Category Archives: Lean Medicine

Essentialism wins

Dear Friends,

I have decided to take a break from my blog for a little while and focus on writing my book.

Sometimes it is a case of realising that you must invest in the big things in your life.

Thank you to my partner and mentor Bernadette. In case you are wondering-yes, she is even better than you know.

Thank you to Greg McKeown for persuading me to focus.

See you again very soon.

Moyez.

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Why the data suggests people don’t get the latest medicine

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It sometimes seems ‘obvious’ why things go ‘wrong’ in practice. For example, the proportion of people with diabetes prescribed a cholesterol reducing drug is low…. because? You might have your favorite answer at the ready. Others certainly do and will climb their hobby horse with little or no encouragement. ‘Prescribers don’t accept the guidelines‘, ‘patients don’t take their medicines‘, ‘people can’t afford the drugs‘ or ‘doctors don’t monitor patients‘. The truth may encompass any or all of these.

Let’s do the maths with reference to Glasziou and Haynes.

Let’s assume 80% is true in each of the following points:

1. Doctors are aware of the guidelines.
2. Doctors accept the evidence underlying these guidelines.
3. Doctors remember to apply the guidelines when the relevant patients present.
4. It is possible to do something practical to comply with the guidelines.
5. Doctors act to prescribe the relevant treatment.
6. Doctors and patients agree on the need for that treatment.
7. Patients comply with the treatment.

If these statements are true 80% of the time then 21% of people with the relevant problem will be managed according to the guidelines (0.8x 0.8x 0.8x 0.8x 0.8x 0.8x 0.8= 0.21). Experience tells us that in many, if not most, conditions only 1 in 5 people will be managed as per research evidence.

A quick review of the literature confirms this.

1. Only 17% of patients with diabetes were screened for sexual dysfunction despite it being a common complication of this condition.

2. A primary care study has shown that despite an active education program over two years the proportion of treated patients whose blood pressure was controlled to < 160/90 mm Hg remained at only 33%.

3. When examining the referral origin of all Colorectal cancer patients diagnosed in one study only 24% had been referred on a pathway that was consistent with national guidelines.

A video summary appears here:

 

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Why don’t people take medical advice?

Significant proportions of people walk out of doctors’ clinics and disregard or fail to act on the opinion offered.  What practitioners can do to help is to review their communication style. As Bungay Stanier has suggested it can’t be assumed that the first thing the person mentions is what is bothering them the most. Bungay Stanier’s suggested questions will reduce the rush to action. A rush that fails to identify the issue that the patient may feel is a greater priority than hypertension or diabetes.

I summarise the issue in this video:

 

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Why medical tests can be misleading

If you have had to consult a healthcare practitioner there will almost certainly have been an occasion when you were advised to have a test or X-ray. But to what extent could you have been misled by the results of that test? Well it depends. The issue may seem complex but the science need not be inaccessible.

Purpose: To conduct a video vignette survey of medical students and doctors investigating test ordering for patients presenting with self-limiting or minor illness.

Methods: Participants were shown six video vignettes of common self-limiting illnesses and invited to devise investigation and management plans for the patients’ current presentation. The number of tests ordered was compared with those recommended by an expert panel. A Theory of Planned Behaviour Questionnaire explored participants’ beliefs and attitudes about ordering tests in the context of self-limiting illness.

Results: Participants (n=61) were recruited from across Australia. All participants ordered at least one test that was not recommended by the experts in most cases. Presentations that focused mainly on symptoms (eg, in cases with bowel habit disturbance and fatigue) resulted in more tests being ordered. A test not recommended by experts was ordered on 54.9% of occasions. With regard to attitudes to test ordering, junior doctors were strongly influenced by social norms. The number of questionable tests ordered in this survey of 366 consultations has a projected cost of $17 000.

Conclusions: This study suggests that there is some evidence of questionable test ordering by these participants with significant implications for costs to the health system. Further research is needed to explore the extent and reasons for test ordering by junior doctors across a range of clinical settings. D’Souza et al

I summarise the issue in this video:

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What is said to people when drugs are prescribed for life?

Every day doctors suggest that one or other of their patients have to take medication for life. Hypertension, diabetes and certain deficiencies are among the many conditions that may benefit from taking medication longterm. On the other hand, many people reject this advice or take the prescribed drugs only sometimes. Ultimately the decision to accept treatment is for the person with the condition to decide. How can the advice be tailored so that the person is making an informed decision?

