The future of healthcareLearn More

A cough is not minor in any sense

 

 Acute cough, which often follows an upper respiratory tract infection, may be initially disruptive but is usually self‐limiting and rarely needs significant medical intervention. Thorax

In adults or children with acute cough, the evidence does not support the effectiveness of over the counter preparations. Cochrane Review

On the other hand:

Oral syrups segment is expected to expand at 2.9% CAGR (Compound annual growth rate) over the estimated period and be valued more than US$ 10 Bn by the end of 2026. The segment is expected to create absolute $ opportunity of a little more than US$ 300 Mn in 2017 over 2016. The segment is the most acceptable dosage form for cough, cold, and sore throat medicines due to ease of administration and pleasant taste. The oral syrups segment dominated the global cold, cough and sore throat remedies market in terms of revenue in 2016 and the trend is projected to continue throughout the forecast period. Oral syrups segment is the most attractive segment, with attractiveness index of 1.5 over the forecast period. FMI

Cough, cough, cough. Every hour on the hour. There appears to be no end to it this season. No symptom is driving more people to seek treatment than the misery of upper respiratory tract infections (URTIs). The impact of the URTIs season on the population is massive as has been demonstrated in data from the US:

More than half (52%) of Americans reported that their cold impacted their daily life a fair amount to a lot. Productivity decreased by a mean 26.4%, and 44.5% of respondents reported work/school absenteeism (usually one to two days) during a cold. Overall, 93% of survey participants reported difficulty sleeping. Among all respondents, 57% reported cough or nasal congestion as the symptoms making sleep difficult. Drug Store News

One issue that appears to be bound up with the epidemic of URTIs is rates of prescribing of antibiotics. Here the available data are encouraging:

Professor Bell suggests that 20–25% of acute URTIs are likely to need antibiotics…..We have shown that over the last 13 years GPs in Australia have decreased their level of prescribing of antibiotics for acute URTI and to a lesser degree, for ‘other RTIs’. Britt et al

However there is an opportunity here over and above the treatment of an annoying self-limiting infection. Most people who seek help want more than anything else to feel better. By 2026 they will spend $10Bn in the attempt. The conversations in consulting rooms and pharmacies around the country focus on symptoms that will improve, eventually. Antibiotics won’t help. But, in the end what people want is to feel better not a lecture on virology. There is an opportunity for a ‘set play’.

Yes, you have a nasty infection and I see that it is making you miserable. Here’s what you can do to help your self.

There is an opportunity to forge a relationship with the patient. The ritual of the consultation complete with examination has the potential to create enormous deposit of social capital. Something that might be critical when the patient presents later in life with life-limiting pathology. There is the chance to understand a lot more about the patient for whom a cold is the final straw. But what’s the context? Be curious, very curious that’s why it’s called the art of medicine.

Picture by Rebecca Brown

It is time for primary care to enter the triggering business

It has been suggested, some would say demonstrated that doctors know very little about their patients. If you are a doctor could you identify your patient’s partner from a line-up of strangers (other than people you see as a couple)?  Or could you tell without seeing the name on the document if this bank statement belonged to that patient? Or whether that utility bill was from where that person lives? Is this internet search history theirs? Do you know how much they spend on lottery tickets? Alcohol? Vegetables?

A few years ago our team then based in the UK was evaluating an intervention to increase access to general practitioners. If the intervention worked we would have to demonstrate improvement over the course of a whole year. Here’s the thing, we noted that year after year there was a pattern to the demand for same day (emergency) appointments- with definite peaks and troughs. So if the intervention worked it would have to be sustained during both the peaks and the troughs. It did. The data on out-of-hours services exhibited very similar patterns- with definite peaks and troughs and at unexpected times of the year. We could not explain the patterns but noted that when the meteorological office recorded  22 hours or more of sunshine in the week the demand for appointments dropped. Not the prevalence of viral or other community pathogens but sunshine of all things! Okay may it was some factor that we hadn’t modelled in the analysis but there was a definite pattern that we could not immediately explain on the basis of what seemed plausible at the time. We called it the Spring Cleaning Effect– we hypothesised that people in the UK were less likely to attend doctors in general practice when there was a run of sunny days on which to do outdoorsy things. We didn’t anticipate this- nor did clinic managers because the patterns of demand were not used to inform the scheduling of doctors’ on-call rosters. It was clear that they were blind to a phenomenon nobody understood fully.

