All that training suggests doctors should know best | Letters

As a team of physicians and social scientists studying how choices are made during consultations, we were disturbed to read that the Royal College of Surgeons agrees with Lady Hale that doctors should not be making treatment recommendations (Report, 27 October). While a “paternalistic” approach is clearly inappropriate for the 21st century, decades of health communication research point to shared decision-making as the best alternative. This is categorically not the same as the “information-only” approach advocated in the new guidance, which requires doctors to withhold their views even when they have good grounds for making a recommendation, and even when the patient asks for one.

In our research, we found numerous problems with the enactment of patient choice, including patients not knowing how to decide, patients seeking the neurologist’s recommendation when it was not offered, and the near impossibility of providing information in a fully neutral fashion. Moreover, we found that there was no evidence that being offered choice was associated with higher levels of patient satisfaction.

Patients vary widely in their knowledge, preferences and decision-making capacity. Part of enacting shared decision-making is to work sensitively with the patient to establish what role they wish to play at that particular time. Certainly, patients should be given clear, balanced information about the range of available options, and the potential risks and benefits of each. But imposing choice on patients who do not want it is just as paternalistic as insisting that they follow doctors’ orders.
Dr Paul Chappell Department of sociology, University of York
Professor Roderick Duncan Associate professor of neurology, University of Otago, New Zealand
Dr Clare Jackson Department of sociology, University of York, UK
Professor Markus Reuber Professor of clinical neurology, University of Sheffield
Dr Merran Toerien Department of sociology, University of York

• It is clearly right that patients are given all the information they need to make a decision concerning their treatment options, but could I have the temerity to suggest that, quite often, doctor does know best? It would be a matter for concern were it not so – we are trained for 12 or more years at taxpayers’ (and, increasingly, our own) expense, and if we didn’t know more about illness and its treatment than the patient, all that money would have been wasted.

Some decisions are so complex that it is not possible to give the patient sufficient insight and knowledge to be able to choose between two courses of action. To fail to take a decision on their behalf in that situation would be an abdication of responsibility, and a betrayal of their trust.
Dr Bob Bury
Leeds

• Re your article (Leading doctors list dozens of procedures that ‘give no benefit’, 24 October), the Academy of Medical Royal Colleges research is a welcome contribution to the debate about the pressures faced by doctors daily. The headlines, however, focus predominantly on the 40 specific treatments and procedures the AMRC consider should no longer be in routine use, when perhaps we should be looking at what underlies GPs’ decisions on their use.

In the study, about 60% of doctors said their decisions were driven by a fear of litigation. A similar proportion said interventions were a result of increasing pressure and expectations from patients. I would argue that these statistics are in fact the most striking and concerning, and they concur with our own research. A survey of 600 GP members showed 67% are fearful of being sued – and of those, 85% say this fear impacts negatively on the way they practise. Furthermore, 86% of our members said they sometimes, most of the time or always encounter challenging experiences with patients when they do not provide the prescription, treatment or referral to a specialist they request.

This paints a clear picture of the increasingly challenging environment in which doctors are working, and highlights the need for doctors to understand and be supported on how to manage patients’ expectations. When expectations are not met, it can lead to dissatisfaction, a breakdown in trust and a greater risk of the patient pursuing a complaint or claim. This is an important debate for all in healthcare today, and for society as a whole.
Dr Pallavi Bradshaw
Senior medicolegal adviser, Medical Protection

• Polly Toynbee (Our nurses are being cast into a perfect Brexit storm, 25 October) suggests cuts were made to the trainee nursing workforce by Health Education England. In fact HEE has increased adult nurse commissions significantly in the past three years. Since our establishment, we have grown adult nurse training places by almost 15%.

Decisions were made in the system prior to HEE’s creation to reduce nurse commissions. Our priority has been to grow this vital workforce and can been seen in our published Workforce Plan for England.

Although our remit is primarily for the future workforce, we have also taken decisive short-term action to help the service. Our return-to-practice campaign has already secured on programmes a further 1,900 nurses. The new nursing associate role and more flexible training pathways into nursing will help to support the service. We are also working with NHS partners to reduce turnover and improve retention in the existing nurse workforce.

Our aim is to make sure that future patient needs are met and that we have enough people with the right skills, values and behaviours available.
Professor Ian Cumming
Chief executive, Health Education England

• Join the debate – email guardian.letters@theguardian.com

All that training suggests doctors should know best | Letters