Matthew Mezey's activity
In group: Primary Care
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Matthew Mezey posted an update in the group Primary Care 3 years, 2 months ago
I’m not involved in Primary Care (but work on Q’s central staff team), so didn’t know what to expect before the fabulous Zoom session @rammya-mathew organised with @william-eric-bostock yesterday.
It certainly made me think, as you can see from this (long!) post…
Will’s rich and deep account of treating the whole person, and catalysing a personal journey of growing change and self-responsibility in (some) patients was certainly unexpected, and rather inspiring. Even if changing someone’s worldview is ‘not an easy therapeutic target’.
For me it had resonances with Edgar Schein’s later books such as ‘Humble Inquiry – the gentle art of asking instead of telling’ and ‘Humble Consulting – How to provide real help faster’.
Schein has moved further and further away from the conventional ‘Diagnostic’ organisation development and change approach and towards the emerging ‘Dialogic’ OD.
For him ‘personalisation’ is key, the consultant and client starting to treat each other as persons, not roles – and revealing more-personal thoughts or feelings. (Going into doctor role is fine if the problem is simple and clear, not if it’s complex and messy).
I had kind of been expecting Will to talk about a neat technical fix of using podcasts as a way to supplement the limits of a 10-minute GP consultation. It did still do that, but so much more as well.It’s obviously been quite a journey for Will too, as he moved from A&E to become a GP – and soon left behind the pre-conception that GPs are simply ‘A&E in the community’!
He also realised he was not just a doctor, but a patient too – and needed to practice what he preached.
He would eventually be so present for his patients that he was almost ‘seeing into their souls’, feeling *with* them. There were often tears.
Will shared his view that he was using ‘mentalisation’ (Peter Fonagy) and was growing ‘Epistemic trust’. I don’t know those labels/models.
It seems to me that what he has started to do demands an uncommon level of psychological maturity from the doctor.
Interestingly, research based on Prof Jane Loevinger’s work on adult ego maturation stages has found that doctors with a higher ego maturity show greater clinical effectiveness. And research with Counsellors has found that ego maturity limits how they are able to learn and behave with clients. (Interestingly, the pioneer of ‘Dialogic’ OD Dr Gervase Bushe suggests that a higher level of ego maturity is needed to be able to successfully practice the emerging ‘Dialogic’ approaches well. Gervase may be doing some Zooms for Q at some point).
As I mentioned in the chat, the journey Will seemed to have gone one and to now be catalysing for some patients was one of building their own (health-related) ‘self-authorship’, a sort of inner compass to guide them. Building self-authorship is an underlying goal for many people in their 20s and 30s. Prof Marcia Baxter Magolda’s book ‘Authoring Your Life – developing a internal voice for navigate life’s challenges’ is good on this, and talk about the characteristics of supportive ‘Learning Partnerships’.
These were my thoughts.
What did you think?
I can’t help wondering whether Will’s day-to-day practice is ahead of his explanatory theory for his practice – at least I’m not sure Fonagy’s work around attachment, mentalisation, children, borderline psychopathology is the most relevant body of theory for what Will is doing. Neighbouring theories like adult Ego Development are just as useful. And plenty of others too.
If we did decide on a definite theoretical model for this deeper dialogue with patents that Will now pursues, I’d love to know whether clinical outcomes are improved by accessing such a deeper quality of connection. It doesn’t seem unlikely – there’s plenty of recent research, for example, showing the positive (clinical) impact of higher levels of ‘Relational Co-ordination’ in healthcare settings, including Primary Care (Jody Hoffer Gittell). In fact, Q may hear from Medical Director Claire Kenwood, a Q member who’s used Relational Coordination, along with others, at some point.
NB We will share the recording of Will’s Zoom soon…
Thanks @matthewmezey for these really rich insights. Have you got a background in philosophy/ psychology? I really enjoyed Will’s talk too. I actually felt that the way Will felt with respect to consulting in primary care was very relatable. All too often we reach out for a prescription pad knowing that it’s not going to be a long term solution to our patients problem, but it’s all we can bring ourselves to do within the constraints of the 10 or so minutes that we have. But I would hypothesise that if we were able to invest this time, perhaps with an IAPT style intervention like Will suggested, our patients would be healthier and happier and feel more in control of their health and wellbeing.
I also reflected back to Joanna’s talk – because practising mentalisation isn’t easy in the general practice setting, but it’s probably not necessary for all our consults. If we design systems that allow us to identify patients ahead of time, that need continuity, need more of our time, and really need us to be present, then we are more likely to be able to do this successfully. As opposed to us trying to do this, in a non descript surgery where we have no idea of what the patient mix will be like. So I think it’s about marrying systems with an emotionally mature consulting style, and also having the assets within the community that will then allow our patients to do the mindfulness, the healthy living etc.