More recently I reviewed some data on certification for low back pain and noted the pattern that as unemployment rates in a locality increased the rates of certification dropped and then plateaued.

Our team is now investigating similar data from a large employers’ records. We hypothesise that rates of submission of sickness certification will show a sharp drop when vacancy rates fall and other markers of economic health decline. People may be far less likely to take time off sick if they are fearful of upsetting their supervisor. With respect to primary care, it is unlikely that doctors will know everything that impacts on their patient’s choices. Time spent with the patient in discovering these things is unlikely to increase as it comes at a financial cost. Therefore doctors will never fully anticipate all the drivers to patient behaviour. Why does that obese person fail to take action on weight management? Why does this other person take ‘medication holidays’ when they need to take the treatment consistently to benefit? Why does the next person refuse to have an X-ray? Why is there a rush of people with relatively minor conditions demanding appointments this week and not last?

Some drivers lead people to behave in unexpected ways as I have commented here previously. Not only that but as Mullainathan and Shafir have postulated people are often unable or perhaps unwilling to follow doctor’s advice. In the end, the best we can hope is to trigger the relevant behaviour in people who are already motivated and seek teachable moments to inspire people to act for their benefit. Primary care may be more about recognising or fishing for opportunities and much less ‘educating’ for change. Such triggers need to fit within the final moments of a 15-minute consult. The work to develop and evaluate such triggers is only beginning. Counselling patients to stop smoking will yield 1:20 quits in a year, showing them a trigger (in less than 5 minutes) that appeals to their vanity results in 1:7 quits. A substantial number (1:5) of obese people will lose weight in 6 months if they are shown what difference that would make to their appearance without having to be extensively counselled on diet and exercise.

Picture by Aimee Rivers

Why when you are sick don’t you do what you can to help yourself?

At 68 Frank has been prescribed the usual mix of medications: three different drugs for blood pressure, a statin and two different pain killers. His problems, as he lists them are fatigue, snoring and back pain. From his doctor’s perspective, the problems are obesity, a dreadful diet, and sedentary lifestyle.

OK doc, but I think I need a referral for my snoring.

Two weeks ago he wanted a different pain killer and the week before that he wanted to be referred to a physiotherapist. The major challenge in helping people who are struggling with chronic disease is persuading them that they have the wherewithal to slow or possibly cease the march towards disability. It seems incredible that someone who cannot walk to the end of the street without stopping for breath several times cannot see any reason to stop eating junk food and sugary drinks while watching telly from 6 pm until two in the morning. Bad habits will drive choices even when people are aware of their growing disabilities. There may be many reasons for this but one that may be worth considering is boredom.

Our culture’s obsession with external sources of entertainment—TV, movies, the Internet, video games—may also play a role in increasing boredom. “I think there is something about our modern experience of sensory overload where there is not the chance and ability to figure out what your interests, what your passions are,” says John Eastwood, a clinical psychologist at York University in Toronto. Anna Gosline.

What is challenging is that some people who have already developed a life-limiting illness cannot be ‘educated’ to make different choices while they don’t admit even to themselves how and why they are contributing to their own demise. If healthcare is to actively promote well-being we need to find ways to help people identify when they are bored and not just focus on the consequences including atheromatous vascular disease. The role of doctors needs to include tackling harmful habits and not limited to therapeutics.

Picture by Craig Sunter

Does encyclopaedic technical knowledge make a doctor?

Life as a clinician is challenging.  Hours are long and resources limited. People may not be helpful, not even the ones who are supposed to be working with you or even for you. There maybe joy but there will also be sadness and even anger. You can expect to feel tired. You may be concerned and even confused. Occasionally you will be very intuitive but just as often you can expect to be wrong. However, you cannot let any of that have an impact on the care provided to patients. And yet each day clinicians respond as if none of this is ‘fair’ and should not be so.

The practice of medicine is more than a technical science. Medicine requires a great sense of personal mastery. An uncommon mastery in which the doctor is resilient and resourceful. Do we prepare young people for such a life?

This week after 30 years I stepped into one of the rooms now decommissioned but where I once spent my teens learning anatomy. It was a core part of that school’s curriculum, the only subject in clinical medicine that was introduced within the first year of a six-year course. The author of one of the seminal texts taught there. His dissections were legendary and the specimens are still preserved to perfection. I reflected on whether the experience of being taught by his protege prepared me in any way for the subsequent years in practice. Did my encyclopaedic knowledge of how the body is constructed allow me to better handle the following years in clinical practice?  By comparison, we learned relatively little about what drives people to make decisions that make no sense. And yet over the 30 years, I have practised medicine it has been more often problematic knowing how to handle someone whose choices will lead to self-destruction than working out exactly which nerve is responsible for the numbness of a portion of his thigh.

