All posts by Moyez Jiwa

Are you addressing the right problem or the one you think you can fix?


The act of consulting a doctor has been shown to be highly ritualized.

Ritual has long been thought to play an important role in the healing processes used by ancient and non-Western healers. In this paper, I suggest that practitioners of Western medicine also interact with patients in a highly ritualized manner. Medical rituals, like religious rituals, serve to alter the meaning of an experience by naming and circumscribing unknown elements of that experience and by enabling patients’ belief in a treatment and their expectancy of healing from that treatment. John Welch. Journal of religion and health

There are five elements to this ritual:

  1. The stage- office, clinic room, cubicle.
  2. The props- what can be seen and or felt.
  3. The actors- doctor, patient and sometimes nurse or therapist.
  4. The script- what is said.
  5. The action- what is done.

All have an impact on the outcome. The doctor’s ‘script’ is of particular importance as it is what the patient hears. The literature offers evidence of the impact of what is said and how it is said on outcomes for patients:

 The quality of communication both in the history-taking segment of the visit and during discussion of the management plan was found to influence patient health outcomes. The outcomes affected were, in descending order of frequency, emotional health, symptom resolution, function, physiologic measures (i.e., blood pressure and blood sugar level) and pain control. M.A Stewart CMAJ

One conclusion of the literature review published in CMAJ was that the process of sharing information includes a discussion about what the patient understands to be the problem and their options with regard to treatment:

These four studies taken together debunk the myth that the only alternative to the physician’s total control of power in the therapeutic relationship is his or her total abdication of power. They indicate that patients do not benefit from the physician’s abdication of power but, rather, from engagement in a process that leads to an agreed management plan.

This issue assumes great significance when it comes to difficult consultations in which it is perceived that the patient is seeking an option that is not in their best interests. Greenhalgh and Gill wrote the following commentary in the BMJ in 1997:

Two thirds of consultations with general practitioners end with the issuing of a prescription. The decision to prescribe is influenced by many factors, to do with the doctor, the patient, the doctor-patient interaction, and the wider social context, including the effects of advertising and the financial incentives and disincentives for all parties. Hardline advocates of rational drug use do not look kindly on variations in prescribing patterns that cannot be explained by purely clinical factors. The prescriber who allows the “Friday night penicillin” phenomenon to sway his or her clinical judgment tends to do so surreptitiously and with a guilty conscience.

The team go on to conclude that:

The act of issuing a prescription is the culmination of a complex chain of decisions. It is open to biomedical, historical, psychosocial and commercial influences, no aspect of which can be singled out as the ”cause” of non-rational prescribing. The search should continue for methods to measure the interplay of these disparate factors on the decision to prescribe.

Michael Bungay Stanier offers an approach to business coaching by focusing on what a person perceives to be their challenge, what they want and how that choice might be impacting on their other options. A similar approach can be taken in medicine. Two decades after Trish Greenhalgh’s editorial in the BMJ there are still many circumstances in which doctors find it challenging to negotiate options these include but are not limited to:

In this context our team surveyed nearly 9000 patients who had been prescribed antibiotics for Upper Respiratory Tract Infections during the latest flu season. We surveyed patients using a validated tool on the third day and the seventh day after a prescription was issued. We look forward to presenting the results at the forthcoming GP17 conference. We will be offering information on the following questions:

  1. What is the profile of patients who were offered a prescription?
  2. What was the symptom profile at these time points and how does this compare with data on patients who have been offered no treatment in other studies?
  3. What are the characteristics of the respondents to the survey?
  4. What proportion of respondents completed the course of treatment?
  5. What proportion of respondents also took regular symptomatic measures?
  6. What is the profile of patients with relatively severe symptoms at each time point?
  7. Are longer consultations or type of antibiotic predictive of compliance with treatment?
  8. Within the limitations of a study that offers only the patient perspective what might help people with Upper Respiratory Tract Infections?

