Listening and measuring

GP income (via QoF) is to depend more than ever on increasingly tighter control of our patients’ blood pressure, diabetes and health-related bahaviour and the collection of ever-increasing amounts of data of little or no relevance to patient care.

GPs in deprived areas will be adversely affected, since most chronic disease management depends not on GP behaviour, but on patient self-motivation. According to the hierarchy of needs of patients where I work, finances, employment, housing, freedom from violence, relief from anxiety and depression and social opportunities to help alleviate boredom, isolation and loneliness, all come above managing hypertension, cholesterol, medication or exercise regimes.

Pertinent to GPs wherever we work is the impact on the doctor-patient relationship of the electronic templates that dominate our patients’ medical record, rather than our patients’ agenda. This paper by Swinglehurst and Greenhalgh provides evidence to back up what many, if not all of us GPs and patients are experiencing: our ability to pay attention to our patients is being severely compromised. Electronic alerts pop up incessantly to remind us that the patient sat in front of us, trying to get our undivided attention needs to be weighed, offered smoking cessation advice, counseled about their alcohol intake, advised to exercise more, reduce their cholesterol and be screened for dementia. Without which we stand to lose money which ultimately means less doctors and even less appointments and time to hear our patients’ concerns.

Much of what is really important, the ability to listen seriously and have meaningful conversations with patients is being lost by the demand that every interaction is measured by data collected, diagnoses made, investigations ordered, treatments prescribed and the procedures undertaken rather than seriously paying attention to what our patients need to say to us.
I’m slowly bringing my next, long blog about loneliness to a conclusion, and it’s clear that if we don’t make time to listen properly to what our patients are telling us, we will treat every type of distress and every presentation as a disease to be coded, investigated and treated. If this happens we will have failed at our most important gatekeeper role, not the one between GP and specialist, but between suffering and disease.

See also

Computer templates in chronic disease management: ethnographic case study in general practice BMJOpen

Life for patients and their families is so much more than data. Kevin MD

Reflections on a Half a Century of Medical Practice: The art of listening to the elderly patient. Bernard Lown

Narrative-based medicine. BMJ series.

Medically Unexplained Stories. John Launer

Love’s Labour Lost, by Iona Heath

An epidemic of loneliness. Lancet.

When Computers Come between Doctors and Patients. NYTimes

Computer use must not affect doctor patient relationship BMJ

Computers take away doctor-patient relationship Murray Feingold

Half of doctors too busy using computers to look patients in the eye. Daily Mail

The Talking Cure for Health Care. Wall St Journal

Holistic vs Fragmented Health Care. Huff Post

The Doctor will see your electronic medical record now

Edit 05.03.2013

Data, data everywhere: The John Henry effect

by Greg Irving. Originally published by BMJ on 5th Feb 2013

The “Ballad of John Henry” tells of the legendary black American steel pin driver, John Henry, who swung a huge nine pound hammer driving railroad spikes on the Chesapeake and Ohio railway in the 1870’s.[1] John Henry was renowned for his strength amongst his fellow workers and could drive in a steel pin into a track with a single blow instead of the usual three. The ballad centers on a competition between John and a mechanical steam powered drill, a controversial innovation that threatened to replace thousands of his fellow laborers in a quest for greater efficiency. When John Henry heard that the output of his fellow laborers were being compared with that of a steam drill, he challenged the railroad company to a contest pitting his own skill and strength against that of the stream drill to see who could lay the track the quickest.

The steam drill was positioned on one side of the track and John Henry on the other. When the signal to start was given two thousand people came to watch the event. John Henry made more progress in a shorter time than the steam drill and when he reached the finish line the steam drill was no where in sight. He won the contests but worked so hard to outperform the machine he collapsed and died in the process. The John Henry is just one example of reactivity, the phenomenon whereby individuals alter their performance or behavior to the awareness that they are being observed. The term John Henry effect, also known as compensatory rivalry, was first suggested by Robert Heinich in 1970 then further developed by Gary Saretsky in 1972 to describe the behavior. [2]

If we were to cast this tale into the future then computers powered by big data would be represented by the steam drill and the doctor by John Henry. Perceiving the consequences of such an innovation as threatening to their jobs, status, or traditional patterns of working, doctors may go to extraordinary lengths to outperform the opposition. However, the increased work required for victory may prove unsustainable for some and come at considerable personal cost.