Picture by Rosebud23

Healthcare will do better when Joe accepts that he is in trouble

There is nothing especially remarkable about Joe. At 49 he works as an administrator for a company in the city. He walks to work from the station having taken a train from the suburbs. He weighs 78Kgs and is 170cm tall (BMI 27). To stay that way he needs to consume no more than 1900 calories per day. He has a bowl of cereal for breakfast, a  panini sandwich for lunch and a home cooked dinner with a glass of wine. That’s about 1900 calories. Joe isn’t inspired at work but he earns a reasonable living. They bought a new car last year and Joe is tied to a hefty car loan, his wife Bridgette gave up her job as a nurse when they had their children ten years ago. They now have three children under 10. The youngest has asthma but he seems so much better since he was put on a steroid inhaler. Joe and Bridgette have had their ups and downs. They worry about money.  Mostly they work hard and are doing their best to raise their boys. At the weekend Joe goes to a football match but since his mid-twenties doesn’t play any sport. With the kids doing sport and music lessons there isn’t time. Joe has never smoked a cigarette.

During the week Joe goes for coffee with his colleagues at 10.30 every morning. He also enjoys a small muffin. Then he has a banana at 2 pm and a couple of small biscuits while he is watching television in the evening. He doesn’t think too much about it. He is consuming 500 calories more than he needs per day and in 6 months when Joe is 50 his BMI will put him over the line into obesity.

Joe rarely sees his doctor. In winter he occasionally gets a chesty cough and makes an emergency appointment with any doctor who is available because Bridgette says he might need an antibiotic. Once or twice since his thirties, a doctor checked his blood pressure and it is always normal. He had a medical as part of his mortgage application when he was 35 and everything was ‘normal’. Most of Joe’s friends are heavier than Joe and he still thinks of himself as ‘healthy’.  After all, he walks to work, has a healthy banana as a snack in the afternoon and he makes sure his evening meal is a healthy one.

Joe doesn’t see any problem. There is really time to talk to the doctor about why he likes that large cup of coffee and the muffin or to say that he is stuck in a dead-end job with a mortgage to pay and children to raise. Joe doesn’t admit that he is bored. The coffee break is the highlight of an otherwise long day of drudgery.  Joe’s trousers are getting a little bit tighter. Bridgette has noticed but his friends are all so much bigger and Joe doesn’t think she’s worried about it. She herself has gone up three dress sizes since the children were born so she doesn’t tease him too much. Besides, he just got a bigger size recently and he still thinks he looks good.

Joe is at risk of becoming a statistic in the epidemic of Globesity. All that stands in the way is the ingenuity and interest of those who care to find a way to help Joe turn things around.

Picture by Khuroshvili Ilya

Deploy rituals and be present in practice

Your next patient or client will want you to:

  • Smile (23.2%);
  • Be friendly, personable, polite, respectful (19.2%);
  • Be attentive and calm, make the patient feel like a priority (16.4%);
  • and make eye contact (13.0%).

(An Evidence-Based Perspective on Greetings in Medical Encounters- Arch Intern Med)

Showing up this way for every patient has to be a habit. Essentially you need to be “present or “mindful”. The issue of mindful practice has also been the focus of academic interest:

In 2008, the authors conducted in-depth, semistructured interviews with primary care physicians .. mindfulness skills improved the participants’ ability to be attentive and listen deeply to patients’ concerns, respond to patients more effectively, and develop adaptive reserve. Academic Medicine.

To make a habit of showing up in this way it may be worth considering deploying a ritual.

Hurdler Michelle Jenneke has her famous warm-up dance, long-jumper Fabrice Lapierre competes with a gold chain in his mouth, Usain Bolt points to the sky before breaking yet another world record, while Michael Phelps blasts Eminem to fire him up before hitting the pool. My body+soul

Consider the distinction between a habit and a ritual:

Habit

An acquired behavior pattern regularly followed until it has become almost involuntary: the habit of looking both ways before crossing the street.

Ritual

An act or series of acts regularly repeated in a set precise manner.

Rituals support habit and focus. Rituals support you to repeat habits and create new behaviour patterns over time. Daily rituals can support you to make new habits stick. You can move from doing something that might take a lot of effort, to it becoming almost automatic or done unconsciously. Mary- Ann Webb

Establishing a ritual can be the prelude to a habit.

