Latest / 'Bone Up' / She said He said: the art of communicating about bones

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She said He said: the art of communicating about bones · 'Bone Up'

0:00
Hello and welcome to Bone Up, the podcast all about bones, how we make them, why we
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break them and if we fully understand them. I'm David Armstrong.
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Hi, and I'm Richie Abel and over this series we're going to be exploring osteoporosis,
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bones, what we know and what we yet to discover and we hope you will join us on the journey.
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So for anyone keen to learn more about our infrastructure of calcified collagen, this
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is Bone Up.
0:55
Hi David, really good to see you again.
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Yeah, it's good to be back for another episode of Bone Up.
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It's been fantastic so far. I've really enjoyed recording these episodes and we're getting
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good feedback from listeners and at the minute we have more than 850 downloads of the episodes
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we've put out.
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Yeah, that's really good. I've had a lot of local feedback and from pharmacists and
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from GP colleagues and even one or two from patients as well. So there's more just than
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your mother listening to us which is reassuring.
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I hear your brother's been listening to us as well.
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Yes, I have to point out a deliberate mistake in the last episode. It was pointed out that
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on a number of occasions I accused Professor McCluskey of having his hand on the rudder
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of the good ship Frax. It's been pointed out to me that the rudder is underneath the
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ship and if you have your hand on the rudder you have fallen overboard and that you should
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actually have your hand on the tiller. So apologies for that and thanks to my brother
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for pointing out that he is a solicitor folks so that's how he makes his money.
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You can always rely on family to point out your mistakes can't you?
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You can.
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I have to say I thought it was a really really good analogy and I didn't spot the difference
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between rudder and tiller. So we're both in it together.
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That's good and it's great to be starting another episode. We talked in the past I think
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how this was not a lecture series on osteoporosis but was really a journey through the world
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of bone health and how we'd be stopping at a lot of ports along the way you might say
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or Odysseus returning home from the Trojan War let's say then running to the local convenience
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store to buy a loaf of bread which is why this week we're talking about something a
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little related maybe to fracture risk but also quite different in many ways and that
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is about how we discuss risk with patients, how we communicate with patients, how we
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talk to patients about fracture risk and about the whole area of bone health and osteoporosis.
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So I think this is going to be a really interesting topic for professionals and also for patients.
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I personally don't really know very much about the patient journey and the process the clinicians
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and the patients go through. At what point during the care process do you talk to patients
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about risk and why?
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I suppose the point at which we talk about risk is usually when we're talking to them
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about starting a medication or making some other big change in management so it's usually
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after they've had the fracture risk assessment usually when they have a frax score from that
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or at the very least after they have a DEXA scan with a T score and we have got the patient
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usually in front of us face to face alone the last year there's been a lot of telephone
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conversations which is another area entirely in terms of communication but we've got the
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patient in front of us and often I would like to suggest to them that they start some new
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medication and I'm trying to share with them the benefits of the medication, the risks
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of not taking the medication, the possible side effects of the medicine that they're
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going to get and trying to just get an idea of where they are on their journey and to
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try to get them I suppose on board with the fact that this medication will be to their
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advantage.
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How successful do you feel you are with that? Do you ever get any feedback from the patients
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about the communication you have with them?
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Yeah, the best feedback you get ultimately is whether the patient takes the medication
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and I think all people involved in osteoporosis, I hope all clinicians involved in osteoporosis,
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I hope it's not just me, at times have what we feel is a very good conversation with the
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patient, we talk about bone health, we explore where they are in terms of bone health, we
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explain the risk of further fracture, we talk about the drugs available, we advise one drug,
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we balance the risks and benefits and the patient says yes I can't wait to start that
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doctor and they go away with their information booklet and then I get a phone call a week
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or two later from a nurse or a pharmacist or a GP to say the patient has decided not
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to go for that drug and clearly there was something wrong with my explanation or with
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the conversation or with the impression that I got when the patient was leaving the room
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of how they understood the issues and as I say I imagine everyone involved in osteoporosis
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has that experience so there's still a lot to learn about how we share this with patients,
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how we explore what the patient feels and how we just do our best to have people on
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the right medication for the right length of time.
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Could it be that after a patient speaks to you they understand the conversation, they
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understand the information and maybe they have made a decision to take the treatment
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but then perhaps there are other sources of information, you know your Facebook's, your
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Twitter's, you know friends and family that may be contradict or disagree with what you
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said maybe lead to people changing their mind.
