Challenging conversations
‘You’re the doctor, whatever you say …’; we hear this phrase from time to time – more commonly from older patients. As a junior doctor I would blunder along, actioning the management plan – happy in the understanding that my patient trusted me. I should have been uncomfortable accepting that statement, as it indicates a lack of health literacy and engagement. I did not begin the challenging conversations necessary to bring understanding of both the hope and the risks involved in our intervention. It was easy to take their trust for granted.
At the opposite end of this spectrum, we increasingly encounter another patient phenomenon. This can be heard in the expressions: ‘I know my own body’ or ‘I’ve done my research’. These statements are true. People are experts in their own experience and have extensive interest and capacity to learn and understand. These factual statements might sometimes also be accompanied by a sense of mistrust towards doctors and mainstream healthcare. This mistrust can cause patient disengagement, declining of recommended care and (sometimes) adverse health outcomes. When confronted with this situation, it is also easy to choose not to engage in the necessary challenging conversation. It is easy to take their mistrust for granted.
Nowhere is this more prominent than with vaccine hesitancy. This increasing situation seems to be the result of the rarity of these preventable diseases, combined with the influence of individuals and organisations who – well-meaning or not – spread misinformation, amplified by the echo-chamber of social media.1,2 Child mortality rates have steadily declined since the advent of childhood vaccines,3 which began with smallpox vaccines being produced in Australia in 1917.4 Over a dozen diseases – once commonplace – have now become rare and unfamiliar as the program has slowly expanded to its current form. However, this trend might be changing. Recent concerning data show decreasing childhood vaccination rates.5 An alarming effect of this is that measles outbreaks are becoming frequent.6 If vaccination rates continue to fall, preventable childhood deaths are inevitable.
Patients have a right to make decisions about their bodies, and parents have a duty to make decisions that they feel are in their children’s best interests. It is human nature to disengage and become untrusting whenever one feels forced; therefore, any difficult conversation should begin, continue and end with acknowledgement of the patient’s autonomy and be guided by compassionate communication. An excellent resource for facilitating respectful, trust-building conversations – including some well-worded suggested questions founded on motivational interviewing techniques – can be found on the Sharing Knowledge About Immunization (SKAI) website.7
Another potentially challenging conversation can be when parents expect a treatment that is not indicated, or might even be harmful. An example of this is illustrated by the Royal Australian College of General Practitioners’ ‘First Do No Harm’ resource on acute otitis media, which provides useful guidelines for doctors;8 and clearly explained, persuasive resources for patients.9
The word ‘doctor’ stems from the Latin ‘docere’, meaning ‘to teach’.10 As conditions become increasingly complex, and as both information and misinformation become more prevalent and accessible, the ‘good GP’ needs to be a great teacher and an excellent communicator. As we work together towards informed choices, children and adults need general practitioners willing to begin these challenging conversations.