Picture by US Army Garrison Red

For a medical test to be of value the patient needs to see a doctor

Among the commonest tests ordered by doctors is a full blood count. The test presents signs of iron deficiency anaemia. The prevalence of that condition is reported as follows:

In Australia in 2011–12, around 760,000 people aged 18 years and over (4.5%) were at risk of anaemia, with women more likely to be at risk than men (6.4% compared with 2.5%). The risk of anaemia was highest among older Australians, with rates rapidly increasing after the age of 65 years. People aged 75 years and older were more likely to be at risk of anaemia than all other Australians, with 16.0% in the at risk range compared with 3.6% of Australians aged less than 75 years. Australian Health Survey

With regard to this blood test (AACC):

  • Haemoglobin (Hb)—may be normal early in the disease but will decrease as anaemia worsens
  • Red blood cell indices—early on, the RBCs may be a normal size and colour (normocytic, normochromic) but as the anaemia progresses, the RBCs become smaller (microcytic) and paler (hypochromic) than normal.
    • Average size of RBCs (mean corpuscular volume, MCV)—decreased
    • Average amount of haemoglobin in RBCs (mean corpuscular haemoglobin, MCH)—decreased
    • Haemoglobin concentration (mean corpuscular haemoglobin concentration, MCHC)—decreased
    • Increased variation in the size of RBCs (red cell distribution width, RDW)
    • A guide to interpreting the test is here

Therefore among the pathognomonic features of established iron deficiency anaemia (IDA) is a low Mean Corpuscular Volume (MCV). The sensitivity and specificity of a low MCV for a diagnosis of iron deficiency anaemia are quoted as  42% and 93%. Assuming a prevalence of 3.6% in the under 75 year old age group this means that if 100 adults in Australia had a full blood count then 3-4 will have iron deficiency anaemia. Screening these people for IDA with this test 8.3% of people will be told they have an abnormal test i.e. 8 people. Of these only 1-2 will be a true positive for IDA. On the other hand 6-7 may be misled into thinking they might have iron deficiency. 91 will be told they have a normal test in this case 2 may be incorrectly reassured. Of course there are other significant conditions which present with a microcytosis ( low MCV) although ‘treatment’ is not necessary in many such cases and also screening for IDA involves other and more sensitive tests.

If the prevalence of the condition was 20%, then even the modest sensitivity and specificity of this test would identify more people at risk of IDA even though it will also miss people with the condition.

  • Number of people with positive test: 14, correctly identified: 8
  • Number of people with negative result: 86, incorrectly reassured: 11

In practice the sensitivity and specificity of tests may be assumed closer to 90% in each case. Given these figures the numbers of people from 100 people test and correctly identified, incorrectly reassured or told they are ill depends on the prevalence. The prevalence of most pathology in the community is low often well below 1%. The figures are presented in the infographic below.

Prevalence 0.005% ( 5 per 1000 people, e.g. hypothyroidism )  2% ( e.g. diabetes)  20% (e.g. common and plantar warts).

From these figures it can be seen that testing is more fruitful in circumstances in which the prevalence is high. The prevalence is higher in those who have signs and symptoms of a condition. One could argue therefore that the ‘prevalence’ is much higher in those who choose to consult a doctor as opposed to the ‘prevalence’ in the community.  For iron deficiency anaemia these circumstances are well known. Which means an effective consultation in which the patient is heard and examined is crucial to interpreting test results. As can be seen from the calculations there is a substantial risk of labelling people as ill, or requiring yet more tests given the modest prevalence of most conditions in the community and where there might be an indiscriminate use of tests.

It is hard to disagree with Campbell and colleagues who considered this issue and noted that:

1) Diagnosis is based on a combination of tests and clinical examination and there is little research based on the sensitivity and specificity of the combination of different examinations as opposed to a one-off test, which is why GPs are unlikely to know the values.

2) It is unclear what is meant by the prevalence of asthma or diabetes for these GPs. It is not the proportion of people in the population with the disease, but rather the proportion of people who come to consult who have the disease (perhaps with similar age and clinical history). This proportion is likely to be quite high and so the issue of overestimating the positive predictive value is less important.

3) The prevalence of the disease will also depend on the severity of the disease being tested for and so this also muddles the calculations.

We might however equally reasonably expect doctors to have an understanding of the issue if only because the practice of medicine involves the most crucial of ‘tests’ the history and the examination and this issue highlights the importance of that activity. Tests that are not appropriately interpreted can be harmful if only because they become a source of anxiety.

Picture by Aplonid

What are the limitations of the physical examination in practice?

