Dr Catherine Calderwood: Healthcare needs to move away from a quick fix

A chief medical officer, being as they are preoccupied with the nation’s health, would not normally be pleased if something ‘went viral’.

Dr Catherine Calderwood, however, has been delighted with the way her vision for ‘Realistic Medicine’ has been received, not just among the clinical community in Scotland but also among the population as a whole and with spreading awareness growing around the world.

The philosophy attempts to cut down on over prescription by moving away from a ‘doctor knows best’ mentality to one where people receiving care are more informed and part of the decision-making process.

‘Realistic Medicine’ was Dr Calderwood’s first annual report as Scotland’s CMO in 2016, and called for open debate among doctors about reducing waste and putting people’s wants and needs at the heart of their care.

“Is there a better way of finding meaningful dialogue?” she asked at the time. 

However, there would prove to be no shortage of meaningful dialogue about her report in the months to come. After delivering 65 talks and presentations on the subject and talking to clinicians across Scotland and beyond, it was clear the idea had made an impression.

On Twitter, Calderwood’s team stopped counting at 15m impressions, while many people wrote to her with their own experiences.

“We have reached every country in the world, including the Arctic Circle,” she smiles.

What started as a conversation between doctors has now evolved to include other professions keen to feed into the debate, such as pharmacists and physiotherapists, as well as the general public. The Health and Social Care Alliance’s ‘Our Voice’ campaign brought together its representative Citizens’ Panel to feed back their expectations of doctors.

Calderwood tells Holyrood she had felt apprehensive about the results because healthcare professionals had told her while they got the concept, they were less optimistic about the public response.

“I sat, it was a Friday night, they sent me the draft results and I was absolutely amazed. It was as if the public had written ‘Realistic Medicine’ without knowing that’s what they were doing,” she says. 

“People were asked what makes a good doctor. Seventy-one per cent said a good doctor had a medical degree, which is reassuring. The GMC will be pleased about that. Also, that they were competent and knowledgeable. But almost as many people, 64 per cent, said it was important that the doctor was a good listener.”

At the heart of the shift required to realise the ‘Realistic Medicine’ ambition is the conversation between doctor and patient, a move away from the idea that a “quick fix – a tablet, a treatment, an intervention” is what is always wanted or needed.

Some of the way her report had been covered in the media had led Calderwood to be concerned people would see the idea as “to do with cuts” instead of outcomes.

“Perhaps people are more realistic than we give them credit for,” she says.

For Calderwood, the cultural shift from a paternalistic NHS providing quick ‘fix me ups’ will need to be a fairly radical one.

“What I’m very keen on is the understanding of people preserving their health,” she says.

“The way we greet each other: ‘how are you?’ – You are enquiring about someone’s physical and mental health in a short three-word greeting. The answer you want is ‘I’m fine’, and then you move on. But if they are not fine, then the whole thing becomes an interaction about why they are not fine.

“I always used to notice this when people were taken ill – their family would come from all round the country to visit. They’d bring chocolate, flowers, and they hadn’t seen them for months. Years, even. 

“Why don’t we visit people when they are well, when we could go for a walk with them, go out, go to the pub? 

“Society’s concern is for illness, when we should be supporting our friends and family to stay well. That’s concern, of course, and don’t get me wrong, I’m not knocking that. But I don’t think we value health until it’s gone, to put it crudely.”

Calderwood points to the “completely illogical” way traditional health spend has stubbornly focused on treatment rather than prevention.

“It’s a little bit like nursery carers being the lowest paid people [in education] when the child’s brain is at its most influential.”

But while clinicians have embraced the philosophy of ‘Realistic Medicine’ – including the GMC now looking at reviewing the consent guidelines for all doctors in the UK, at Calderwood’s suggestion – the focus of practice and spending remains on the firefighting, as Scotland tackles the challenge of an ageing population who are living with multiple complex conditions.

How realistic is it to expect clinicians to find the time for person-centred conversations?

