Can’t you see them? They’re everywhere. When you start looking, you can’t help but notice them. There they are, huge important sections of teaching about patient management that we’ve locked away in a black box so we don’t have to think about them. We don’t think about the mechanisms or the workings, and we can clamber back onto the comfort zone of biology, like a safe island in a choppy sea of uncertainty.
Some of our black boxes are black box referrals. These are where a solution to a problem slips away from the prescription pad or a set of simple instructions, but into another professional’s domain. We may be comfortable with referrals to other medical colleagues, but what goes on with the speech pathologist or family violence worker? The black box referral works to say:
‘This patient has a problem. Please can you make it go away by some means before I see them again?’
What actually happens with the patient remains unknown. The classic example used to be with psychologists, where the merest presence of an emotion in the consultation would result in a black box referral. Now that we know about the existence of cognitive behavioural therapy, problem solving, or supportive counselling we have some labels for the black box, even if we’ve not quite peered inside to see what they mean.
One of our other significant black boxes is something called ‘patient education.’ This one is used liberally at any point where the patient may need to be told something longer than a few sentences. It can be used to mean almost anything from ‘I would tell the patient a series of facts that I remember from medical school’, to ‘I would give the patient a printed information leaflet, though I have no idea what it may contain’. It’s a particularly large black box, with a particularly strong lock, to avoid having to actually say with any specificity what you’ll do:
‘Oh, yes, I’ll prescribe metformin 500 mg twice daily, and then do some patient education.’
‘Right. On what exactly?’
‘Yes. You know. Patient education. On lifestyle.’
If we grab a chisel, and wedge open the patient education black box, what would we find? Everyone’s box may be different. For some, their patient education box contains a medical textbook to read to the patient. For others, there’s a communication skills manual mislaid from some other part of the course. For others, there’s a copy of How to Win Friends and Influence People. One or two of us may even just have a video of Malcolm Tucker shouting.
When we don’t have a little peek inside these black boxes, we contract out key parts of the doctor–patient relationship. We need medical education to prise open these boxes and to describe their contents in more detail. If we know the sort of approaches the psychologist may take for this problem, our referral will be more effective, and we can let the patient know what to expect and reinforce the work.
If we share the contents of each other’s patient education black boxes, we may give people a whole range of approaches. Once we start noticing these black boxes everywhere in medical education, we’ll find we have chisels and tin openers to rummage around inside.