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I think that's true and I think my honest response to the situation which I have just
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described is that while I feel at times probably I could have done better in my explanation
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or my discussion there are clearly times where people have gone away and have found things
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on the internet or spoken to other people and that has changed their mind.
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It's one of the issues we face in medicine in general at the moment and that is not just
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within osteoporosis but within all aspects of medicine and that is authority of sources
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or authority of experts because people will sometimes give credence to things they read
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on the internet, things they see in social media and weigh that more heavily perhaps
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than advice they're being given by the doctor or nurse or pharmacist, someone who has 20
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or 30 or 40 years experience in the field and is also accountable to them in that they
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work locally and they will see them again and they have a responsibility for their care.
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Sometimes people will be persuaded by reading things on the internet written by someone
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who they don't know, who doesn't live or work anywhere near them and who has no long term
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accountability or responsibility.
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But we live in a world now where information is freely available and we actively encourage
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people to go out and seek information and educate themselves about their condition but
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it's just the quality of that information and the authority behind that information
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but as I say that's a big issue in medicine in general at the moment.
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It's almost as though we need some sort of podcast interviewing experts about the disease
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and how it can be treated and managed better.
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Well that's true and do you know it is people sometimes say AI could almost take over from
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a doctor, you type your symptoms into the internet and it tells you what your disease
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is and what the medication is but I still think there is something to be said for the
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doctor-patient relationship and trusting the person opposite you that they seem to be an
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honest individual who is doing their best, using their expertise and working for your
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benefit because they are in a position of having more information and more experience
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than you will have from this and I say that's core to the doctor-patient relationship in
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many ways.
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Do you feel pressure at all to continually learn and develop and try and do better and
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improve your communications with the patients and is there any training for you?
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You certainly, that's almost two questions there in terms of do you feel pressure to
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learn and keep up to date and do better?
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Absolutely and it's one positive I think from the fact that patients can go onto the internet
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and do huge amount of research.
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If you are not up to date with the paper published last week and the patient is up to date with
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the paper published last week then they have more data than you do about whatever particular
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issue you are discussing, they may not have the experience and the general wisdom on the
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subject that you do to put it like that but they certainly have all the up to date information
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because it's widely available.
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So in a positive way the fact that information is so widely available now does put you under
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pressure to keep up to date.
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Specifically in terms of communication, I mentioned briefly about the telephone clinic
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which is something that all of us have been doing in the last year and for which I would
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suspect almost no doctors or nurses had any formal training and a lot of that has been
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learning on the job.
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I'd have to say when I was training you received relatively little education or training about
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communication or communication skills.
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I think it is something certainly can be taught and can be improved but it does depend to
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some extent as well I think on your personality and on just the sort of doctor-patient relationship
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that you build up.
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So that's maybe a good point to introduce our guest for the episode and that is Dr. Zoe
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Paskins and Zoe is someone who has a wealth of expertise on communication with patients
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and indeed has led and continues to lead research in the area of patient communication in the
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field of musculoskeletal health.
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So welcome to Zoe and over to you Richie.
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So our second guest today is Dr. Zoe Paskins, a reader in rheumatology and honorary consultant
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from Keel University.
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Zoe, it's really, really wonderful to have you on the show.
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My first question is what is rheumatology?
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Oh great, well thank you for starting with an easy question.
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I should have this at the tip of my tongue and I think it's quite hard to describe so
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I think rheumatologists look after people with long-term musculoskeletal conditions and inflammatory
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conditions.
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And to that effect I may not really be much of a proper rheumatologist because I actually
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don't see patients in my clinical practice very much with what we call inflammatory conditions.
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So these are things like rheumatoid arthritis which is kind of probably the bread and butter
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of rheumatology where there's inflammation in the joints and things.
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So my principal clinical interest and research interests are non-inflammatory long-term musculoskeletal
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diseases like osteoarthritis and osteoporosis.
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And I guess actually in reality many people with those conditions aren't looked after
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by rheumatologists, they're probably looked after by their GP.
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But yeah, that's my area of interest.
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It's good to get you started off with the easy questions.
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The next question is going to be a good one as well.
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I was wondering Zoe if you could tell our audience about your research programme.
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So I lead an osteoporosis research group in a primary care research centre and I'm what
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you'd call an applied health services researcher.
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So my research is mainly around very practical things that can improve care and particularly
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patient-centred care for people with osteoporosis.
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And when you say primary healthcare centre, is that a GP surgery?
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Yeah, so it's a primary care research centre within the School of Medicine at Keel.
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So there are over 100 researchers there who are focusing on the primary care angle of
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things.
