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Education

Creative consulting: why aim for it?


David Reilly explains why you and your patients will miss out if you don't

By: David Reilly Published: 01 October 2001 DOI: 10.1136/sbmj.0110364 Cite this as: Student BMJ 2001;09:357398

The editorials linked to this series listed reasons for becoming more aware and skilled in your consulting.[1] [2] If you have decided to do this then use this article to revisit and reflect on these reasons, preparing the ground for the later articles which will help you consider how. Human impact can sometimes have more effect than technical skills or interventions, and can change the effects of those interventions. So let us revisit reasons for studying this.
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It is happening already--so wise up


You cannot have meeting without impact--you would be better to make it creative and successful. Let your patients teach you. Have a look at the quotes in box 1 captured in a clinic when I asked people about their previous care. They can tell us what changes we need as individuals, and at a system level. Some examples of formalising this with qualitative research will be explored later.
Box 1: Patients as our teachers

See a different doctor at each visit. I feel rushed. And unlistened to. Only seem to prescribe drugs. Ignore me as a person, more interested in my disease. Try asking your patients at the end of your consultations, How was our meeting, how could I have done this better? In a long meeting ask in the middle, How do you feel about this meeting, is it going okay? As a student you also have the advantage of asking patients about consultations you have just observed.
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It's humane, which is what patients and carers want


People are feeling that medicine has lost its way, becoming overtechnical, even dehumanised. Placing patients and our humanity before disease helps restore the perspective. Do the patient quotes in the box matter? Could you end up treating someone that way? Perhaps you or one of your loved ones have had such experiences? Too many people have. Despite medicine's increasing technical excellence more and more people in the West (around 40% a year) are seeking complementary or alternative medicine,[3] and often they say what they valued most were the human factors of listening, time, and touch--human caring. What will you need to do not to fall into the dehumanisation trap? Try studying the carers around you and identify whose in, and who has escaped, the trap and learn from both groups what you will need to do. Cross reference this to the patient questions mentioned

above. Some of the dehumanising factors may be beyond your influence for now--they are cultural and structural-but some are very much in your control. Medical education is improving, but your fellow students' view in box 2 suggests that it is you and not your curriculum that must supply the motivation and much of the skills that you will need. Day to day life, not medical training, is your best teacher. The downloaded full report of the special study module on human healing from Glasgow University might interest you.[4]
Box 2: Students' views

Students are taught the science of medicine and how to ask questions to gain information, to perform basic practical procedures, and to use high tech investigations to gain yet more information. But are they taught the basic skills of human interaction? Are they shown how they can use their greatest resources--themselves--to facilitate human healing? If they do not have these basic skills how can they hope to use orthodox or complementary and alternative medicine to beneficial effect? Remember your challenge as a professional health carer is often to relieve suffering on those many occasions when cure is not possible or is limited--keep considering how will you do that.
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It is enriching
Patients, students, and carers say that when the human side is valued, medicine gets more rewarding. You might think that having to be more human is just an added burden to the technical job. However, the opposite seems true. Real human contact seems to nourish us and stop burnout. Have a look in box 3 at the effects a course which explored a holistic approach had on established GPs and think what they must have been like before the course.[6] The course was on homoeopathy but it could have been a 100 other things.
Box 3: Responses to holistic approach course

Listen more/less dismissive. Relearnt history taking. Now find patients' expectations for antibiotics, etc, difficult. More aware of natural healing. More broadminded. Now see patients as a whole, not at a cellular biochemical level. Rekindled my interest in clinical medicine. Find practice richer and more fascinating. I marvel at my lack of knowledge. How did I manage without it?
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It is creative
Making good contact and then working it towards a good outcome can be one of the most rewarding and creative parts of the job, but it takes as much effort and practice as learning a musical instrument or sport. It gives the more artistic and creative side of us a place in our work. Do not fall into the science only trap. You can learn to combine both art and science--a sort of artience of medicine. Have a look at the studies stemming from

psychobiologist Roger W Sperry's Nobel prize research on the different modes of thinking of our right and left hemispheres.[7] For a practical exploration of these art and science modes you could look at Betty Edwards's book on enhancing creativity where you can learn how to draw in five days.[8]Perhaps we could wake up similar processes in learning to consult.
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It is our responsibility
The General Medical Council has condensed a doctor's duty down to 14 points (see box 4).[9]Notice that all 14 involve your human skills and only two or three emphasise technical knowledge or skill.
Box 4: Duties of a doctor

Patients must be able to trust doctors with their lives and wellbeing. To justify that trust, we as a profession have a duty to maintain a good standard of practice and care and to show respect for human life. In particular as a doctor you must:

Make the care of your patient your first concern. Treat every patient politely and considerately. Respect patients' dignity and privacy. Listen to patients and respect their views. Give patients information in a way they can understand. Respect the rights of patients to be fully involved in decisions about their care. Keep your professional knowledge and skills up to date. Recognise the limits of your professional competence. Be honest and trustworthy. Respect and protect confidential information. Make sure that your personal beliefs do not prejudice your patients' care. Act quickly to protect patients from risk if you have good reason to believe that you or a colleague may not be fit to practise.