 

The ideal innovation is inexpensive, readily incorporated into practice and has substantial patient benefits. In this context the humble physical examination is a strong candidate. However it is reported that in practice laboratory and or radiological tests are requested more often than not. Here is a quote from an editorial in the British Medical Journal (2009):

In the first camp are those who pine for the old days, bemoan the loss of clinical bedside diagnostic skills, and complain that no one knows Traube’s space or Kronig’s isthmus. In the second camp are those who say good riddance and point out that evidence based studies show that many physical signs are useless; some might even argue that examining the patient is just a waste of time. Verghese and Horwitz

Research suggests that most diagnoses are based on the history and examination:

In this prospective study of 80 medical outpatients ….in 61 patients (76%), the history led to the final diagnosis. The physical examination led to the diagnosis in 10 patients (12%), and the laboratory investigation led to the diagnosis in 9 patients (11%). The internists’ confidence in the correct diagnosis increased from 7.1 on a scale of 1 to 10 after the history to 8.2 after the physical examination and 9.3 after the laboratory investigation. These data support the concept that most diagnoses are made from the medical history. The results of physical examination and the laboratory investigation led to fewer diagnoses, but they were instrumental in excluding certain diagnostic possibilities and in increasing the physicians’ confidence in their diagnoses. Peterson et al

In only one of six patients in whom the physician was unable to make any diagnosis after taking the history and examining the patient did laboratory investigations lead to a positive diagnosis. BMJ 1975

Also the value of tests is contested in some cases:

Information from the history, physical examination, and routine procedures should be used in assessing the yield of a new test. As an example, the method is applied to the use of the treadmill exercise test in evaluating the prognosis of patients with suspected coronary artery disease. The treadmill test is shown to provide surprisingly little prognostic information beyond that obtained from basic clinical measurements. The JAMA network

A considerable number of plain abdominal films taken for patients with acute abdominal pain could be avoided by focusing on clinical variables relevant to the diagnosis of bowel obstruction. European Journal of Surgery

However the predictive value of the physical examination appears to depend on the clinical scenario. If the patient appears ill it is far more likely that they will have clinical signs:

In order to study the occurrence and positive predictive value of history and physical examination findings suggestive of serious illness in ill-appearing and well-appearing febrile children, 103 consecutive children aged ≤24 months with fever ≥38.3°C were evaluated from July 1, 1982 to Nov 24, 1982….The positive predictive values of abnormal physical examination findings for serious illness in ill-appearing (11 of 14, 79%) and well-appearing children (3 of 12, 25%) were significantly different (P = .02 by Fisher’s exact test). The trends for abnormal history findings in ill-appearing and well-appearing children were similar to those for abnormal physical examination findings but did not achieve statistical significance. The results, indicating an important interaction between a febrile child’s appearance and physical examination findings, are discussed in terms of probability reasoning in clinical decision making. McCarthy et al

In some common clinical scenarios it is difficult to find objective evidence in support of a diagnosis and tests are necessary. There are many examples including:

Irritable bowel syndrome

Individual symptoms have limited accuracy for diagnosing IBS in patients referred with lower gastrointestinal tract symptoms. The accuracy of the Manning criteria and Kruis scoring system were only modest. Despite strong advocacy for use of the Rome criteria, only the Rome I classification has been validated. Future research should concentrate on validating existing diagnostic criteria or developing more accurate ways of predicting a diagnosis of IBS without the need for investigation of the lower gastrointestinal tract. Ford et al

Heart Failure

Differences in clinical parameters in heart failure patients with decreased versus normal systolic function cannot predict systolic function in these patients, supporting recommendations that heart failure patients should undergo specialized testing to measure ventricular function. Thomas et al

Painful shoulder

Thirty one consecutive patients with a first flare of shoulder pain were prospectively included in the study. All had a physical examination performed by two blinded rheumatologists. Ultrasonographic examination was carried out within one week of the physical examination by a third rheumatologist experienced in this technique who had no knowledge of the clinical findings. Ultrasonography was considered the optimal diagnostic technique. Naredo et al

Also relevant are the physician’s skill in eliciting and interpreting signs:

Agreement between 24 physicians on the presence or absence of respiratory signs was investigated. The physicians were divided into six sets of 4; each set examined 4 patients with well-defined chest signs. There was generally poor agreement about particular signs. Overall, the 4 physicians in a set were in complete agreement only 55% of the time. Some signs such as wheezing seemed to be more reliably elicited than others such as whispering pectoriloquy. Comparison of diagnoses based on the clinical findings with the correct diagnoses supported by investigations showed that 28% of physicians’ diagnoses were incorrect. The more often the examiners differed from the majority on the presence or absence of a sign, the more likely they were to make an incorrect diagnosis.  The Lancet

In some cases physical signs are unreliable:

A review of published studies of patients suspected of having pneumonia reveals that there are no individual clinical findings, or combinations of findings, that can rule in the diagnosis of pneumonia for a patient suspected of having this illness. However, some studies have shown that the absence of any vital sign abnormalities or any abnormalities on chest auscultation substantially reduces the likelihood of pneumonia to a point where further diagnostic evaluation may be unnecessary. JAMA

Therefore always relying on physical signs without conducting tests is unsafe. However the value of the clinical examination as an integral part of the patient experience was eloquently articulated in the BMJ editorial:

A third view of the bedside examination, and one that we advocate, is that it is not just a means of data gathering and hypothesis generation and testing, but is a vital ritual, perhaps the ritual that defines the internist. Rituals are all about transformation. The elaborate rituals of weddings, funerals, or inaugurations of presidents are associated with visible transformation. When viewed in that fashion, the ritual of the bedside examination involves two people meeting in a special place (the hospital or clinic), wearing ritualised garments (patient gowns and white coats for the doctors) and with ritualised instruments, and most importantly, the patient undresses and allows the doctor to touch them. Disrobing and touching in any other context would be assault, but not as part of this ritual, which dates back to antiquity. Verghese and Horwitz

Common sense dictates that where the patient appears unwell the physical examination will have a higher yield. In those circumstances clinical examination is crucial:

Misdiagnosis of acute appendicitis is more likely to occur with patients who present atypically, are not thoroughly examined (as indexed by documentation of a rectal examination), are given IM narcotic pain medication and then discharged from the ED, are diagnosed as having gastroenteritis (despite the absence of the typical diagnostic criteria), and with patients who do not receive appropriate discharge or follow-up instructions. Rusnak et al

Therefore the physical examination has an incalculable value not necessarily obviating the need for tests but increasing patient satisfaction and reducing the risk of litigation. Click the link for an excellent video on examination.

 

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More talking less testing in medicine

According to Mark Schlesinger and Rachel Grob writing in Milbank Quarterly in 2017:

As much as 30% of US health care spending may be unnecessary… Most Americans who anticipate benefits hope that less testing and treatment will be replaced by more interactive and personalized care. Even without media priming, many Americans would avoid common forms of low-value care like unnecessary antibiotics or excess imaging for lower back pain, but few favor clinicians who avoid these practices.

This suggest that if people leave the doctor’s clinic without a script or a blood test they are dissatisfied. The question is whether a test or treatment is expected or as seems equally likely that patients are not making an informed decision. There are websites that indicate what test might be done:

Lab Test Online

So for example for Fibromyalgia the site advises:

Although rarely talked about, fibromyalgia is a relatively common disorder that affects about 3.4% of all women and 0.5% of all men, primarily those of early middle age. It has been estimated that on a typical day, about 5% of the people in a doctor’s waiting room are affected by fibromyalgia. For most rheumatologists, doctors who specialise in rheumatic diseases, it is the second or third most common condition diagnosed.

There are many variable symptoms associated with fibromyalgia, but the condition almost always starts with chronic widespread pain and pain upon palpation in particular areas called “tender points.” Most people with fibromyalgia also have some degree of chronic fatigue and interrupted sleep.

But at the same time the site recommends:

Therefore a 30 year old female presenting with the typical symptoms might expect a blood test.

On the other hand hypothyroidism usually presents with more features than simply muscles aches and pains. It also presents with lethargy, sensitivity to cold, weight gain, mental dullness, bradycardia or a combination of these symptoms. [ . 1970 Jan; 29(1): 10–14.] Such signs and symptoms can be elicited from the history and examination.

With respect to screening for thyroid dysfunction in fibromyalgia (FM):

 A cross-sectional descriptive study was performed in 400 consecutive female outpatients with suspected FM and in 384 controls from January 2001 to October 2004. TSH measurement was used as the first line test to detect Thyroid Disorder (TD). RESULTS: The prevalence of TD in patients with suspected FM (40/400; 10%; 95% CI: 7-13%) and controls was similar (46/384; 12%; 95% CI: 9-15%). No differences were found in the types and grades of TD. The prevalence of TD was higher in patients with suspected FM and connective tissue diseases (12%) than in those without these diseases (5%). The most frequent TD was subclinical hypothyroidism (5.5% in suspected FM and 6.7% in controls), and in 93% of these cases TSH concentrations were <10 mIU/L. FM persisted in all women with hypothyroidism even after euthyroidism was achieved with levothyroxine. A total of 870 TSH determinations were performed in 360 euthyroid patients with suspected FM. CONCLUSIONS: The prevalence of TD in women with suspected FM does not differ from that in the general population. Screening for TD does not appear to be justified in women without diseases that increase their risk. In many cases the request for thyroid function tests is excessive. Treatment for hypothyroidism does not affect FM. Reumatologia Clinica 