With a research hat on, what I’d love to see is Will randomly choosing which patients get the deeper connection from him and which get something more standard. Does the deeper connection lead to higher ratings on the ‘Patient Activation Measure’ (PAM) or not? And does higher PAM lead to clinical improvements (though that’s probably being researched in various other places already).
Slightly more difficult, perhaps – would be great to see a conversation analysis of the deeper consultations vs standard ones. Is the amount of advocating and interrupting reduced – and more inquiring taking place? (I’ve seen this done with surgical teams, but GP consultations must have been researched too).
It certainly seems like it could be valuable to know a patient is coming with a more simple, technical problem vs a more complex one – as different approached are presumably needed, as I think you’re saying. That said, you can argue that anything involving humans is probably messy and complex, in reality. Never technical. (Although the NHS is basically set up for technical!).
I certainly have an interest in psychology, and philosophy to an extent, Rammya – particularly more integrative approaches that try to bridge multiple (competing) approaches.
Really looking forward to seeing /hearing the recording! Have to admit that I’m not familiar with any of the literature you mention Matthew but it all sounds quite relevent to the mission of encouraging self-management, shared-decision making and person centred care.
The work around relationship-centred care and Relational Co-ordination that Jody Hoffer Gittell, Edgar Schein and Anthony Suchman are involved in certainly feels very relevant to this.
Recording should be coming round on Wednesday, I think…
Thank You Matthew and Rammya for your thoughtful comments. It has certainly given me a lot to think about. I have not come across the work you mention Matthew, I will add it to my (ever increasing) reading list. It certainly does sound like a similar approach. The sentiment about personalisation and not treating each other as roles certainly resonates.
I suspect that many of these models are attempts to describe the same existential ideas. Fonagy points out that there are 1246 different types of psychological therapy, but the “active ingredient” is probably the same for many (mentalization, epistemic trust, and as a result improved ability for the patient to learn and adapt within their own social environment). This is mirrored in Transactional Analysis education theory, and the concept of “encounter” as a prerequisite for learning.
In some ways, these ideas don’t easily lend themselves to scientific enquiry. We are straying into existential concepts of love, beauty, connection, and higher meaning. These are not often considered viable tools for scientists. Perhaps we can better learn about them from a Dostoevsky novel than from formal research. If we read a PHD thesis on humour it may not itself be very funny, and we might have learnt more from a night at a comedy club.
I can see this is inadequate when asking for funding from the CCG, and perhaps that is why this work mostly happens on a personal level. I suspect it is the same resource that the “Improving Joy in work” SIG are trying to tap into.
It is interesting you mention the PAM score. I was just discussing this yesterday with a pain clinic consultant who is proposing using PAM to stratify which patients are likely to respond to their pain intervention programs.
I could see this work being used as a tool for “priming” patients in primary care so they can get the maximum benefit from secondary care input. I think PAM could be a viable outcome measure pre and post a structured podcast based intervention.
Thanks so much for sharing your insights Matthew; a very sophisticated (and actually very affirming; thank you) external view of the many facets of the role of a GP – the dialogic sitting above the purely diagnostic.(I must watch back the recording) Those insights point to some of the fundamental differences between hospital-focussed clinical practice and the community focus: transactional care vs relational care.
Many GPs do not even realise that they see the world differently to their hospital colleagues (the transition is insidious perhaps) but the principles that underpin their clinical practice have different ontological and epistemological foundations.Several years ago I heard a Professor of Family Medicine from USA say that when she was an undergraduate student she realised that she didn’t just want to a good doctor, she wanted to be “somebody’s doctor”; that is a profound self-realisation.
Of course it is not only the preserve of GPs and Family Physicians; I recall what you referred to as the ‘with’ was also referred to by Paul Kalinithi (a neurosurgeon) in his book “When breath becomes air”, that there was something of profound value beyond the ‘transaction’.
An old text which will be familiar to many GP Trainees but which, I suspect, few have actually read is ‘The Inner Apprentice’ by Roger Neighbour (mentioned here https://www.bmj.com/content/337/bmj.a1574.full); I would recommend it.
Many of the ‘lost in translation’ understandings between Primary and Secondary/ Tertiary care perspectives go back to the way we teach / learn medicine and if you are really interested in some of the roots of this I refer you way back to the Flexner Report (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3178858/) which established the ‘Biomedical’ model as the dominant narrative in medical training – we teach about diseases, pathologies, aetiologies, treatments etc, too leaving the person out of the discussion altogether. Medical education in recent times has been parsed further into ‘learning outcomes’, competencies and ever-more granular end-goals.
People will often say that GPs are interested in the Bio-Psycho-Social; not always noted out of respect. If you fancy an examination of difference perspectives you may be interested to read this by my colleague Dr Jenny Johnston: https://onlinelibrary.wiley.com/doi/abs/10.1111/medu.13758
Why is all of this of interest in a chat group regarding QI in Primary Care? I have been leading a QI training programme for GP trainees in Northern Ireland for the last 5 years; we call it EQUIP. It has been rewarding in many ways but truthfully it has been uphill, not because of the trainees but because the GP Trainers fundamentally don’t get it (especially the more experienced GPs) and I wonder if this lack of resonance may have it’s roots in those paradigm differences as the QI models have their roots in largely hospital settings.