The term ritual refers to a type of expressive, symbolic activity constructed of multiple behaviors that occur in a fixed, episodic sequence, and that tend to be repeated over time. Ritual behavior is dramatically scripted and acted out and is performed with formality, seriousness, and inner intensity. Rook, Dennis W. (1985), “The Ritual Dimension of Consumer Behavior,” Journal of Consumer Research, 12 (December), 251-264.

The pathway goes from behaviour, to ritual and then to habit. Charles Duhigg  spoke of the ‘habit loop’.This loop has three components:

  • The Cue: This is the trigger that tells your brain to go into automatic mode and which habit to use.
  • The Routine: This is the behaviour itself. This can be an emotional, mental or physical behaviour.
  • The Reward: This is the reason you’re motivated to do the behaviour and a way your brain can encode the behaviour in your neurology, if it’s a repeated behaviour.

All habitual cues fit into one of five categories: location, time, emotional state, other people, and immediately preceding action. An immediately preceding action is the most stable cue because it’s triggered by an existing habit. So to build a new habit match it with an old habitual cue.

B.J. Fogg, asks:

“What does this behaviour most naturally follow?”

To implement this technique, decide on an existing habit and complete the following sentence:

“After I [EXISTING HABIT] I will immediately [NEW HABIT]”.

Therefore to make a habit of being present for the next patient the “cue” is when you terminate the previous consultation.

The “routine” or ritual: At the end of one consult you might close the notes, tidy your desk and wash your hands. Metaphorically you also wash the previous consult out of your mind. This has physical and psychological components.

Then when you are happy that the previous consult no longer lingers in your thoughts proceed to the next consult, stand in a specific spot, call the patient, introduce yourself and smile. Shake the patient’s hand. Walk with them to the consulting room. Don’t start the consult until you make eye contact. How the patient responds to such a greeting is the “reward“.

Picture by Rob Bertholf

She’s furious but what does your reaction say about you?

Where there is anger there is fear. Health issues are frightening. They pose a real and sometimes imminent threat to our basic needs. Sometimes even a threat to life itself.

There is a strong relationship between anger and fear. Anger is the fight part of the age-old fight-or-flight response to threat. Most animals respond to threat by either fighting or fleeing. But, we don’t always have the option to fight what threatens us. Instead, we have anger. Psychology 

Anger is an emotion that doctors encounter often. Unfortunately they may also find themselves getting annoyed at that angry patient who has been kept waiting, that angry mother who thinks her child’s test results should be available today, that angry young man who says he will be fired unless he gets a backdated certificate, that angry Boomer who is convinced her cancer can be cured if only this doctor arranges an appointment for coffee enemas.

Doctors can choose how to respond. How to interpret that emotion. Doctors too can be angry. Angry about having to work in a healthcare system where one sector doesn’t coordinate with another, a payment schedule that doesn’t reward for time spent waiting on the phone, a system where people come with undifferentiated problems and can’t give a clear history of their symptoms. They can choose whether or not to express this emotion during a heated conversation.

At the end of the day, doctors can go home- for the mother of the child with cystic fibrosis, the young man with the heartless employer, the old lady with bowel cancer there is no such escape. A response that may help is to acknowledge the anger but address the fear. It may even reduce the frequency with which people might see the doctor standing in the way of something they think will immediately reduce the threat. It may also help when doctors are angry that those who are the target of that anger confront the issues rather engage in recrimination.

Picture by Petras Gaglias 

Can the patient relay what was done for them?

A perennial source of dissatisfaction in healthcare (as documented here and here) is the poor flow of information from one sector to another. ‘Joe’ (speaking here– video from BMJ open) couldn’t tell me, his doctor, anything helpful about what had been done while he had been in hospital. That means we have to schedule several appointments to try to unpack it all. He was an in-patient for two weeks and someone had decided one Thursday morning that it was time for him to go home. It wasn’t really clear to Joe or to me why that particular morning or what was to happen when he got home other than that he should contact his ‘local GP’. A letter would follow some time in the future. There may have been good or bad reasons for sending him home. We could only guess what was in the mind of the person who made the decision:

We needed the bed. Joe was fine. His observations were normal, he was ambulant his wife was happy to take him home.

