Dr Karine Nohr takes issue with certain QOF targets on the management of depression
One of the irritating requirements of current general practice, for me, is the emphasis on using the PHQ-9 questionnaire in the management of depression. Although in some instances it might be helpful to provide structure and clarity, I usually find it a useless exercise, both for myself and for the patient. It wastes valuable and limited consultation time, diverting the focus of the consultation away from a potentially meaningful and authentic engagement with the patient.
I appreciate that the quality of management of depression by GP’s varies enormously, but I find it difficult to believe that imposing measurement of the PHQ-9 as a QOF standard will in anyway improve or enhance this quandary. There seems to be such an obsession with quantifying and measuring performance. Do we undertake these actions because we believe in them, because they will benefit the patient, because we are paid to do them or because we are lead to believe that it will make us feel better doctors?
In this area, the Art of Medicine for me is sabotaged by the imposition of external control. There is a misapprehension that it is constructive to impose technology (measurement) and set targets, as a means of supposedly examining standards. What happened to professionalism, the use of initiative and creativity, the ability to draw on my years of training and expertise, to consult in a person-centred fashion?
In imposing the PHQ-9, the subject matter of the consultation becomes an attempt for me, as doctor, to address my own ideas, concerns and expectations, rather than those of the patient. I find my intuition and compassion interrupted by this absurd game-playing, mechanistic, box-ticking exercise.
In an attempt to make doctors more effective and accountable, the imposition of measurement, paradoxically, risks making us not only less effective but also less transparent. We may seek tactical improvements to give us short-term ‘success’. But success at what?
As we strive to ‘perform’, the weight of stress, competitiveness and being externally managed can nudge us away from honest facilitation of narrative, one that might enable the patient in their despair. There is a shift from listening, empathy and unravelling, away from individualisation, towards diagnosis and organisational performance.
A previous both capable and mature registrar had seen a patient who was in great distress. Her PHQ-9 score was very high, the doctor wanted to refer her for possible acute psychiatric admission. She asked me for my view and I returned to her consulting room with her to see the patient. I asked the patient to tell me what was happening. She howled in despair and I listened, offering her a safe space to tell and make sense of her story. None of the content of this narrative touched on aspects covered by the PHQ-9.
By the end of this 15 minute consultation, the patient had reached a place of relative cohesion and position of safety. There was no need for acute psychiatric intervention. She was alright and felt safe to leave the surgery with a follow-up appointment.
It was clear that the PHQ-9 questionnaire had got in the way of the registrar working intuitively and usefully with this patient. Her priorities were misplaced, although in terms of measured performance she had gone by the book. I am sure that I am amongst many GPs in feeling exasperation and frustration at the pointless erosion of our professional integrity, by the imposition of external control, in areas of our work such as these.
Dr Karine Nohr is a GP in Sheffield
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