Tag Archives: biggest healthcare problem

Meet the emotion that drives fresh ideas

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Whose choices would be limited by the adoption of your ideas?

  • Users
  • Your boss
  • Funders
  • Your employer
  • Government
  • God
  • All of the above

If the answer included any of the above you will experience the mother of innovation aka frustration. The same can be said of job satisfaction or happiness. Frustration is a powerful emotion to be greeted as the most effective teacher. It can literally drive you to think again so that eventually, some but not all people who experience it will find wisdom if not satisfaction lurking on the other side. Those who refuse to learn her lessons remain in the classroom unhappy. First work out which is the horse and which is the cart.

Two notable examples:

Instagram is changing the way we eat:

While looking at pictures of food can provoke a physiological reaction that makes the observer hungry, taking pictures of food can be an effective means of sticking to a diet. Menulog

Google searches are helping to identify epidemics of infections disease.

One way to improve early detection is to monitor health-seeking behaviour in the form of queries to online search engines, which are submitted by millions of users around the world each day. Ginsberg et al

In both cases the driver- Instagram and Google do not require the user to deploy their services specifically in order to achieve the requisite goals above. Innovations that depend on any one using a tool to solve one specific problem, for someone else, are going to meet our friend frustration.

People’s fundamental needs have been described long ago. First and foremost people need food, fresh air and rest. Then they need to feel their future is secure. After that they want to feel a sense of connection with others and to be valued in their social circle. Then and only then will they to compelled to creatively solve problems for other people.

Neither Instagram nor Google was set up only to help tackle obesity or infectious diseases. Both serve more fundamental needs in human society. How do your ideas fit in this paradigm? Is your latest innovative idea designed to be useful in very limited circumstances? In that case it will be of value to only a limited market and you will please a few people a little of the time. If that’s okay you will you have avoided frustration otherwise it’s back to the drawing board.

Picture by Brent Moore

Don’t curse the dark, light a candle

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Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light.

Dylan Thomas

My young colleague recently received the following note from the editors of a well known primary care medical journal:

Thank you for submitting your manuscript, [ Title here], manuscript number XYZ-601-14 Version 1, for consideration by the Most Important Journal of Family Medicine. The editors have completed their evaluation and we regret that we are unable to accept the paper for publication. This decision reflects a variety of factors, including the large number of manuscripts competing for limited space and the paper’s priority relative to others we are considering.

She was especially disappointed because the paper was summarily dismissed. Her submission was a painstaking review of the literature that demonstrates the equivocal evidence for the successful management of obesity in general practice. The paper was co-authored by two senior colleagues and she had been encouraged to submit it as a quality piece of writing. I could show her my collection of similar letters. I have kept them all. It seems, ‘space’ is lacking rather than the value of this young researchers offering. A researcher who will one day become a leader in her profession. Her paper will be published of that there is no doubt but not in that journal. An experience that is all too common for those trying to make an impression in the early part of their career.

Five years ago a team of us decided we’d like to make a small difference to people in this position and so, in 2008,  the AMJ was launched. We administered the journal on a shoe string budget and brought it to the attention of medical students via face book. In the early days it was hard work. In fact it was an expensive and time consuming hobby. Today the AMJ is an established and recognised peer reviewed medical journal, it is listed on most of the major databases and is entirely self sustaining. Some of the papers the AMJ has published have made an enormous impact.  It makes a small but reasonable contribution to the work of people who often find themselves sidelined because editors of the ‘far too important’ journals can’t see the value of their ideas or care how their dismissive and impersonal tone can crush their junior colleagues. And so we say to our colleagues, there is no point cursing the darkness because today with global access a mouse click away, with a little tenacity, it is possible to reach out to many. If only a few like minded people respond what started as a small candle in the gloom may one day become a beacon. At a time when primary care in so many parts of the world seems to be undervalued we need to do a small thing to assist our cause rather than whinging about how unfair it all is.

Picture by Justin McMurray

Primary care is not a panacea

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Barbara Starfield’s thoughts still resonate with many of us who work in primary care. Primary care serves to reduce costs in a health care system essentially by keeping people out of hospital.  However, recently there have been attempts to tinker with how the sector is configured in many countries where one would have assumed that no adjustment was necessary.

The demand for general practitioner services continues to rise. It may be tempting to assume that the drivers for this trend are the same as they have always been: infections, gluttony, sloth, ageing, substance abuse, accidents and genetics. And yet the literature records that practitioners know very little about their patients biography. So what does primary care actually do and what does this tell us about the way forward?