But of course Joe comes home with lots of questions, which I now struggle to answer without making phone calls to track down the busy medical team. The problem is articulated by several ‘stakeholders’ members of the ‘multidisciplinary team’ on the ward none of whom feel they own the problem of telling this man what he needs to know. There is only one constant in this story- Joe. If Joe can collect the information we need during the course of his hospital stay we might begin to improve the outcome:

In addition to increasing the burden on GPs, it engenders a need for a subsequent GP appointment; it limits GP capacity to respond to patient concerns and queries, at least on one occasion; it may result in a re-referral to the specialist; and it increases GP dissatisfaction with the care provided to the patient by the hospital. BMJ

The problem is Joe often does not know what he needs to know by the end of his hospital stay. It isn’t impossible to work out how to trigger questions for Joe to ask throughout his hospitalisation. What is far more difficult is to motivate every hospital ward and every discipline in a team to address this challenge consistently. It is ‘easier’ to nudge one individual than enlist the cooperation of the dozens of health professionals who will come into contact with Joe. Making people active in healthcare processes has achieved results before:

Influence at Work, a training and consultancy company that Cialdini founded, worked with the United Kingdom’s National Health Service (NHS) in a set of studies aimed at reducing the number of patients who fail to show up for medical appointments. They did this by simply making patients more involved in the appointment-making process, such as asking the patient to write down the details of the appointment themselves rather than simply receiving an appointment card. Sleek

Picture by Michael Coghlan

Doctors need better tools to help people recognise danger

Doctors see it all the time. The fifty-year-old with a BMI of 28, the teenager who is developing a taste for cigarettes, the twenty-year-old who now binge drinks every weekend, the soon-to-be-mum who is ‘eating for two’. Small choices that may become habits and habits that lead to consequences. Where I work the average consultation is fifteen minutes. In that time we address whatever symptoms or problems have been tabled. The list may be long. Occasionally it’s possible to raise a topic that I’m worried about. The problem is the patient may not be worried about that issue.

Afterall doctor I don’t drink any more than my mates do or I don’t really eat that much.

What’s needed are tools that help frame the issue from the perspective of the patient, not the practitioner. Tools that help us address public health priorities that speak TO that person, not AT everyone. Before making any changes the person needs to agree that their choices might blight their hopes for the future. These are not inconsiderable challenges given the gloomy predictions for the future.

At the other end of the malnutrition scale, obesity is one of today’s most blatantly visible – yet most neglected – public health problems. Paradoxically coexisting with undernutrition, an escalating global epidemic of overweight and obesity – “globesity” – is taking over many parts of the world. If immediate action is not taken, millions will suffer from an array of serious health disorders. The World Health Organisation

Diabetes is likely to cement its place as the fastest growing epidemic in history. The Medical Journal of Australia

In addition, youthful drinking is associated with an increased likelihood of developing alcohol abuse or dependence later in life. Early intervention is essential to prevent the development of serious alcohol problems among youth between the ages of 12 and 20. NIH

Picture by Marcelo Nava

A small act that never goes unnoticed

Much can be said about the way we greet people. However nothing is more telling than the memory of the last time we were greeted when we were in need. Those who have travelled overseas know exactly what it’s like to be in an alien environment, where things are unfamiliar and a little threatening. Like pulling up at an immigration check point, passport in one hand and tired kids at your feet.

The one that sticks in mind was the experience at Italian passport control decades ago when we arrived in Rome with our then very young brood. The smartly dressed official eyed us all in turn from behind the tall counter, then made to count our children, smiled broadly at the parents, nodding as if in approval of the size of the family and waved us through. A charming start to the holiday. That was fifteen years ago and we still  talk about it.

Last week in Bali the receptionists stood up every time a guest passed the desk, bowed with hands clasped to heart smiling brightly. It set the tone for the whole day.

My favourite greeting is Malay.

“The traditional Malay handshake, known as ‘salam’, involves both parties extending their arms and clasping each other’s hand in a brief but firm grip,” advised Lew Wai Gin, the guest liaison manager at Tanjong Jara Resort. “The man can then offer either one or both hands, grasp his friend’s hands, and then bring a hand back to his chest, which means: ‘I greet you from my heart’.” Grantourismo

Having experienced the impact it has when I travel for work in that country it persuaded me that how we greet each other matters more than we might realise. It’s a small choice which costs nothing. In medicine the provider has the opportunity to set the tone for what follows which can be to agree or disagree, to give good or bad news. Whatever follows people remember the way they were made to feel when they were most vulnerable. They might even write about it decades later!

Picture by Ben Smith