BACKGROUND: ‘Concordance’ has been proposed as a new approach towards sub-optimal medication use; however, it is not clear how this may be achieved in practice. AIM: To develop a strategy for understanding sub-optimal medication use and seek concordance during primary care consultations. DESIGN: A developmental qualitative study using a modified action research design. SETTING: Three Scottish general practices. METHOD: Patients using treatment sub-optimally and having poor clinical control were offered extended consultations to explore their situation. Their authority to make treatment decisions was made explicit throughout. Clinicians refined a consultation model during ten ‘Balint-style’ meetings that ran in parallel with the analysis. The analysis included all material from the consultations, meetings, and discussion with patients after the intervention. RESULTS: Three practitioners recorded 59 consultations with 24 adult patients. A six-stage process was developed, first to understand and then to discuss existing medication use. Understanding of medication use was best established using a structured exploration of patients’ beliefs about their illness and medication. Four problematic issues were identified: understanding, acceptance, level of personal control, and motivation. Pragmatic interventions were developed that were tailored to the issues identified. Of the 22 subjects usefully engaged in the process, 14 had improved clinical control or medication use three months after intervention ceased. CONCLUSIONS: A sensitive, structured exploration of patients’ beliefs can elucidate useful insights that explain medication use and expose barriers to change. Identifying and discussing these barriers improved management for some. A model to assist such concordant prescribing is presented. Dowell et al BJGP

I summarise the issue in this video:

https://youtu.be/xFQ2kVOMS64

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The healthcare experience must change

The person who believes they have a problem must be fully involved in the options offered for treatment if healthcare is to result in the best outcomes. Research and experience suggests that may not always be the case:

OBJECTIVE: To evaluate hospitalized patients’ understanding of their plan of care.

PATIENTS AND METHODS: Interviews of a cross-sectional sample of hospitalized patients and their physicians were conducted from June 6 through June 26, 2008. Patients were asked whether they knew the name of the physician and nurse responsible for their care and specific questions about 6 aspects of the plan of care for the day (primary diagnosis, planned tests, planned procedures, medication changes, physician services consulted, and the expected length of stay). Physicians were interviewed and asked about the plan of care in the same fashion as for the patients. Two board-certified internists reviewed responses and rated patient-physician agreement on each aspect of the plan of care as none, partial, or complete agreement.

RESULTS: Of 250 eligible patients, 241 (96%) agreed to be interviewed. A total of 233 (97%) of 241 physicians completed the interview, although sample sizes vary because of missing data elements. Of 239 patients, 77 (32%) correctly named at least 1 of their hospital physicians, and 143 patients (60%) correctly named their nurses. For each aspect of care, patients and physicians lacked agreement on the plan of care in a large number of instances. Specifically, there was no agreement between patients and physicians on planned tests or procedures for the day in 87 (38%) of 229 instances and in 22 (10%) of 220 instances. Complete agreement on the anticipated length of stay occurred in only 85 (39%) of 218 instances.

CONCLUSION: A substantial portion of hospitalized patients do not understand their plan of care. Patients’ limited understanding of their plan of care may adversely affect their ability to provide informed consent for hospital treatments and to assume their own care after discharge. O’Leary et al

Here is my summary of this topic:

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The future arriving at an unprecedented speed

  •   As a general practitioner you must show a commitment to patient-centred medicine, displaying a non-judgmental attitude, promoting equality and valuing diversity
  •   Clear, sensitive and effective communication with your patient and their advocates is essential for a successful consultation
  •   The epidemiology of new illness presenting in general practice requires a normality-orientated approach, reducing medicalisation and promoting self-care
  •   Negotiating management plans with the patient involves balancing the patient’s values and preferences with the best available evidence and relevant ethical and legal principles
  •   As a general practitioner you must manage complexity, uncertainty and continuity of care within the time-restricted setting of a consultation
  •   The increasing availability of digital technology brings opportunities for easier sharing of information and different formats of consulting, as well as raising concerns around information security. RCGP

The summary suggests that the consultation will survive. However the rate of change in every other service is such that the notion of ‘negotiating’ seem quaint as more choices are made directly available to the consumer. Healthcare providers need to be part of the solution as was suggested in this research:

Communications technologies are variably utilised in healthcare. Policymakers globally have espoused the potential benefits of alternatives to face-to-face consultations, but research is in its infancy. The aim of this essay is to provide thinking tools for policymakers, practitioners and researchers who are involved in planning, implementing and evaluating alternative forms of consultation in primary care.

We draw on preparations for a focussed ethnographic study being conducted in eight general practice settings in the UK, knowledge of the literature, qualitative social science and Cochrane reviews. In this essay we consider different types of patients, and also reflect on how the work, practice and professional identities of different members of staff in primary care might be affected.