A study of 50 patients with Fibromyalgia concluded that:

Patients were usually seen by many physicians who failed to provide a definite diagnosis despite frequent unnecessary investigations…. Management is usually gratifying in these frustrated patients. The most important aspects are a definite diagnosis, explanation of the various possible mechanisms responsible for the symptoms, and reassurance regarding the benign nature of this condition. A combination of reassurance, nonsteroidal antiinflammatory drugs, good sleep, local tender point injections, and various modes of physical therapy is successful in most cases. Yunus et al

A previous study noted a similar challenge with laboratory testing for patients presenting with ‘unexplained fatigue’. The authors recommend not testing patients for 4 weeks after the initial presentation. The advise was based on these data form patients presenting with unexplained fatigue in general practice:

325 patients were analysed (71% women; mean age 41 years). Eight per cent of patients had a somatic illness that was detectable by blood-test ordering. The number of false-positive test results increased in particular in the expanded test set. Patients rarely re-consulted after 4 weeks. Test postponement did not affect the distribution of patients over the two-by-two tables. No independent consultation-related determinants of abnormal test results were found. Koch et al

In a previous post I explained why  tests can be harmful with respect to the limited positive predictive value of tests in general practice. We need simple and effective interventions that reduce the prospect of patients being tested but which are designed in the context of general practice. I suggested a road map.

Therefore we might agree with Mark Schlesinger and Rachel Grob when they concluded:

Long-term robust public support for addressing low-value care may require shifting the focus from particular tests and treatments to emphasize, instead, the potential for better communication and more personalized attention if clinicians spend more time talking and less time testing.

If you are a clinician it might help to start by making a list of circumstances in which you order a test.

Picture by Lori Greig

To stem healthcare costs offer more time in the consulting room

It is evident that healthcare costs are outstripping inflation. The drivers are increasing utilisation of services and exponential cost of treatment.

As healthcare continues to take up a larger part of the overall economy, structural changes-such as the push toward paying for value, greater emphasis on care management and increased cost sharing with consumers-are taking a stronger hold, pulling back against rapid healthcare spending growth. Still, with medical cost trend hovering between 6 and 7 percent for several years, health spending continues to outpace the economy. Even the “new normal” is not sustainable. PWC

New or increased use of medical technology contributes 40–50% to annual cost increases, and controlling this technology is the most important factor in reducing them. The Hastings centre

What has been shown to reduce costs is General Practice.

Despite contentious debate over the new national health care reform law, there is an emerging consensus that strengthening primary care will improve health outcomes and restrain the growth of health care spending. HealthAffairs

There are several ways in which doctors in this sector can save the day:

  1. Reduce test ordering.
  2. Prescribe generic drugs where appropriate and avoiding prescribing drugs that have not been proven to be effective.
  3. Stop polypharmacy especially for older people.
  4. Help patients to determine what has marginal value and what is essential if not life saving.

These goals are easier to achieve when:

  1. Doctors have time with patients
  2. Doctors are able to communicate with patients
  3. Doctors clinics/ office are designed to engage patients.

Primary care is also being perceived as ripe for disruption by technological innovation. However not everyone agrees that technology is likely to help:

1. Telehealth.

Direct-to-consumer telehealth may increase access by making care more convenient for certain patients, but it may also increase utilization and health care spending. Ashwood et al

Using a panel dataset from a large healthcare system in the United States, we find that e-visits trigger about 6% additional office visits, with mixed results on phone visits and patient health. These additional visits come at the sacrifice of new patients: physicians accept 15% fewer new patients each month following e-visit adoption. Bavafa et al

2. Wearable technologies.

35% will stop wearing their devices after six months. It is not known what proportion of people with smartwatches actually use the fitness tracking capabilities of these watches on an ongoing basis. There is little information about the demographics of people who purchase fitness trackers and smartwatches; however, given the cost, consumers are likely to be the “wealthy well”. People suffering from chronic disease on the other hand are more likely to come from the less educated and lower income population. And then there is the issue of what data these devices collect and what we can actually do with that data.  The Conversation