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So although I'm a secondary care doctor, so I'm a hospital specialist, so I'm a little
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bit unusual to be working in a primary care research centre.
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It does include GPs, but of course primary care is a lot more than GPs.
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It's a range of other multidisciplinary clinicians and within our research centre we have a lot
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of primary researchers as well who are clinicians.
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What's the purpose of stepping out of the secondary care world into the primary care
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world?
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Well for me, it's about my sort of goal is for long-term common musculoskeletal conditions
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to be managed better.
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And for that reason, because I need to go into the primary care world because as I say,
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they often don't see rheumatologists.
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And part of primary care management, I suppose, is deciding who needs that specialist care.
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And so to be involved in those kind of discussions and decisions, you kind of need to move in
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that direction.
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I guess musculoskeletal diseases in general have probably got a bit of a low profile compared
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to other problems like cancer or cardiovascular disease.
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So part of our problem I think is the community is about raising the profile.
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And to that I think we have to step outside of our specialty silo a little bit.
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I understand that you do some research around risk and communicating risk.
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Yeah, so I think an element of my research is about risk communication, but I think it
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probably goes back to what you were just saying about raising awareness.
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For me, it's not just about awareness, but it's also about the quality of that information
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and messaging because there's a lot of misinformation around our condition, particularly off-stay
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process, which we're focusing around today.
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So I guess I've got a broad interest in communication generally and then within that risk communication
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as well.
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Hi, Zoe.
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Hi.
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Welcome to the Calcified Collagen Club.
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I'm glad you're able to join us today.
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You've got your glass of milk at the door, I hope.
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Of course.
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Can I ask just maybe some lessons from your experience and from the research you've done
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in the area of communication and quality of information?
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Because we're very keen to learn about how we explain risk to patients and how we discuss
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risk with patients.
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Now, as you know, I have a very practical brain, so if I can maybe arrange this around
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a practical question.
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If a patient, let's say a 75-year-old lady comes to you and says that she has a 10% 10-year
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risk of hip fracture and when we heard earlier from Eugene how we sort of developed that
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algorithm and how we produced that figure, she has maybe been seen at a fracture liaison
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service.
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She has a recluting radiographer who has calculated a frack score for her and she's got the impression
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from the other clinicians that a 10% 10-year risk of hip fracture is a high risk.
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And yet there are other things in life for which a 10% risk would not seem a particularly
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high risk.
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So how do you approach that whole area of discussing risk with a patient, particularly
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an older patient maybe who has comorbidities?
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Okay, so I mean you presented a scenario which I think is probably fairly unusual, isn't
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it, where somebody comes to you and says they've been told a specific figure and what have
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you.
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So the first question or thought when thinking about communicating risk with a patient is
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to find out what their own perception of their risk is.
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And that can be quite a hard question for people to answer I think.
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So I might ask them before going into any sort of risk communication about what they
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think about their bone strength.
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And I think it's really important to have that conversation first because if you don't,
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anything you say about risk may kind of fall on deaf ears if somebody doesn't believe what
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you're saying.
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So in the context of, did you say hip fracture risk when you said 10%?
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Yes, I mean it's an example you could have calculated yourself, but let's say a 10% 10-year
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risk of hip fracture, which as you know and we know from what we've heard earlier, but
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frax that puts you into the red area, that puts you into the high risk category.
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Yeah, so you and I would perceive a 10% risk as high wouldn't we?
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We don't know how this person feels about that and it's really important to unpick
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that first and I think there's lots of qualitative research that shows that not uncommonly people
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have been given a risk and they don't believe it.
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And so all the conversation that comes afterwards kind of almost falls on deaf ears because
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particularly if people say have fractured, but they have decided that they fractured
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because they fell over the cat or because whatever and anyone would have fractured in
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that circumstance.
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So for me, I think it's really important to ask what they think about their bone strength
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first and if they say, as this happened the last time I asked a patient he said, well
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I thought my bones were quite strong.
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So I had to do a little bit of work explaining what his risk factors were and how his bone
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density results and how that was just part of a picture of his overall bone strength
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and actually this gentleman had other risk factors, for example his medical conditions
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or medicines that would affect his bone strength.
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So I had to do that and then the patient I think is starting to realise will be more
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open to a discussion that they might be at perhaps higher risk than they thought they
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were.
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So that's the first thing to kind of preface any discussion on risk discussion I think
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with what they think.
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Then I'd want to kind of unpick in this scenario what they think by a 10% 10 year risk means
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because that's really complicated, right?