Such effects may confound evaluation outcomes unless controlled for by robust experimental design e.g. adequate blinding. When such evaluations ultimately take place (and they will) we should not forget that doctors do far more than just crunch data (or lay track). Indeed, the interpersonal warmth, trust and informality which characterise most clinical consultations is where we witness the real victory of human dignity, intuition, and lateral thinking over the politically driven degradations of the machine age.


1. Belafonte, H. John Henry. 1959

2. Saretsky G. The OEO PC experiment and the John Henry Effect. Phi Delta Kappa 1972; 53:579–581
3. Metcalfe D. Competence, administration and learning. London: MSD Foundation 1989.

Competing interests: None declared

9 responses to “Listening and measuring

  1. Would it satisfy the need for data and the GP’s relationship with the patient if you were able to decide individual treatment plans based on that patient’s needs, rather than subscribing to generic ones? I understand the need for data but people never benefit from being treated like widgets, and you’re so right about the importance of connection.

  2. Yes! Thank you for restoring my rapidly diminishing faith in the medical,profession. Wouldn’t it be wonderful if,,instead of relegating important skills like listening, true reflection and, yes, even storytelling, to the ‘soft’ skills the, these things were valued as essential skills and qualities for every health worker?

  3. I just commented on another blog yesterday about this and the fact that the ‘template’ is restructuring the GP consultation. I have strongly believed for a long time (I started a PhD in 2000 on the implementation of new information strategies in the NHS – not completed) that the introduction of the new (at the time) information technologies would change the nature of healthcare.

    From my perspective of a patient with a chronic disease rather than a HCP , I do feel that chronic disease management is more targeted to getting the right numbers and getting them logged on the computers than knowing the patient first. I always had a history of higher than normal BP, but it only became a problem that needed medication when I became a diabetic because I was ‘out of target levels’ for diabetics. And don’t let me rant on about the fact that I always get asked about smoking when the answer in the past has always been ‘never’. 🙂

    Good blog, thanks for sharing!

  4. The way GPs get paid has (like most of the rest of country) never been fair.

    Yes, we get paid more for QoF, but we wouldn’t starve if we didn’t do any QoF.
    Yes, there are QoF popups reminders on our computers, but you can turn them off if you want or just ignore them.
    Yes there are issues about whats in the patients best interest at any time but you can make simple rules about QoF. Ours are
    • We put patient welfare before QOF points
    • We don’t do things which are without medical value if they inconvenience the patient
    • We exempt patients if it is in their best interest, not just ours
    • We code all important diagnoses (even if failure to code would be financially helpful)
    • We only change, add or merge QoF codes retrospectively if this coding is clearly supported by free text evidence and improves the quality of the medical record

    Do we really want to go back to the days when there was no quality measure of general practice. QoF is imperfect and must evolve but it does seem a reasonable approach to changing the behaviour of GPs.

  5. As a patient I find it infuriating to be offered tests/advice etc which I haven’t asked for and don’t want. I don’t blame the doctor but what I see as the ‘nagging’ does keep me away from visiting the surgery. I know I am not the only one of my friends who reacts like this so maybe it should sometimes be left to the discretion of the patient to request what they feel is required.

  6. Really well articulate. Thank you. Do you mind if I copy and paste to print off for my less internet-savvy colleagues…? Will not of course take the credit!

  7. Pingback: Frontline Friday round-up 15th February 2013

  8. This is what i was thinking about clash of agendas. In Turkey our performance and salaries are based on same sort of performance measures like obesity reproductive health and vaccination. It is interesting when a women asks you about cough but your ehr asks you about contraceptive methods

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