Calderwood says the examples she has heard actually haven’t required more time. 

“It changes what they perhaps say to people, and they put in an option which is – ‘you could do nothing’. You do realise you could do nothing? 

“Sometimes the patient is relieved. ‘I don’t have to have dialysis?’ ‘I don’t have to have an operation?’ They can be relieved to have been given permission because they didn’t want to do whatever it was in the first place.”

Cambridge University medical students have 26 half days of training on quality communication with patients, she points out. 

“If we train people to have these conversations, they take less time. People’s perception is that really good shared decision-making will take ages and be rambling, doing this and that. But if you do them according to a formula, in the same way I’d do a caesarean section to a formula, the time thing is actually a myth.”

Another example of embedding the approach in training is the Dick Vet school in Edinburgh, she jokes, where the entrance interview is attended by a dog to see how candidates can relate to animals. 

“I think we will practise better medicine if we take into account what people’s priorities are,” she says.

The demographic change, Calderwood argues, is “a success story” rather than a burden, but does mean traditional ways of treating people will need to be “reset”. 

“Of course, people want to be at home, of course, they want to be looked after properly but actually, they want to do things within their own community. 

“And if we’re taking people from their communities and plopping them in an acute setting, that isn’t what anybody would want, I don’t think, for themselves or for their families. We have made a very rigid and expensive way of treating people and we need to unpick it.

“If you had appendicitis, you and I would both want you in a shiny hospital as soon as possible, but not when it’s to do with a lot of older people living longer. Why would the model be the same? But we’ve done that. We put them in care for the elderly wards. That is not an acute state of being.”

Treatment for acute exacerbations such as chemotherapy, blood transfusions and intravenous antibiotics can increasingly be done at home, Calderwood points out, describing the success of Hospital at Home in Fife and the Highlands.

“Those changes are maybe being driven by demand, maybe by resources, but maybe it’ll force us to practise better medicine.”

But there are also community examples of where realistic medicine is flourishing. A group of mothers in Fife cut the use of antenatal antidepressants after organising a “rain or shine” buggy walk. 
“You can see it. Out and about. New friends. Fresh air. All good for your wellbeing.”

Another is a choir of people with chronic obstructive pulmonary disease (COPD) in Stockbridge in Edinburgh, known as the Cheyne Gang after the street where they practise.

The idea formed after a community nurse noticed her choir were doing exercises which the physio was encouraging COPD patients to do. However, attendance at the physio was poor. The COPD choir started with six, but now has over 80 attendees and is expanding to elsewhere in the city.

“The evidence from other countries is it is at least as good as physio. But it also changes people’s isolation. They make friends. And they attend,” says Calderwood. 

“They invited me to go and see them. I spoke to lots of people in the choir, and they are using less medication, they are fitter and one woman had never been able to give up smoking – after 60 years, she’d given up smoking. Nothing had convinced her, but she wanted to sing. And she didn’t want to let her friends down.”

If 60 years of traditional NHS treatments hadn’t worked for this woman, but finding something she really wanted did, isn’t she the embodiment of ‘Realistic Medicine’?

By understanding personal goals like wanting to feel loved and valued, and to do things you are interested in, people can be motivated to improve their own health, she says. 

“If you had said to me I’d be telling you that when I was a junior doctor, I would have scoffed,” says Calderwood. “I would have said I’ll hand this person an inhaler, which is what I’d been trained to do. But the idea is it’s better for them than the medicines. It’s breaking that tradition.”

Calderwood is bringing together Scotland’s first atlas of variation which will map out inconsistencies in treatment and public health outcomes, and, she hopes, find the good examples for others to follow.

“Some of it will be acute procedure, some of it will be the public health stuff like what the rates of obesity in children are. 

“What it does is highlight that there are parts of the same country able to deliver care in different ways.”

Ultimately, the atlas of variation can eliminate “unnecessary variation”, according to the CMO.

“I think that will be very powerful for Scotland,” she says. “We’re a small nation and we know each other.”