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So first of all it involves percentages and there's the old adage that 50% of people don't
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know what 50% means and not only is it a percentage it's got this element of time as well.
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So one of the ways that these kind of risk things can be misinterpreted is that people
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may think they're only at risk for 10% of the time instead of being at 10% risk.
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So you can see how easy these are to be misconstrued.
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So the good news about risk communication is that there's actually a huge literature
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of evidence to draw on outwith of the approach and if people are interested in this the FDA
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have produced a book on it which is available online and it summarises all the evidence.
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But the kind of if I'd have been the person to give this person their frax result I wouldn't
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have said they are at 10% risk over 10 years.
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I would say that they had a one in 10 risk over 10 years.
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So it's about using simple frequencies one in 10 instead of 10%.
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Okay that's a very useful point.
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And in general when we use those simple frequencies the denominator, the second number the easier
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it is to understand.
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So I've done a bit of mental maths there and changed 10% which is really 10 in 100 to one
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in 10.
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However, if you're talking about multiple risks in the same conversation it's important
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to try and use the same second number because it makes it easier for the patient to do some
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comparisons.
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So but in this example I probably said I had a one in 10 year risk.
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Now the other thing about risk communication is that you're supposed to do something called
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positive and negative framing.
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So in other words you'd say the risk of something happening and the risk of something not happening.
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And that avoids the sort of cognitive biases where we focus on one event rather than the
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other.
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And I particularly do this when I'm talking about side effects.
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So if I said that somebody had a one in 1000 risk of getting a jaw bone problem if they
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took a bisphosonate for 10 years for example I'd also say that they had a 999 in 1000
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chance of that not happening.
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So that's positive and negative framing and tries to avoid the focus on one rather than
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the other.
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And it's certainly something I think comes up in this whereas a 10 or 15% risk of hip
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fracture is perceived as high but if you turn that around and frame it positively and say
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85 or 90% risk of not having a hip fracture then the patient probably justifiably would
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go away thinking well that was a positive outcome.
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And I think we probably as all as doctors can be guilty of that a little maybe pushing
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the positive or pushing the negative if we're hoping to persuade people towards one outcome
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or another.
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Yeah.
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We're walking this tightrope between shared decision making where we're supposed to present
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all the facts in a very neutral and unbiased way and beneficent persuasion where we're
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actually trying to encourage the patient to make a decision that's in line with their
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values.
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And it's a very fine tightrope I think and I think there is ethical justification in
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some situations to kind of use what we know as long as it's not going too far into just
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persuasion and what have you.
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So I think when we know maybe in that context in my own practice I haven't actually thought
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about this before but actually now I do think about it.
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I probably wouldn't use positive and negative framing when I was talking about fracture
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risk but I would do when I'm talking about side effects because I think there's an over
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focus on the negative.
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Absolutely.
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Yes.
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To some extent you're correcting what might be an incorrect perception.
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Yeah.
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Why we're in that area it's something that I felt probably increasingly aware of in my
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practice over the last few years and that is comparing diseases and the risks of comparing
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diseases and it's something I probably did in the first episode of this and it's comparing
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the outcome in whatever disease you're talking about with the outcome in cancer.
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And particular and I think in the first episode I quoted that around 25% of men with hip fracture
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will die within a year and compare that by saying that most cancers for example have
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a better outcome than that.
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Do you think it's fair comparing diseases like that and in particular do you think using
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comparison with cancer is fair for patients?
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Do you think it's helpful or do you think comparing diseases just clouds the issue?
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Well, that's another corking question and it's like two or three questions in one so
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you have to give out fairness.
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Yeah, we're getting our value for money.
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Yeah, so I guess it depends on your purpose is my answer to that because I think in the
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risk communication literature one of the techniques for getting people to appreciate
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what a risk actually means is to compare it to the frequency of another event but usually
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you see this more in rare things.
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So maybe if you were again talking about side effects you might say the chance of that happening
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is equivalent to being run over or being in a car accident or something like that and
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there's visual ways of showing risk compared to the risk of other events in your life.
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In the example that you gave I think that the purpose is a bit different it's not to aid
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understanding but it's almost to kind of emphasise the importance possibly and I don't think that's
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a particularly personally effective or helpful because I think the although what you do raise
25:52
is a really important point and again this is context for this risk conversation.
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Before you've even started talking about this risk and an individual's risk you've hopefully
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set the scene about why obviously a process is important and what the consequences of
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it are and the physical, social and psychological consequences of fracture and for me that's
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the important conversation.
