achieve considerable change and at the same time kept the goodwill of their patients.

The challenges

Ideas about primary care consulting continue to develop. As new ideas emerge, so family doctors must adjust their consulting performance. They have shown themselves to be ready and willing to respond to such challenges. It would be wrong to think that the observed changes and improvements in family doctor consulting skills are just a reaction to changing political, social and organisational circumstances. The most important engine driving forward developments in family doctor consulting is the fact that individual family doctors want to improve, to ‘do it better’ next time.

Changing social attitudes towards professionalism and professional groups necessitate new consultation skills. The medical profession is no longer regarded as what Goffman termed in 1959 a ‘sacred team’ immune from criticism.⁵ It is no longer acceptable for medicine to be closed and internally regulated, without outside scrutiny. Changing social realities inevitably lead to changes in the way that family doctors are accredited as being fit to practise. This is not a challenge just for medical professionals – many other professional groups are obliged to cope with very similar problems. However, if family doctors are no longer members of a ‘sacred team’, immune from criticism, then the power relationships (the relative authority in the relationship as perceived by the participants) within individual consultations alter, and family doctors must adjust their performance accordingly.

Changing attitudes towards the rights of consumers of services also present consulting challenges. Patients and society at large are ever more vociferous about what they want and expect from a family doctor consultation. The promotion of clinical guidelines (and in some instances their production) by authoritative bodies such as governments provides a framework of standards that patients can expect by right. If her patient’s cholesterol or blood pressure is not in the target range, a family doctor can expect that patient to be banging on the door and asking why. People generally expect to be satisfied when they are consumers of a service, and will not be automatically content with what they are given. They are less prepared than in the past to tolerate rudeness or a sub-optimal clinical performance, and are more likely to complain when offended.⁴ Of course family doctors (with a tiny number of dishonourable exceptions) do not go out of their way to behave badly or provide poor clinical care, and never have done so, but they must now reflect more carefully on the consequences if their performance is perceived to be not up to the required standard.

Developments in technology present consulting challenges. If more consultations are to take place by telephone or over the Internet, then skills appropriate to such developments need to be learned by family doctors. The authority of the medical profession has traditionally depended (in part) on doctors knowing more about medicine than their patients. However, medical information is no longer exclusive information, and is potentially accessible to anyone with a modem. The extent of medical information also makes it abundantly clear that no doctor can possibly know everything there is to know. An extra problem for family doctors is that the specialised knowledge of family medicine, and the special qualities of the generalist, although vital to the success of healthcare delivery, are still often considered the poor relations of all the sexy things that go on in hospitals.

Organisational changes within primary care require new consulting skills from family doctors, and the pace of organisational change shows no sign of slowing. Where nurses provide more first-up patient care, the family doctor has to assume a role as a second-line practitioner and second opinion. Her consultations will be concerned with more complex medical problems, the ones that the nurse has not been able to deal with. Sometimes she may need considerable powers of diplomacy to sort out situations where there has been a problem with the nurse-patient interaction. It is not at all clear that traditional consulting methods will be appropriate to deal with such changes. The work of the family doctor of the future will certainly be more intensive, and it is debatable whether she will be able to sustain the quality of her performance for the number of hours of the traditional family doctor’s working day.

Organisational changes that superficially appear to be patient-friendly are also not neutral in the consulting challenges they can present. Primary care should be readily available to those who need it, but it is often only possible to make an assessment of whether a patient’s ‘want’ was just a want or a need after a consultation. Patients consult a doctor when they are concerned about something, and it is the doctor’s job to translate that concern into a diagnosis and management plan. Thus better attention to patient need is usually interpreted as shorter waits to see a doctor. Such a process means either having more available family doctors (which for many practical reasons is not going to happen, and certainly not quickly), or offering patients a consultation with a non-doctor – a process that presents its own challenges (see above). If patients present with their illnesses at an earlier stage, then primary care workers need to get better at recognising and managing those illnesses at an unfamiliar earlier stage. If a primary care consultation is more readily available, it may be regarded as less important by patients, further altering the power relationships within the ensuing consultation. The consultation techniques that family doctors use depend in part on the authority they have in relation to their patients. If this balance is disrupted, it is not certain that those same techniques will continue to work.

Healthy solutions

It is tempting to seek solutions to new challenges by doing more of the same – by the expansion of tried and tested methods. This is the Boxer approach to problems (the horse from Orwell’s Animal Farm) – ‘I will work harder’. It didn’t work for Boxer and it is unlikely to work for family doctors. When a significant challenge presents itself, it is often necessary to go back to basics to find a solution, and not be limited by how things have always been done. Such a ‘root-and-branch’ review is not always needed, but such an option must always be on any agenda for change.

Any solutions adopted by family doctors for their problems must not jeopardise their own health and well-being. A family doctor who has retired early, is off sick or is dead is unlikely to deliver good care. The track record is not very good – the mental health of family doctors in the UK is reported to be poor, significantly worse than the average for the general population,⁶,⁷ and (intriguingly) also significantly worse than the average for the patients for whom they are caring. Family doctors spend a lot of their time consulting, probably more time than on any other single professional activity. The consultation is also central to the care delivery process, the job for which all family doctors have been trained. Each consultation should be a source of intellectual and professional satisfaction and self-esteem for a family doctor. It need not and must not be just another reason to feel guilty and frustrated.

Consultation models

A number of authoritative, elegant, well-researched and thought-provoking consulting models are available – a ‘toolbox’ of valuable insights into the dayto-day experience of work as a family doctor. Some of the more comprehensive consultation models are published as assessment devices. Because they are comprehensive, these models are more likely to be aspired to by family doctors (even if they are not being formally assessed), and provide a benchmark against which family doctors will inevitably measure themselves. The fact that they are designed for assessment purposes does not mean that these are any less important as consultation models.

The most widely used consultation model for training and assessment in UK family practice is the one implied by the video module of the examination for Membership of the Royal College of General Practitioners (MRCGP), a model which is also used for Membership by Assessment of Performance (MAP) and Fellowship by Assessment (FBA) (see Appendix 1.1 for details of this model). The model is derived from the suggestions for teaching consultation skills through the use of video contained in The Consultation: an approach to teaching and learning by Pendleton et al.⁸ Like many of the other models in widespread use, it is primarily ‘task based’ in so far as it sets out a list of things that family doctors ought to be able to do when consulting.

All consultation models must be considered as ‘work in progress’. Skill...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Forewords
• Preface
• Acknowledgements
• Note on the text
• 1 An introduction to BARD
• 2 The role of a family doctor
• 3 ‘B’ is for behaviour
• 4 ‘A’ is for aims
• 5 ‘R’ is for room
• 6 ‘D’ is for dialogue
• 7 Training for BARD
• 8 The ethics of BARD
• Index