Elements of practice are inevitably lost when consultations are no longer face-to-face, and we know little about the impact on core aspects of the primary care relationship. Resistance to change is normal and concerns about the introduction of alternative methods of consultation are often expressed using proxy reasons; for example, concerns about patient safety. Any planning or research in the field of new technologies should be attuned to the potential for unintended consequences.

Implementation of alternatives to the face-to-face consultation is more likely to succeed if approached as co-designed initiatives that start with the least controversial and most promising changes for the practice. Researchers and evaluators should explore actual experiences of the different consultation types amongst patients and the primary care team rather than hypothetical perspectives.

Here is my perspective on the challenge:

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It’s not the infrastructure it’s you that makes the difference.

CONTEXT:
Communication education has become integral to pre- and post-qualification clinical curricula, but it is not informed by research into how practitioners think that good communication arises.
OBJECTIVES:
This study was conducted to explore how surgeons conceptualise their communication with patients with breast cancer in order to inform the design and delivery of communication curricula.
METHODS:
We carried out 19 interviews with eight breast surgeons. Each interview centred on a specific consultation with a different patient. We analysed the transcripts of the surgeons’ interviews qualitatively using a constant comparative approach.
RESULTS:
All of the surgeons described communication as central to their role. Communication could be learned to some extent, not from formal training, but by selectively incorporating practices they observed in other practitioners and by being mindful in consultations. Surgeons explained that their own values and character shaped how they communicated and what they wanted to achieve, and constrained what could be learned.
CONCLUSIONS:
These surgeons’ understanding of communication is consistent with recent suggestions that communication education: (i) should place practitioners’ goals at its centre, and (ii) might be enhanced by approaches that support ‘mindful’ practice. By contrast, surgeons’ understanding diverged markedly from the current emphasis on ‘communication skills’. Research that explores practitioners’ perspectives might help educators to design communication curricula that engage practitioners by seeking to enhance their own ways of learning about communication.

Mendick et al

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For sustained behaviour change: show don’t tell

BACKGROUND:
This randomised controlled study evaluated a computer-generated future self-image as a personalised, visual motivational tool for weight loss in adults.
METHODS:
One hundred and forty-five people (age 18-79 years) with a Body Mass Index (BMI) of at least 25 kg/m2 were randomised to receive a hard copy future self-image at recruitment (early image) or after 8 weeks (delayed image). Participants received general healthy lifestyle information at recruitment and were weighed at 4-weekly intervals for 24 weeks. The image was created using an iPad app called ‘Future Me’. A second randomisation at 16 weeks allocated either an additional future self-image or no additional image.
RESULTS:
Seventy-four participants were allocated to receive their image at commencement, and 71 to the delayed-image group. Regarding to weight loss, the delayed-image group did consistently better in all analyses. Twenty-four recruits were deemed non-starters, comprising 15 (21%) in the delayed-image group and 9 (12%) in the early-image group (χ2(1) = 2.1, p = 0.15). At 24 weeks there was a significant change in weight overall (p < 0.0001), and a difference in rate of change between groups (delayed-image group: -0.60 kg, early-image group: -0.42 kg, p = 0.01). Men lost weight faster than women. The group into which participants were allocated at week 16 (second image or not) appeared not to influence the outcome (p = 0.31). Analysis of all completers and withdrawals showed a strong trend over time (p < 0.0001), and a difference in rate of change between groups (delayed-image: -0.50 kg, early-image: -0.27 kg, p = 0.0008).
CONCLUSION:
One in five participants in the delayed-image group completing the 24-week intervention achieved a clinically significant weight loss, having received only future self-images and general lifestyle advice. Timing the provision of future self-images appears to be significant, and promising for future research to clarify their efficacy.

Trials. 2017 Apr 18;18(1):180. doi: 10.1186/s13063-017-1907-6.

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Dog walking may assist weight control

Height and weight were measured for 281 children aged 5–6 years and 864 children aged 10–12 years. One parent reported their own and their partner’s height and weight (n=1,108), dog ownership, usual frequency their child walks a dog, and usual frequency of walking the dog as a family. Logistic regression analyses were adjusted for sex (children only), physical activity, education, neighbourhood SES, parental weight status (children only) and clustering by school.

Dog ownership ranged from 45–57% in the two age groups. Nearly one in four 5–6 year-olds and 37% of 10–12 year-olds walked a dog at least once/week. Weekly dog walking as a family was reported by 24–28% of respondents. The odds of being overweight or obese were lower among younger children who owned a dog (OR=0.5, 95% CI 0.3–0.8) and higher among mothers whose family walked the dog together (OR=1.3, 95% CI 1.0–1.7). Health Promotion Journal of Australia

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