3. Genetic testing.

Cost is also a factor. Estimates of national spending on genetic and molecular testing vary, partly because there are so many different types of tests for different conditions. A 2012 analysis by UnitedHealth Group of national trends estimated the U.S. could see overall spending on genetic tests reach between $15 billion and $25 billion by 2021, up from $5 billion in 2010. Despite the uncertainties, Independence CEO Daniel J. Hilferty said the insurer felt it was important to try to help some members learn more about their disease. He declined to say how much the program would cost but said the expected number of patients would be small, perhaps in the hundreds. Medpage today

4. Electronic medical records.

Electronic health record (EHR) advocates argue that EHRs lead to reduced errors and reduced costs. Many reports suggest otherwise. The EHR often leads to higher billings and declines in provider productivity with no change in provider-to-patient ratios. Error reduction is inconsistent and has yet to be linked to savings or malpractice premiums. As interest in patient-centeredness, shared decision making, teaming, group visits, open access, and accountability grows, the EHR is better viewed as an insufficient yet necessary ingredient. Absent other fundamental interventions that alter medical practice, it is unlikely that the U.S. health care bill will decline as a result of the EHR alone. Health Affairs

On the other hand there are simple things that doctors can already do when consulting patients to reduce the cost of healthcare. Here are three which have been featured in leanmedicine as well as in the Wall Street Journal before:

a. Slow down

b. Active communication

c.  Minimise competing agendas

In short: ” If you want doctors to improve communication skills with patients, then pay them for their time to do it”

Image by Roswell Park

The encounter could end well if you give it a chance

There is a moment in any consultation when someone could take an unhelpful perspective. That perspective could severely undermine the subsequent exchanges between those concerned.

In social categorization, we place people into categories. People also reflexively distinguish members of in-groups (groups of which the subject is a member) from members of out-groups. Furthermore, people tend to evaluate out-groups more negatively than in-groups. In this way, social categories easily lend themselves to stereotypes in general and to negative stereotypes in particular. Cohen

The problem with such categorization is that we then rate aspects as positive and negative disregarding evidence to the contrary. In a series of classic studies researchers recruited a group of 12 year old boys to attend a summer camp. The boys were divided into two teams which were then pitted against each other in competitive games. Following these games, the boys very clearly displayed in-group chauvinism. They consistently rated their own team’s performance as superior to the other team’s. Furthermore 90% of the boys identified their best friends from within their own group even though, prior to group assignment, many had best friends in the other group. M&C Sherif

Healthcare professionals can also be prone to social categorisation:

It is equally important to recognize that physicians and other health care workers are not mere empty vessels into which new cultural knowledge and attitudes need to be poured. They are already participants in 2 cultures: that of the mainstream society, in which some degree of bias is always a component, and the culture of medicine itself, which has its own values, assumptions and understandings of what should be done and how it should be done. Reducing racially or culturally based inequity in medical care is a moral imperative. As is the case for most tasks of this nature, the first steps, at both the individual and societal levels, are honest self-examination and the acknowledgement of need. Geiger

The patient opened the consultation saying ‘I don’t sleep well’. He wore a raggy teeshirt, torn jeans and old trainers. A baseball cap was perched atop an untidy mop of greasy hair. He was overweight verging on obese and had two days of growth on an unshaven face. He worked in a warehouse. Thirty seconds into the encounter I caught myself thinking ‘he wants a prescription for a hypnotic’ but stopped myself launching into a prepared speech on the addictive dangers of hypnotics. It turned out that he had worked to lose 15kgs, studied and practiced sleep hygiene and was keen to explore any option other than drugs. He was far from interested in a script for Temazepam. It turned out that he was keen to hear if I approved of his low carb diet and wondered if yoga and meditation might help. The next seventeen minutes were a mutually satisfying consultation which ended with a handshake. A sure sign that it had gone well.

This small study suggests that most handshakes offered by patients towards the end of consultations reflect patient satisfaction — ‘the happy handshake’. Indeed, many reasons were recorded using superlatives such as ‘very’ and ‘much’ representing a high level of patient satisfaction — ‘the very happy handshake’ BJGP

Therefore there is a point in the consultation when the healthcare professional needs to scan their impressions for evidence of  stereotyping.

Picture by David Baxendale

Road map to better health outcomes

  • Improvements in healthcare outcomes warrant small changes. [Previous post].
  • Those best placed to know where and how to make those adjustments will change the future.
  • The most effective changes will trigger behaviours that we are already motivated and easily able to assimilate in practice.
  • The best interventions are those in which all concerned are rewarded in some way.

