The Ashya King case highlights the importance of doctor-patient dialogue

http://www.theguardian.com/society/2014/sep/09/ashya-king-doctor-patient-dialogue

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I trained as a GP in an affluent rural practice. Often our patients were well-informed scientists, teachers or university lecturers. They did extensive research on the unusual ailment or the latest groundbreaking medication.

As a trainee GP with little experience, it was often daunting to manage these intense patient-led encounters. Whether prescribing a statin for high cholesterol or referring for investigations, everything involved negotiation with the patient. It was immaterial that there were 10-15 minutes allocated to each encounter: the consultation finished when a plan was reached.

It would seem this is not such a bad model of care. It ensures patient compliance and makes for a better doctor-patient relationship, once the doctor has willingly given up a paternalistic "doctor knows best" attitude in favour of patient-centred holistic care.

The case of Ashya King and his parents brings home the difficulties when health beliefs collide and there is a breakdown in the doctor-patient relationship. Sadly, this is not an isolated case. There are countless patients who feel alienated in hospitals and GP surgeries because we are disconnected, rushed, or dismissive.

When I moved to an urban practice, I found that suggesting different options often led to confusion. Many of my older patients asked what I would recommend and accepted it at that. However, it would be easy to be sucked into the stereotype that poorer or working-class patients are not well informed and need a health professional to make decisions for them. This is simply not the case. There is no typical patient who walks through the door.

I have known James for a few years. He suffers from frequent severe migraines. These are debilitating and he has to stay in bed for days during an attack. He has been referred to occupational health and is being performance-managed at his workplace.

He has tried various migraine medications and even Botox injections, which are thought to help some people, without improvement in his symptoms.

He is keen to explore the possibility of closure of a patent foramen ovale (PFO). This is a hole between the two upper chambers of the heart that is normally present in a foetus and closes soon after birth. In some cases, it remains open but does not usually cause problems. Some studies have suggested a link between PFO and migraines, with reduction in frequency after closure, though other studies have not confirmed this association. Research continues in this area.

The National Institute for Health and Care Excellence says there is inadequate evidence on the efficacy of this procedure, which consists of passing a device through a vessel in the groin into the heart to close the hole, and also a small risk of complications.

I discuss all this with James who has talked it through with his neurologist and is about to see a cardiologist. He has high hopes that this treatment will help him. He has read a wealth of information on the internet, a lot of it in forums, blogs or testimonials. But I remain cautious and talk about a lack of robust trials and meta-analysis. Somewhere along the line, I feel that we are no longer on the same page.

As health professionals, it is important that we take a step back to reflect when we reach that point. As David Pendleton, a psychologist who has written a lot on the consultation theory that is taught to medical students, said: "Consultation is the central act of medicine which deserves to be understood."

The King case may not change how we consult generally but it will certainly affect situations where there are different religious or health beliefs, children, or a disabled patient who is a ward of court or lacks capacity to make their own decisions.