Avoid abusing your position as a doctor. Work with colleagues in the ways that best serve patients' interests. In all these matters you must never discriminate unfairly against your patients or colleagues. And you must always be prepared to justify your actions to them.
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You get better results--and become a broader scientist


There is a medical macho myth about real science. It says, We don't have time for all that soft touchy feelie stuff, and it doesn't matter any way because getting the correct scientific treatment is real medicine. In fact, if you fail to establish an alliance and trust based partnership with your patients you will get worse results, and more side effects (more on this later). Even the hard scientist in us has to take account of human dimensions if we want to be scientific. Science takes many forms. You can measure enablement after consultations (the patient feeling better informed and empowered and now feeling better able to cope and move forward) and see how this

varies significantly between doctors. It is highest when the patients feel that they know the doctor and when more time is taken.[10] So think about what makes you feel you know someone well. Don't set up a brick wall in your imagination by thinking it always needs a long time--how long does it take you to feel if someone is really interested in what you are saying to them? Perhaps there is a hint for us from another study where enablement was strongly linked to the level of empathy the patient experienced. In 200 cases there was not one instance of enablement without empathy. Yet empathy was not enough to guarantee enablement.[11] So what do you need to do to develop good relationships and empathy? Fortunately, the ability is in built, so keep your eyes and ears (and heart) open for inspiration. Later in the series you might pick up some hints, and we will see how such human factors can then affect the subsequent impact of any medicine prescribed during your consultation. The double blind controlled trial is not a great tool when looking at genuine warm human caring, but one review of 25 randomised controlled trials, which examined the effects of human care interactions on outcome, including studies comparing the effects of positive and negative or neutral consultations, found that only studies combining emotional care with cognitive care seem to have made a positive difference.[12] In one such study a GP randomly assigned 200 of his patients with self limiting problems to a positive or negative encounter with him.[13] Two weeks later, 64% of the positive group, but only 39% of the negative group, reported that they had got better --less than would be expected to resolve spontaneously by then, suggesting the negative encounter had adverse effects. Watch out for examples of such encounters (sadly you will not have too look too hard). Some work suggests that good therapeutic alliance can reduce wasteful use of healthcare resources and the over-reliance on drugs. As you study your teachers, wonder what they would have to offer if their prescription pad was removed. Perhaps they would do less harm.
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You might do less harm


People are worried about side effects--it is a big reason for the rise of complementary and alternative medicine. Serious adverse drug reactions cause alarming problems in Western medicine--it was estimated in 1994 in the United States that 2.2m hospital patients had serious adverse drug reactions and 106000 had fatal reactions, making these reactions between the fourth and sixth leading cause of death in America.[14] So helping patients whenever possible to find better ways than drugs to deal with their problems will be a critical skill for you. Your consultations are your main way of achieving this. But did you realise that your encounters can produce side effects? You have heard about placebo responses (when people react to dummy tablets and the like)--but perhaps not about nocebo responses--adverse placebo effects? Negative messages can have negative impact--for example, placebos can produce pain in normal subjects. Headaches were reported by 70% of students told that a (non-existent) electric current was passing through their heads.[15]Medical voodoo curses.
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It is more scientific
There is interesting research into how meetings and their context, ritual, content, and meaning to the participants all have an impact. Here nocebo and placebo research is worth studying for the insights it brings to healing reactions. Medical students are good subjects for these studies--they found two placebo capsules to be stronger

than one, and injections produced larger effects than pills. Larger capsules tend to be viewed as stronger, yellow capsules tend to be viewed as stimulants or antidepressants, and white capsules tend to be perceived as analgesics or narcotics.[16] [17] So symbolism has medical impact. And it is not just the patients' expectations and experience that counts. Your confidence in your own treatment can transmit itself to people and change the physiological response to your prescriptions--turning on or off the healing reaction in people.[18]
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Because there is a mind and body link