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I think comparing it with cancer, cancer is a very emotive word and people will react
26:20
to it very very differently and have different experiences and thoughts about it and as soon
26:24
as you mention it you know but somebody might be going off on a different train of thought.
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So I think for me it's about what's your purpose and if it's to emphasise that this
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is common it's important absolutely that's important but I think we should be doing that
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in other ways.
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For example some of our research has centred around this, around how best to do this without
26:47
driving fear of living God into somebody but one of the things that people commonly don't
26:54
understand is the effect of spinal fractures and the fact that they although they heal
27:00
they remain misshapen and then that can affect your posture and so on and actually being
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able to show somebody that and explain that is an important part I think of explaining
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what the consequences of osteoporosis might be and why it's important to take steps to
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lower the risk of fractures and try and protect the spine and so on.
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Yeah it's something I used to say I have become probably more uncomfortable with comparing
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things with cancer because you don't always know the patient's background, their lived
27:31
experience and exactly it's a very emotive issue and then I've probably tried to move
27:37
away from that so I mean you've mentioned that we should rather than use percentages
27:43
we should probably break things down to one in ten or one in twenty.
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I think the positive and negative framing is very useful.
27:51
Have you any other tips for us from your experience or from your research about explaining
27:58
risk to patients?
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Do you think patients deal with the concept of risk more easily or deal with the concept
28:05
of something wrong with a tissue in the body more easily?
28:10
Because I think when we're moving away from using DEXA just for diagnosis to using FRACs
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and risk scores to inform treatment do you think people are people find it easier to
28:23
deal with the concept of a tissue wrong in their body than this mathematical concept
28:27
of risk?
28:30
Yeah so again you've asked me two questions in one letter so I'm going to go with the
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right I want to hold on to the first one which was about any other tips for risk and then
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we'll come to that second one which I think is really really important.
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So the first one was have you got any other tips around how to communicate risk and I
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did just want to touch on the use of words because we've already said in the scenario
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you painted earlier that this woman has got a high risk with use of word high haven't
29:00
we?
29:01
Yeah.
29:02
So if I said that you had a high risk of COVID infection what kind of percentage risk
29:08
Ritchie would you think that you had?
29:10
5%
29:11
Okay that wasn't the answer I was saying.
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Okay 5% so if someone said you had a very high risk of COVID what would you think?
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Maybe 90% and what would that affect your behaviours?
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I suppose I'd work from home or avoid contact with other people.
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I might be inclined to tell other people that I'm at high risk so they might change their
29:34
behaviour and stay away from me.
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So I think words are interpreted very differently from person to person and the Royal Osteoporosidium
29:47
Society helpline gets called every day from people who've been told they're either at
29:51
high or very high risk of fracture and are terrified to go outside and they're probably
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equating a high risk to more of a sort of you know I am going to fracture and I mustn't
30:01
leave the house kind of frame of mentality and clearly we're talking about high in the
30:05
context of a 1 in 10 risk which where the balance of probability is that this person
30:11
won't have a fracture isn't it?
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So we need to be very careful about the use of high risk particularly and very high and
30:20
because these words are used very differently again the kind of risk communication literature
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advises that you don't use them or if you do use them you qualify them with the numbers
30:29
as well you don't use them on their own and again talking about side effects is why I
30:34
think it's really helpful when you talk about risk for side effects so studies have shown
30:37
that people interpret rare very differently is one in 10 or one in a thousand so they
30:42
just saying oh don't worry it's very rare is not helpful and of course people tend to
30:48
think in a binary way as well they don't think in a risk probability way if somebody knows
30:52
somebody who's had an event particularly osteonecrosis of the jaw and you tell them the risk is
30:58
one in a thousand then it's kind of meaningless because they think about their own personal
31:03
experience and their own personal narrative so all sorts of difficulties there so going
31:10
back to the scenario I think the important thing is not to use the word high on its
31:17
own to use words in combination with frequencies and then to try and if you're going to use
31:26
a word or a label use a meaningful word or a label so you could say in this patient in
31:31
this example if they wanted to know whether 10% was high or low for their age you could
31:37
say well this risk falls into the treatment zone rather than saying it falls into the
31:41
high risk you could say it falls into the treatment zone for your age and you could
31:46
show them the nog graph to kind of illustrate that where it plots risk in sort of green
31:50
or red depending on their age.