Such interventions:
1. Build on something the target is already doing. Anything that adds to workload or requires practitioners or indeed patients to do something significantly different in the course of going about their business is a waste of effort [example].
2. Need very few people to adopt them.  Ideas that require an orchestrated change in patient and or their general practitioner and or the specialist will disappoint [example].
3. Must be anchored by something that already occurs in practice. Practitioners routinely reach the point where they must agree or disagree with the patient and then do something.  An intervention that is anchored at that point is more likely to be assimilated in practice [example].
4. Can be incorporated into the habits or rituals of the target. Doctors vaccinate patients and patients regularly use their phones. Ideas that combine such aspects are likely to succeed [example].
5. Provide something the target wants. Interventions that are at odds with the target’s ideas, concerns or expectations are unlikely to succeed [example]. Interventions that speak to the target’s desires can be highly effective [example].

 

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Small changes big impact in healthcare

According to the Royal College of General Practitioners, UK:

The consultation is at the heart of general practice… As a general practitioner, if you lack a clear understanding of what the consultation is, and how the successful consultation is achieved, you will fail your patients. RCGP

The impact of the consultation varies because of the different perspectives between doctors and their patients:

…. in the consultation the patient is most commonly construed as a purely “biomedical” entity—that is, a person with disconnected bodily symptoms, wanting a label for what is wrong and a prescription to put it right. Even under this guise the patient still sometimes fails to report their full biomedical agenda. Not all symptoms were reported and not all desires for a prescription were voiced. Barry et al BMJ

Much of what transpires in the consult is a ritual. Over the course of a professional lifetime most doctors will greet the patient in the same way, say the same sort of thing, prescribe similar drugs and order the same sorts of tests.  This occurs for a variety of reasons perhaps because a doctor learns to present herself and behave in a specific way but also because the doctor’s training and experience has a significant impact on their clinical practice. There is ample evidence that how doctors interact with their patients is crucial to the outcome of the consultation and ultimately to outcomes in healthcare:

An increasing body of work over the last 20 years has demonstrated the relationship between doctors’ non-verbal communication (in the form of eye-contact, head nods and gestures, position and tone of voice) with the following outcomes: patient satisfaction, patient understanding, physician detection of emotional distress, and physician malpractice claim history. Although more work needs to be done, there is now significant evidence that doctors need to pay considerable attention to their own non-verbal behavior. Silverman BJGP 2010

With this in mind, if you are a doctor you may want to consider seven components of your interaction with patients that warrant occasional re-evaluation:

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On the question of quality context is everything

The question of quality in primary care is a vexed one. According to the King’s Fund:

We have suggested some ways that practices could begin to audit their own practice…. and made recommendations about how the work we have begun could be used as the basis for future development of quality indicators in general practice. While some of these are harder to define we think that many of these aspects of care can be captured by measuring how patients experience care. King’s Fund 2011

The issue is addressed in some detail in the report which includes the following key points:

The key activity in general practice is the consultation. The consultation has been dissected for its component parts by Deveugele et al :

8% Social behavior, 15% agreement, 4% rapport building, 10% partnership building, 11% giving directions, 28% giving information, 14% asking questions and 7% counselling.

Much of what transpires in that consultation can only be reliably interpreted within the local context of that consultation. Therefore any interpretation of the outcome must take into account factors that are not generalisable. That makes it difficult to draw reliable and safe conclusions and by corollary to set benchmarks that apply across every setting.

If the King’s Fund report makes any contribution it is that it highlights the need for further research into interventions that can be deployed within the context of the consultation to reduce diagnostic errors, to understand differences in referral rates and to explain variation in prescribing practice. It also highlights that we have inadequate data on what interventions are best deployed in the context of primary care to support health promotion.

Finally the report makes a very important observation that patients need to be more involved in their healthcare and that the patient experience should be the basis on which we focus on this issue going forward.

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What is the role of doctors in health promotion?

Our health is a cause for concern.

  • Over 1 in 5 Australians aged 18+ (22%) reported having Cardiovascular disease in 2011.
  • In 2009, the risk of being diagnosed with cancer before their 85th birthday was 1 in 2 for males and 1 in 3 for females.
  • 1 in 10 Australians aged 18+ (10%) had biomedical signs of chronic kidney disease in 2011–12, with the majority of these showing early signs of the disease.
  • 1 in 19 Australians (5.4%) had diabetes in 2011–12 (self–reported and measured data). This is includes approximately 1% of the population who did not self-report they had diabetes, which may indicate they were unaware they had the condition.
  • In 2007, 1 in 5 Australians aged 16–85 (20%) experienced a mental disorder in the previous 12 months.
    In 2013–14, 1 in 7 children aged 4–17 (14%) were assessed as having mental health disorders in the previous 12 months .
  • Over 1 in 4 Australians (28%) reported having arthritis and other musculoskeletal conditions in 2011–12. The most prevalent conditions were back problems, osteoarthritis, osteoporosis and rheumatoid arthritis.
  • 3 in 10 Australians aged 25–44 had untreated tooth decay in 2004–06.
  • 1 in 10 Australians (10%) reported having asthma in 2011–12. This rate is significantly lower than the rate of 11.6% in 2001.
    1 in 42 Australians (2.4%) reported having COPD in 2011–12. The development of COPD occurs over many years and mainly affects middle aged and older people.

