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I forgot to ask ...
  1. Fiona Moss
  1. Editor, Quality in Health Care

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    Simple interventions are sometimes very effective. Providing parents of children attending a paediatric neurology clinic with a sheet inviting written questions encourages many to ask questions that otherwise may not have been articulated—at least not in the clinic.1 The immediate benefits to parents, and children, whose worries were resolved are clear, but doctors also noted that parents seemed to take more initiative on subsequent visits. This approach to enabling patients to discuss questions and concerns has wide applicability. It is not a new idea—the authors refer to some of the background literature—and to an outsider it must seem staggering that the use of simple question sheets is not standard clinic practice throughout the NHS.

    This story of the introduction of an intervention that does not cost much, has obvious benefit, and probably little potential for harm illustrates two important barriers to quality improvement. Firstly, the information gap: unless we know that there is a better way of doing things then change is unlikely. Secondly, the education gap: unless healthcare professionals have the training that enables them to understand health care from patients' perspective it will be difficult for them to respond effectively to patients' expectations and needs.

    Information is one of the major currencies of health care. Patients and healthcare professionals need it, use it, and exchange it. In the past healthcare professionals—especially doctors—had an assumed monopoly on information. But that has changed: technology now allows everyone immediate access to a vast amount of information about health care, biomedical advances, and other innovations in health care. Yet the fact that large amounts of information are available does not mean that people are necessarily more knowledgeable or better equipped to use it.

    The key is to encourage the dissemination of effective information—that is, information that seems relevant to the recipients and which they can use. The principles are the same whether the recipients of information are healthcare professionals or their patients. The case for exploring and understanding the dissemination process, finding out what helps, and what is a waste of time, is made in another paper in this issue.2 We know, for example, that the provision of information alone is unlikely to be sufficient. Marriott et al show that multiple channels may be needed; care must be taken not to overload the recipients of information; the process of informing may need to be done in stages; and recipients' existing attitudes and beliefs need to be understood.

    Moreover, some kinds of information are much more available than others. Healthcare practitioners are increasingly likely to have access to information about clinical interventions, but much less information is available about the merits of organisational interventions or about simple ways of making patients' interactions with healthcare services more tolerable or about how to enable patients to get the advice and reassurance they need from their doctors.

    Many patients experience a gap between what they expect and what they get. That some doctors were surprised to find that some of the questions parents wrote on their question sheets were “biologically implausible” is revealing and suggests a gap in medical education. Biomedical science is the basis of many clinical interventions and is the cornerstone of medical education. But effective health care depends on an understanding of many other disciplines. For health care to progress and improve, those working in clinical disciplines need to be provided with the appropriate education and range of skills and competencies to allow them to meet the expectations and needs of their patients. Patients' expectations have changed, so consultations should be less about telling patients what they should do or what will be done and more about exploring and meeting their needs. Doctors should be advisors able to help to steer and address concerns rather than be sole arbiters of what is to be done.

    Knowledge alone is not enough. As the pace of change quickens and ever more effective interventions become available, healthcare professionals need the skills to be able to change their own practice and to work with others to make the necessary organisational changes to support improvements in the quality of care. The theoretical background of quality improvement comes from several disciplines, including statistics, social psychology, industrial engineering, and systems theory.3 The skills needed include the ability to aggregate outcome data, to understand work as a process, and to enter into collaborative exchange with patients; team working skills4; and an understanding of organisational development and change management.5 But these are unlikely to feature prominently, if at all, in undergraduate or even postgraduate curricula.

    Schon questioned the assumption that professional knowledge taught in schools prepares practitioners for the real world of routine practice.6 Reducing this mismatch between what is taught and the skills needed for effective practice should be a matter of priority. Perhaps the first step is to define effective practice in terms of the skills needed to meet the expectations and needs of both present and future patients. These skills, will, of course, include technical and clinical competencies and knowledge of biomedical science. But they also include the ability to help patients to express their deep concerns—however implausible—and to be able to come back and say “I forgot to ask ... ”


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