31:52
It's really interesting that you say that because I've always been concerned with the
31:56
term high risk to me high risk of rain to me means that it's more than likely it's going
32:03
to rain than not going to rain and I've always wondered about using the term high risk in
32:09
patients and I wonder and I know it opens a whole new discussion but using terms like
32:14
high for your age or higher than average which indicates that we're concerned but qualifies
32:22
it in some way and as you know we're now developing or there's this term imminent risk as well
32:29
which is being used which could be a very useful term but again to me it suggests to
32:34
patients that they are about to fracture and that we would be surprised if they didn't
32:39
fracture and fracture in the near future whereas for most people who we say had very
32:44
high risk or imminent risk we know that that's not the case.
32:49
We almost need to tune down our language do you think?
32:53
We almost need to move it down from suggesting that this is very dangerous to suggesting
33:00
that something you can positively do something about.
33:04
Absolutely and I think that kind of speaks to what your second question was a few questions
33:11
back which was about does it, I'm paraphrasing now I'm not going to get it right but it was
33:17
telling you around does it matter that we're giving people a risk score rather than giving
33:24
them a kind of tissue diagnosis I think that was what you were talking about.
33:27
Yeah I just wondered if people find it easier to deal with the concept of a tissue diagnosis
33:32
as opposed to dealing with the concept of a figure of risk.
33:39
There's a helpful psychological model for how people make sense of disease and it's
33:44
got five elements to it to how people make sense of the disease and all their condition
33:49
and then that affects what behaviours and actions they'll put in place to deal with
33:53
it and the first element is the identity so what is it that is this condition and can
33:59
you describe it how do you characterise it what symptoms does it give you and so on and
34:03
I think we can do that frosty approach and I think that I personally don't think it's
34:09
matter whether it's a scan or a tissue or whatever I think it does osteoporosis does
34:13
have an identity.
34:16
The second element is the consequences of it so what does it lead to and in our case
34:23
again we talk about fractures then there's the causes importantly and we talked before
34:30
about really important to help people understand what their own particular risk factors are
34:34
so they can accept the diagnosis or the risk that we're talking to them about.
34:40
Third element is the timeline so what happens to it over time and that contributes to how
34:46
much you care about doing something about it and links to the consequences and the final
34:51
bit is the controllability so can I do something about this or is it just sort of fate that
34:56
it's an osteoporosis is this just a natural consequence of ageing that is not for which
35:03
treatment is futile a lot of people hold that belief and they may have been told you've
35:08
got osteoporosis but it's normal for your age so why on earth would you take a tablet for
35:12
your osteoporosis if you've got something that's normal for your age so we need to attend to
35:18
all these elements when we're giving somebody a diagnosis and it's harder to do when you're
35:23
talking about risk alone and you haven't got that osteoporosis diagnosis you can to a little
35:29
extent but I think for people to understand the identity what does that mean is a little
35:35
bit harder but I think it makes it a lot easier if you can give somebody a clinical diagnosis
35:42
of osteoporosis so there are often times I think scenarios where we don't either don't
35:47
have a bone density result because it's not recommended in people over a certain age or
35:57
because of bone density scan isn't practical but we know they've got bone fragility particularly
36:02
in people who've had hip or spinal fractures before and in those contexts I think a clinical
36:07
diagnosis of osteoporosis is a very sensible approach well it's not strictly speaking what
36:12
the World Health Organization criteria would encourage us to do but and I think it's really
36:18
important for patients to help make sense of their condition and make changes to their
36:25
health behaviours to mitigate that. Part of our research I think is to try and get some
36:35
quick and simple take home messages for around communication and translation of scientific
36:41
evidence. There's some quick and easy wins I think that we're doing really badly I mean
36:47
one quick example if I may is we've just sort of reviewed the quality and readability
36:53
of nine different patient information sources about osteoporosis that are available online
36:59
from charities and NHS and so on and we looked at the language that was used and you wouldn't
37:05
believe the power of a single word that's in the wrong place or with them can have real
37:12
massive consequences so for example a lot of the information about osteoporosis drugs
37:21
talks about them preventing fractures and we know that the general principle at a population
37:28
level of osteoporosis drugs is for fracture prevention but on an individual level if you
37:35
tell a patient that their drug is going to prevent fractures it doesn't it lowers the
37:40
risk and then if that individual then has a fracture their treatment expectations aren't
37:46
met and they'll stop taking the tablet and there's so much of that that we don't make
37:52
clear what medicines do in osteoporosis and we're not clear about it ourselves I think
38:00
amongst the community they're let alone to express that clearly to patients. Within osteoporosis
38:05
I think there are some small quick wins that we could just be a lot better at and I think
38:11
that's what we're trying to spread the message about. It all brings it back to that understanding
38:17
of risk doesn't it in that if a patient has an infection and you give them an antibiotic
38:24
their goal is that the infection is cleared and that's a binary outcome the infection
38:28
is gone or it's not gone if they have high blood pressure and you give them an antihypertensive
38:33
they expect to have the blood pressure checked and be told it's back to normal but it's harder
38:38
to hold in your head the concept that my risk of fracture has now reduced from 10% to 5%
38:45
because I don't actually feel any different knowing that my risk of fracture has reduced.