It seems:

  • We eat too much. Almost 2 in 3 Australian adults (63%) are overweight or obese. 1 in 4 Australian children (25%) are overweight or obese.
  • We don’t take enough exercise. Based on estimates that between 60 and 70 per cent of the Australian population is sedentary, or has low levels of physical activity, it has been suggested that increasing participation in physical activity by 10 per cent would lead to opportunity cost savings of $258 million, with 37 per cent of savings arising in the health sector.
  • We drink too much alcohol and have been drinking more every year.
  • We don’t eat enough vegetables. In 2007–08, just over half of all children aged 5–7 years (57%) and a third of children aged 8–11 years (32%) ate the recommended amount of fruit and vegetables but only 5% of people aged 12–18 years and 6% of people 19 years and over did so.
  • Too few of us avail of cancer screening tests.
  • We drive too fast. Speeding is a factor in about one third of road fatalities in Australia. Additionally, more than 4100 people are injured in speed-related incidents each year.

Someone must be to blame for all this- if only they would do their job and tell us to eat and drink less, exercise more and slow down.  But wait there are industries profiting from our bad choices. We are influenced by more than our doctor. We have known this for decades. It is known as the Bronfenbrenner’s Ecological Model:

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At the core of Bronfenbrenner’s ecological model is the child’s biological and psychological makeup, based on individual and genetic developmental history. This makeup continues to be affected and modified by the child’s immediate physical and social environment (microsystem) as well as interactions among the systems within the environment (mesosystems). Other broader social, political and economic conditions (exosystem) influence the structure and availability of microsystems and the manner in which they affect the child. Finally, social, political, and economic conditions are themselves influenced by the general beliefs and attitudes (macrosystems) shared by members of the society. Wikipedia

Most Australians (13 Million) spend over 18 hours a day online. One in every five minutes (3.6 hours) a day is spent on social media. On the other hand time spent with general practitioners (GPs) is declining:

The proportion of GPs providing ‘Level C’ consultations (longer than 20 minutes) is substantial (96%) and constant; however, the number of long consultations provided per GP decreased by 21% between 2006 and 2010. The proportion of GPs providing Level D consultations (longer than 40 minutes) decreased from 72% in 2006 to 62% in 2009, while the number of Level D consultations provided per GP decreased by 26%. AHHA

Secondly the number of problems presented to doctors in increasing. In one survey of the 8707 patients sampled from 290 GPs, approximately half (47.4%, 95% CI: 45.2–49.6) had two or more chronic conditions.

Junk food is cheap and readily available. It is advertised to children. Fresh fruit and vegetables are less available, more expensive and of poorer quality in rural and remote Australia. These areas are also among our most economically disadvantaged and residents generally have less disposable income to spend on expensive, healthier food options. According to one report a multinational fast food company paid $500 million in taxes to the Australian government and might be due to pay more.

A 2017 poll  found that most Australians (78 per cent) believe Australia has a drinking problem, 74 per cent believe our drinking habits will worsen over the next five to ten years, and a growing majority (81 per cent) think more should be done to reduce alcohol harm. A price increase of 10%  on alcohol has been shown to reduce consumption by an average of 5%. Similarly for every 10% increase in price, consumption of tobacco reduces by about 4%. Finally a significant proportion of people are unhappy at work and this has been associated with snacking and weight gain.

So it seems that we are choices are triggered by far more than a doctor informing us that we are making bad choices. Doctors can make a huge difference to the individual who seeks advice in a teachable moment and can be triggered to make better choices. This requires more time with the patient and a greater focus on the needs of that individual patient rather than the distraction of a public health agenda.  At a public health level doctors’ impact is miniscule because of the much more powerful and ubiquitous drivers of poor choices that are fueled by those who profit from our dubious behaviour. A summary:

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