Interview with Professor David Price, Primary Care Respiratory Society Professor of Primary Care Respiratory Medicine, by Kelly Llewellyn, Assistant Editor for EMJ
According to the European Respiratory Society, respiratory diseases are among the leading causes of death worldwide. Statistically, asthma affects around 300 million individuals worldwide; 65 million people are estimated to have chronic obstructive pulmonary disease (COPD); and lung cancer causes around 1.4 million deaths per year globally. It is because of these drastic figures that communication between patients and doctors is so important. We spoke to Prof David Price, Primary Care Respiratory Society Professor of Primary Care Respiratory Medicine, University of Aberdeen, Aberdeen, UK, about how effective communication could lead to positive outcomes.
Prof David Price also leads the Respiratory Effectiveness Group, which is: “Really trying to get everyone setting standards for real-life research and also working together on a number of real-life research projects.”
“One of the initial impacts beyond actually doing research is the global initiative for asthma…[which] now recognises within their document the importance of the effectiveness of interventions as well as the efficacy; not just how well they work in perfect patients but how well they work in the real world. Also, they have recognised the importance of proper interaction with the patients and I think also the whole concept of trying to phenotype patients as well; rather than saying everyone is the same, they actually think about the differences and try and come up with a treatment regime that fits the patient,” said Prof Price.
“The most important thing is about truly finding out about our patients’ needs and agendas as well as being clear about what our healthcare agenda is. The more honest and open that communication is, the easier it becomes,” commented Prof Price.
Effective communication between doctors and patients will not only allow for a more effective doctor-patient relationship, but it will also allow for development within this field.
Prof Price suggests: “There are a number of barriers that exist to getting effective outcomes, and I think the first of those is actually getting a prompt and early diagnosis, and I think there is often an expectation on patients’ part that little can be done, or they are actually not going to get a diagnosis that can be treated.
“We have seen this in the area of smoking-related lung disease where the patient in our survey tends to feel that they are not going to get properly treated or get a diagnosis, or they are expected to be told to stop smoking; whilst that is important, someone needs to engage with them.
“I think there is a misunderstanding on what the healthcare system might well be able to provide for them, even before the point of a diagnosis. I also think that people need to truly understand what a diagnostic label means for them, and partly I think doctors have shied away from that, particularly in COPD.” The reason for this could be because they did not know what the prognosis was as, until recently, there was little long-term data.
What will be the most effective ways to engage with the patient and to implement palliative care?
Prof Price replied: “My opening question whenever a patient is referred to me with obstructive lung disease is to ask them what is it they would like to be different: what is it we can realistically change for you that you are maybe not quite able to be like, what is the main thing about this which would actually make a big difference to your life? And whether that is at the mild, moderate, or severe end, the same question still applies. By doing that there is a real engagement with the patient; it changes the whole discussion and moves it away from being doctor-centred to patient-centred, and I think if we do that then everything is on the table from there and that makes it very easy.
“I always advocate the best way to get started on a good patient-centred consultation is simply to find out what the patient’s agenda is.”
Allowing patients to take control of their consultation allows the process to become easier; while doctors may be worried about time constraints, they are able to gain a clearer picture of the situation and all the information the doctor needs will be available to them.
THE ROLES OF DOCTORS
Prof Price said: “I think in some countries [doctors in] primary care [are] getting trained in communication skills, but often specialists are less well trained so I think it is essential that people learn those very… incredibly simple skills, but to start using them at the beginning is quite scary for doctors.”
“I do think there is a real value in providing high-quality, proper education about what is going on in COPD, in particular,” emphasised Prof Price.
In the view of Prof Price, questionnaires such as the COPD assessment test, or the clinical COPD questionnaire are useful to give an evaluation of the patient status. “I am quite a strong believer, although they have their limitations, in really making it a core part of a clinical assessment to properly evaluate the impact of that disease on the patient. So I think the simplest thing is an absolute insistence that an evaluation of the patient’s level of symptoms is made in a formal systematic way,” suggested Prof Price.
“Ideally I want to change every consultation so that the doctors actually open it up and listen to their patients. I guess the other thing about trying to motive doctors to do that is if we look at the persistence with both asthma and COPD therapies, it is very poor and many patients stop taking [treatments], and they get poor outcomes as a result. If there had been a shared understanding at the beginning there would be a much better likelihood of the patient then taking that treatment and understanding why they are taking it,” added Prof Price.
Other than questionnaires, Prof Price has also suggested: “Treatment has to be simple if possible; our treatment regimes have to fit into a style of practice.”
Moreover, Prof Price said: “Bringing in the specialists for the right patients at the right time would be a major step forward.”
Adding: “I do think we need to ensure that patients have proper access where treatment is not achieving the aims we would like with appropriate specialist input. I think if we do use good tools in the consultations… it will actually make a big difference, to be honest, and I think that will be the easiest and first thing we can implement.”
From Prof Price’s point of view, combined with the work of the Respiratory Effectiveness Group, assessing patients in real-life settings to achieve better aims is of great importance. Prof Price said: “[The group] is very keen on trying to achieve better effects for some treatments in real life, by both evaluating them in real life and also trying to help people use them better in real life and think a bit harder about the evidence.”
“I think the big gap [in research] is how well things work in real life, why they do not work in real life, what interventions in real life make a difference, and I think being able to show people that if you go for a more patient-centred consultation, if you do evaluate these things as part of your usual care, you will see better outcomes, you cannot see those in a randomised trial,” highlighted Prof Price.
All of these changes combined could lead not only to better treatments but also better care for patients, improving their outcomes and quality of life.
“I think doctors, other than the super-interested, may become very confused about the treatment of many of the lung diseases. It has become more complex…people have been confused by the guidelines changing, and also potentially the marketing they receive sometimes from the pharmaceutical industry, which obviously majors in what matters to that company, but cannot encompass the whole of the treatment regime. So there is a lot of complexity there for people and they do not quite know what to do,” said Prof Price.
Prof Price also emphasised the need for guidelines to change, explaining: “They have got to evolve…I think they are recognising that they have to get into the whole effectiveness arena, they also have to stop calling themselves guidelines…it is like a resource document rather than a way you have to manage your patients.”
“I think you also need to recognise the limitations of guidelines; the guidelines often tell us the best first choice, they do not tell us what to do next, so they say this is evidenced-based and this is better than that, but actually what it should say is ‘well if this does not work then you need to switch over to this and you need to do this.’ There needs to be a very clear pathway that doctors can say ‘ok I tried that and I will do this next’ and you can also share that with your patients,” recommended Prof Price.
To those just starting their medical career, whether within the field of Respiratory or not, Prof Price advised: “Take time to listen to your patient; they will actually give you most of the answers and they will make your life 100% easier.”
“I had to do a lot of work by videoing myself and working with other experts in the field, really having to focus in on what you are doing yourself and having people critiquing your consultations; it is a very good way to learn, it is incredibly effective,” reflected Prof Price.