The dominant QI models and tools being advanced by IHI, Health Foundation, RCGP (in the UK) and others (including MFI, PDSA, Run Charts etc) are fundamentally at odds with our domains of clinical care – would it be fair to say these models have greater resonances with transactional rather than relational understandings? I know they do have value but after 5 years of experience of trying (and at times struggling) to nurture a QI literacy among next generation GPs I am starting to think we may need to re-imagine a QI ethos that is uniquely aligned to the paradigm of clinical practice that is ours.
Thanks for the literature which you have shared. I too have not come across some of those books and I look forward ro reading them. Thank you Rammya for creating this space for dialogue about the place of QI / CI in Primary Care.
Nigel, You may be interested in my research. I’ve been looking at a different approach to using the QI methodology. Rather than trying to improve output using tools like run charts, I apply the improvement activity to process. This methodology is called a Process Approach. Many of the QI improvement tools are relevant but much less emphasis is placed n output measures and run charts. Once processes are defined a key activity is to align the processes with the IT systems that are in use. I’m currently applying this methodology with a PCN. In my experience around 25% of the available features of IT systems are used. Joanna Bircher’s webinar the other week was a good example of how you can make your IT system work better for you. Lots of data is held by your IT systems and this can be utilised in process improvement projects. The first step is identifying your processes. This activity is often the stumbling block but it needn’t be if approached logically. Please have a look at my recent blog for a bit more information.
@nigelhart – this is a very thought provoking perspective. I wonder what this new model of quality improvement would look like, that is bespoke to primary care? How do we do QI that is person centred, and respects the relational care that we provide in general practice. I would love to crowd source some ideas from the group?
I’m also wondering – do we not do both in primary care – both relational and transactional? Examples of the latter being flu jabs, health checks, repeat prescribing etc. I think that if we use QI to improve efficiency of the multiple processes we employ within the practice, then it allows us to invest our time and energy into providing high quality relational care (which I agree is less amenable to traditional QI). As you’ve alluded to, and as @william-eric-bostock discusses, this is more about the consultation and our ability to be ‘present’ in the moment, to make a connection, to build trust, and to pass on the knowledge that the other person (our patient) needs to help make themselves better.
Rammya, I agree with you that improving the process efficiency will create more time for care. Care or clinical processes are not the same as business processes.
I agree with Thomas. One of the key ways for QI in GP which addresses many of the areas of inefficiency, is better & quicker IT with automising and standardising of the many of the repetitive clinical processes we currently do on an individual basis with variable quality. Looking at human factors in GP could resolve many problems. How many safety critical industries would put up with the huge ergonomic problems we have in medicine? This ultimately leads to potential error, patient harm and doctor burnout. Once we have a solid foundation for all of GP, we can build on this and more targeted QI initiatives will be easier to sustain. The ideas are already out there but the way we practice currently has been normalised and we have little time to think outside this.
Anne, It would be great to try adapting QI to a process rather that an output measure. If you would like to give it a go I’d like to help. Please let me know. My email is t.rose.1@bham.ac.uk
This issue is fundamental. Medicine is siloed in a fundamental way. Doctors are grouped, trained and rewarded (think distinction/clinical excellence awards) according to their specialty. This affects the whole system (as Aneurin Bevan recognised). I doubt this problem will be sorted any time soon, but in the mean time any one-size-fits-all solution needs to be looked at very carefuly.
As one example, one of the problems of the Read Codes (used for 30 years in primary care) was a mandate that the scheme, which worked well in GP practices, could and should be extended to cover all medical care, without fully recognising that different specialties speak different dialects.
Both Matthew and Wiliam mention PAM, which has been around for some time. You might also check out the Health Confidence Score (HCS), which is newer, broader and shorter but does much the same job.
https://bmjopenquality.bmj.com/content/bmjqir/8/2/e000411.full.pdf
Hi @william-eric-bostock, @nigelhart and @timbenson – will sit down and reply properly when I have a bit more time.
I know the Health Foundation itself was involved in work on PAM (might’ve even been connected to Islington). I’ll see if I can surface any of it…
Enjoying this conversation on the quest for QI approaches that are more befitting of general practice than those traditionally employed in the very different context of hospital medicine!
In our work at THIS Institute, we are trying to understand operational problems in general practice using GPs’ perspectives.
We currently have a live survey seeking prioritisation of operational problems in general practice, based on our previous research. We’re only including GPs in this round but will be broadening engagement to practice managers etc later.
The link is here if any of you would like to participate- it requires log in to our online survey platform Thiscovery first, and the survey will take about 15 minutes to complete.
https://ths.im/3qfMrgQ