38:51
Yeah so we've done some work with patients about how to best explain that and now we're using
39:00
language about uh you'd like this uh David because it's a metaphor. Oh I love metaphors yeah
39:06
and similesh you've got to save up in your bone bank is one I haven't used this in patients yet
39:12
but it's like saving up to go on holiday and if you checked your piggy bank in six months and
39:17
just stop saving then you'd be disappointed because you wouldn't have enough to go on holiday
39:21
I can actually this one this one is from Rob Horn so I must acknowledge him on this one
39:26
and um yeah so you and also emphasizing that it works silently in the background
39:31
um and that you can't feel your bones strengthening again this is another thing if people feel
39:37
common reason why people stop taking their medicines they don't feel better because their
39:42
treatment expectations haven't been met they don't feel better they've been told they'll be
39:46
stronger they think they'll feel stronger and be able to garden better and all the rest of it.
39:51
Absolutely and you know that's something I have any of my patients are actually listening to this
39:55
many of them have heard me saying you will not feel stronger after you take this medication
40:01
I often sort of raise my right arm to show them my biceps and say to them you will not
40:06
go out after receiving your IVs, ulntronic acid and feel stronger but you'll know that you've
40:12
done something to reduce your risk of having one of those fractures again.
40:19
How do you research the doctor patient interactions do you bring people in and watch these interactions
40:26
in a lab setting do you record them for quality control what's the process? Well there's all
40:32
sorts of things you can do so um you can you can observe interactions and then you could analyse
40:38
that either qualitatively or quantitatively actually for my phd i video recorded 200 gp
40:45
consultations and qualitatively qualitatively analyse them and I that was around osteoarthritis
40:53
and how that was discussed and then I interviewed patients and gps afterwards and showed them clips
40:58
of their consultation and then using a method called video stimulated recall to get their further
41:04
sort of perceptions on what had happened and what meanings they'd taken from things um but you can
41:10
you don't have to do observe it I mean probably the best way of finding out what actually happens
41:15
in a consultation is to observe it but indirectly I suppose the most common commonly we find out
41:21
information about what people think about their consultations afterwards through through interviews
41:27
or less commonly surveys or focus groups or whatever and where do you think the future of
41:33
this research is going to go? Well that's a really good question we've still got loads to do we're
41:43
in we've got a condition which within osteoporosis if we're talking about osteoporosis we've got a
41:50
condition which is very poorly managed poorly identified is not patient-centered at all in its
41:57
approach and has very poor treatment uptake so we've got and actually the communication
42:06
both between between researchers and clinicians between clinicians and between clinicians and
42:11
patients is at the root of lots of these problems so really it could go in many directions and
42:17
there's still an awful lot of work to do. It sounds like what we need is some sort of
42:23
infotaining podcast about bone health and osteoporosis. If only if only we have that that would be
42:28
amazing. With interesting and exciting guests in to be. Yeah completely that's what we need.
42:38
Zoe that has been an absolutely enthralling conversation I think it's going to be really
42:43
interesting for the people who are patients listening to this I think it's going to be nice to get an
42:48
insight into the thinking that goes in from the clinical side both within a consultation but also
42:55
all the research that's going in behind those scenes to make sure those consultations improve.
43:00
The doctor-patient interaction is the most fundamental thing in healthcare and all those
43:06
problems that you just listed poor identification of the disease poor uptake of treatment etc.
43:11
We could go a long way to solving those problems if you can improve those consultations and also
43:18
you know more widely the public information that is disseminated around the condition.
43:24
Thank you Richard that's a great summary of why I exist thank you.
43:29
It's such an important area of research and we can put so much money into finding a new drug
43:36
and yet if the doctor uses one wrong word in that first consultation and the patient decides not to
43:43
take the drug then all the research on the benefit of the drug really doesn't matter and I think I
43:50
agree with Richie it's why this type of research in this area of medicine is the foundation in
43:56
which everything else is built. Thank you Zoe. Thank you. Thank you.