It is artificial to separate the treatment, the patients' physiology, and the patients' feelings and inner experience. And then you become an added active ingredient in the mix. Ballint spoke of the doctor as a drug and helped sow awareness of these effects in today's general practice,[19] but perhaps it is time not to be so drug fixated, perhaps it is time to think of the doctor as a doctor having therapeutic effect. The emerging field of psychoneuroimmunology is studying how our feelings are wired into our bodies and change our susceptibility to illness and recovery--for example, people undergoing bereavement show depressed responses in their white blood cells,[20] which may partly explain the observations that people who are under stress or dispirited show increased illness and poorer recovery. Take heart disease--there is more disease, worse progression, and poorer survival among men with high levels of hopelessness.[20] [21] Your job as a carer and a scientist is therefore to consider not just the disease in the artery, but whose artery. We will look at this link in more depth later in the series.
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You will make an ally of the patient's self healing


Healing responses are innate to nature. Often everything hangs on them; when they are fatally weakened even the best of all indicated interventions will fail. Study then directly--what enhances them, what inhibits them?[22] We ignore them at our peril (or rather our patients' peril). Too much of our thinking is focused exclusively on blocking disease reactions in the body, not enough on strengthening the opposing forces. The therapeutic encounter influences those forces.
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You will do yourself some good


Your risk of burn out seems to increase if you have no real satisfying contact with your patients--so learning to make rapid relationships is a self protective skill in a busy and pressured environment. And this works the other way, the less burnt out you are the more effective you will be--so the question of self care becomes central. How is yours? I welcome your ideas, feedback, and questions and they will help shape the series as it develops.
David Reilly, lead consultant1

Correspondence to: davidreilly1@compuserve.com

References
1. 2. Reilly D. Creative consulting--you can make a difference. Student BMJ 2001;9:30910. Reilly D. Enhancing human healing. BMJ 2001;322:1201.

3.

Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbance TL. Unconventional medicine in the United States. Prevalence costs, and patterns of use. N Engl J Med 1993;328:24652.

4.

Report on a special study module for medical students, Glasgow University. Human healing: perspectives, alternatives and controversies. Bryden H, ed. Glasgow: ADHOM, 1999.www.adhom.org.

5.

Owen DK, Lewith G, Stephens CR. Can doctors respond to patient's increasing interest in complementary and alternative medicine? BMJ 2001; 322:1548.

6.

Reilly DT, Taylor M. Review of postgraduate education experiment in developing integrated medicine. Report of the RCCM research fellowship Glasgow University. Complementary Ther Med 1993;suppl 1:150.

7. 8. 9.

Sperry RW. Hemisphere disconnection and unity in conscious awareness. Am Psychol1968;23:72333. Edwards B. Drawing on the right side of the brain. London: Souvenir Press, 2000. General Medical Council. Good medical practice. Duties and responsibilities of doctors. London: GMC, 2001. www.gmcuk.org (accessed 7 Sep 2001)

10. Howie JGR, Heaney DJ, Maxwell M, Walker JJ, Freeman GK, Rai H. Quality at general practice consultations: cross sectional survey. BMJ 1999;319:73843. 11. Mercer SW, Watt GCM, Reilly D. Empathy is important for enablement. BMJ 2001;322:865www.bmj.com/cgi/content/full/322/7290/865 12. Blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J. Influence of context effects on health outcomes: a systematic review. Lancet 2001;357:75762. 13. Thomas KB. General practice consultations: is there any point in being positive? BMJ1987;294:12002. 14. Lazarou J, Pomeranz BH, Corey P. Incidence of adverse drug reactions in hospitalised patients: a meta-analysis of prospective studies. JAMA 1998;279:12005. 15. Schweiger A, Parducci A. Nocebo: the psychologic induction of pain. Pav J Biol Sci 1981;16:1403. 16. Blackwell B, Bloomfield SS, Buncher CR. Demonstration to medical students of placebo responses and non-drug factors. Lancet 1972;13:111. 17. Buckalew LW, Coffield KE. An investigation of drug expectancy as a function of capsule colour and size and preparation form. J Clin Psychopharmacol 1982;2:2458. 18. Gracely RH, Dubner R, Deeter WR, Wolksee PJ. Clinicians' expectations influence placebo analgesia.Lancet 1985;i:4. 19. Ballint M. The doctor, his patient and the illlness. Tunbridge Wells: Pitman Medical Publishing, 1964. 20. Schliefer SJ, Keller SE, Camerino M,Thornton JC, Stein M. Suppression of lymphocyte stimulation following bereavement. JAMA 1983;250:3747. 21. Everson SA, Kaplan GA, Goldberg DE, Salonen R, Jukka T. Hopelessness and a 4-year progression of carotid atherosclerosis: the Kuopio ischemic heart disease risk factor study. Arterioscler Thromb Biol 1997;17:14905. 22. Glassman AH, Shapiro A. Depression and the course of coronary artery disease. Am J Psychiatry1998;155:411.

Cite this as: Student BMJ 2001;09:357398

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