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