44:01
So David I really enjoyed the interview we did with Zoe I thought she was very articulate and
44:10
very clear and it was a really interesting insight for me into the you know doctor-patient
44:17
relationship and the kind of communication that goes on. What for you do you think were the key
44:23
takeaway points? I have to say the first takeaway point I had was not to ask three questions at once
44:33
particularly not to Zoe who was very keen to draw me up on that and that's just to improve my
44:39
interviewing technique. I mean I think one of the most important things she said was just to
44:46
just to set the scene for the patient and find out a little about what the patient's expectations
44:53
are and what their beliefs are because if a patient thinks they've broken their hip because they
44:59
tripped over the dog then if you immediately launch into discussion of fracture risk and
45:05
assessments and bone density and and and drugs you may have lost the patient because they're not
45:11
on the same page and just a little time at the start finding out what they think and then if
45:18
you as the clinician feel that they're maybe not up to speed with the risk as I appreciate it then
45:25
a little discussion about well you know your sister has broken her hip and you've taken steroids and
45:32
you know do you not think maybe your bones maybe brittle you may be at risk and just a little just
45:38
a five or ten minutes spent doing that can make such a difference in the long term as we said earlier
45:44
you can have a fantastic expensive drug but if you get the word wrong at the start if the patient's
45:50
not on board right at the start then if the drug's not taken then they get no benefit from it so I
45:57
think that's setting the background and finding out what the patient's understanding of the problem
46:03
is before you start is really useful there were other just small things for example like using
46:11
I think the term is vulgar fraction rather than a percentage and if I'm wrong in that please
46:17
please do correct me but rather than saying 25 percent saying one in four because people find
46:24
that much easier to understand that's something I might change next week in the clinic when I'm
46:30
talking to people it's interesting that you would make changes in how you talk to patients
46:37
based on the discussions that we've had today are there any other changes do you think that you'd
46:43
make I enjoyed our discussion briefly about I think the technical term is positive and negative
46:49
framing because that's a very powerful tool and as I think we mentioned earlier and so if you say
46:56
to a patient you have a you have a 10% risk of suffering a hip fracture in the next 10 years and
47:02
hip fractures are a terrible thing to happen I can say it like that if I'm really trying to
47:08
persuade the patient to take a drug but you can frame that negatively and say there's a 90% chance
47:14
that you won't have a hip fracture and I can use that if I'm really trying to persuade the patient
47:20
let's say not to take the drug and those are very powerful tools and Zoe discussed how you know we
47:28
need to use those carefully and how while in some circumstances we should both positively and negatively
47:35
frame things for example if we're trying to put the risk of very rare side effects from bisphosphonates
47:43
into perspective it's important to negatively frame things but there are some instances in which if
47:49
you if you give the that flip side that 50 or 60 or 70% chance on something not happening then you
47:56
can actually dilute your message so I think she used the term tight rope we're always walking a
48:02
tight rope trying to respect the patient's view trying to help them make the decision I think she
48:09
used the term in keeping with their values but also at the same time realizing that you are the
48:16
expert and you have the knowledge and that you're trying to use that to enable them to make what you
48:22
think is the right decision or the best decision and that positive and negative framing of things is
48:28
a very powerful tool and again that's something I think I probably need to think about how I use
48:34
that at the clinic and the other people in the clinic then are the patients the people living
48:40
with osteoporosis what do you think would be the key takeaways for the patients from today's interview
48:50
I suppose the correct answer to that is that we'd love to hear from the patients because I wouldn't
48:56
I wouldn't dare to speak on their behalf and certainly we have had a lot of feedback from
49:02
patients and we're keen to have more I suppose the general answer to that is what we're trying to do
49:08
in this podcast series and that is is educate and inform and entertain but ultimately to I suppose
49:18
empower patients that they feel educated about osteoporosis and that specifically they feel
49:26
empowered to get the most out of the interaction with the clinician we know that time with a
49:34
clinician particularly with an expert in the hospital for example is precious and often quite
49:39
short and we want to really empower people that they feel they can get the most out of that by
49:45
being knowledgeable asking the right questions and coming away feeling confident about the
49:51
decision that they've made and if what we've talked about today contributes to that well then
49:58
I think the episode a little bit worthwhile that's really fantastic I love that really positive and
50:07
empowering message and it's going to be really really really good if we can help anybody to do
50:12
that so if you're listening to the podcast and you have learned anything interesting or you do
50:17
find the information useful or you do take it into a consultation then please let us know for
50:22
better or worse how it went I suppose now we should draw the episode to a close bye bye everyone
50:31
bye now