Dr David Griffiths is Clinical Lead of the ‘Time for Care’ General Practice Development Programme at NHS England.
If we all agree that the medical model is outdated, why is it so resilient? This was one of the most insightful questions at the recent thought-provoking workshop for the Rethinking Medicine programme.
It was asked by Chris Van Tulleken, now a well-known media doctor, but back in the day a peer of mine at medical school.
The ‘medical model’ refers to the way that doctors in particular are trained and practice. Traditionally, medical students are taught to take a history (assessing symptoms in the context of historical factors), examining the patient, testing hypotheses in order to create and refine a diagnosis and prescribe treatment.
As a GP, I still work in this way some of the time, admittedly cutting corners and moving back and forth between the different segments. Often, though, my consultations bear little relationship to this model.
The medical model tends to look for an underlying, treatable disease process to explain a patient’s symptoms. This does happen of course: I may be (almost) certain that a patient’s sore throat requires antibiotics or that their blood pressure should be lowered.
However, much of the time I am uncertain whether I can explain symptoms through the diagnosis of a disease process. For example, patients may have interacting long-term conditions (multi-morbidity) and psychological factors can have a huge impact on their presentation.
In these cases, trying to consult using the medical model is likely to be useless at best, and possibly harmful. Tests and treatments can even worsen symptoms. This is the paradox that Rethinking Medicine is addressing: that a model of thinking and caring, used with the best of intentions, often feels like it is making things worse.
So why is the model so pervasive? I thought it would be useful to think a bit more about this because, as Chris pointed out, to encourage change we need to understand the forces inhibiting it. The thoughts that follow are my own, and there may well be other factors that I have missed.
The medical profession is ring-fenced. There is a mystique created about what doctors do which starts in medical school. Doctors are recruited for intellectual ability and then trained in a rigorous and highly structured fashion. Experienced doctors pass on not just technical knowledge but also cultural norms from the first moments of training.
One of the seductive elements, I suspect, is the central concept that the expert doctor is uniquely able to solve these problems.
The medical model is deceptively simple, being a list of steps that even brand new students can learn. It is relatively easy to teach and yet it is incredibly flexible; doctors can adapt it to their own personality simply, and it can be used in multiple specialties. As time goes on, it may become a looser template but still something comforting to return to if a consultation is going less well.
Having spent a considerable amount of time learning and becoming expert in the model, it is perhaps unsurprising that many clinicians will be resistant to changing their behaviour. “It’s just the way we do things around here” is a surprisingly difficult issue to address.
Time, effort, skills
The problem with the alternatives is that they are not immediately easier to adopt. The medical model fits the 1:1 consultation, the doctor:patient relationship and the traditional model of care in both hospitals and general practice. More patient-centred care, asking “What matters to you?”, and addressing the whole patient, in the context of their life, is a more difficult thing to do. It requires support from other professionals and non-professionals. It is very difficult to do in a 10-minute GP consultation!
As with any new skill, training and practice is required. What is more, our current modes of communication mean that more work will often be needed, for example in trying to share information with other parties.
It is important to remember that it’s often the way our systems are set up that determines the way we behave. Most of the time this is completely tacit. The systems we have in the NHS are designed firmly around the medical model: 10-minute GP appointments, outpatient clinics, the medical take. It’s not just clinicians who think in this way; I’m sure that healthcare managers and patients are all indoctrinated into the model.
In a later blog, I’ll give some ideas that I think could be helpful in trying to address this. How can we find the win-wins which will see behaviour change and outcomes improve? A big question for next time…