We know that seeing a general practitioner is not going to ‘cure’:

  • Divorce
  • Child abuse
  • Boredom
  • Debts
  • Loneliness
  • Poor parenting
  • illiteracy

Seeing a general practitioner for ten or fifteen minutes, even quite frequently, isn’t going to change these circumstances. Perhaps a perceived failure to improve outcomes for people living with these problems is the driver for reform of the sector in parts of the world. At best primary care might help people to cope, at worst it might add to problems through iatrogenesis. Then there is a possibility that our inability to cope has a biological basis and that attempts to deal with the symptoms alone may be misguided. After all such thinking led to at least one Nobel prize for medicine.

If primary care needs to be reformed than the first issue is to recognise the limitations. For those who live in relative poverty, those with multimorbidity, those with competing priorities in complex lives more of the same primary care cannot be the only response to degenerative and chronic conditions.

Picture by Mike Smail

Removing the triggers to unhealthy choices

Much of the work in medicine is persuading people to give things up; tobacco, fizzy drinks, junk food, alcohol. Health professional also need people to do things- take medication, have surgery, keep appointments, exercise and so on. An entire industry profits on persuading people to make such choices and on helping doctors to sell more effectively. BJ Fogg has distilled such business into a simple equation.

My Behavior Model shows that three elements must converge at the same moment for a behavior to occur: Motivation, Ability, and Trigger. When a behavior does not occur, at least one of those three elements is missing. (Behaviour= Trigger+ ( Motivation+ Ability)

Our health and well being depends on how effectively doctors can do this. Notwithstanding that medicine hasn’t always got it right. Not that long ago doctors were trying to persuade people to take up smoking. Perhaps something like this could happen again, but I digress. The point is that health professionals are in the business of selling health messages, services and treatment. Last week I raised concerns about how some elements of this industry has taken to offering data as the key cue to action. Data elicitation and display has become a very profitable business. This week I explore this issue with reference to obesity.

It is often assumed that people make decisions about food and eating in rational conscious ways. However, if this were so, the obesity epidemic would not be happening. People overconsume in response to environmental cues and they lack insight into the extent to which their food choices and eating behaviors are being manipulated by sophisticated advertising and marketing techniques. They also have a limited capacity to sort through the increasingly overwhelming mountains of information and claims about food choices and, as a result, too often choose default option foods high in fat and sugar that, when consumed routinely, lead to chronic diseases. Deborah A. Cohen

So the challenge is trying to persuade people to eat less or at least less often. I offer four pieces of empirical advice to any of my patients who wants to lose weight some of which has come from the extensive review by Cutler, Glaeser and Shapiro:

1. Don’t put anything in your mouth while standing up other than a tooth brush-based on the observation that people consume a lot of calories while preparing food or snacking on the move.

2. Don’t eat other than at a dinning table- people often eat at their desks or worse, in front of the TV.

3. Don’t go shopping when you are hungry- it tempts you to bring things home that will sabotage your efforts to reduce consumption.

4. Don’t eat between meals…Duhhh!

Foggs Behavior Wizard suggests that to persuade people to decrease a behaviour:

  1. Remove the trigger that leads to the undesirable behaviour
  2. Reduce ability to perform the behaviour (make it harder to do)
  3. Replace motivation for doing the behaviour with de-motivators:  pain, fear, or social rejection

So the trigger that leads to the undesirable behaviour is the feeling that you are ‘hungry’. What Fogg recommends is:

When you design for persuasion, you don’t start by manipulation for motivation. That’s what you do last.

Therefore targeting motivation through calorie counting or calorie expenditure isn’t going to work. There are too many hours left in the day after you’ve consumed the few calories you need to lose weight and you have to do an unrealistic amount of exercise to be able to consume more. The real  problem is that people misinterpret four emotions associated with the urge to eat:

  1. Hunger
  2. Thirst
  3. Boredom
  4. Unhappiness

Therefore the trigger is often unrelated to the need for food and more to do with something else that hasn’t been acknowledged. To remove the trigger it must first be recognised as false. Therefore you might substitute or associate with another established trigger – namely answering a mobile phone or checking for email or facebook updates. By associating the urge to eat with checking an app on their mobile phone the person can work out if what they really want is food or something else. To reduce the ability to perform the behaviour (eat that popcorn, cake or choclate bar) the person needs to remove themselves from the place (physical or psychological) where the behaviour takes place- in front of the TV, at their desk at work or on the concourse at the station. This means either finding a new hobby, making a habit of only eating at a dinning table or carrying a bottle of water to and from work. Finally replacing the motivation for doing the behaviour with de-motivators could be part of the proposed solution by offering a diary of the poor choices that have tempted the individual between meals. I look forward to sharing a solution soon. Wearable not required.

 

Quantified self – the downside

The manufacturers of wearable health tech devices are set to make millions if not billions. Wearables are relatively cheap adjuncts to existing technology. But what difference will they make to the health and well being of the average user?  We have been offered a preview of what these devices can do- monitor your heart rate, blood pressure and blood glucose. Keep track of your respiratory rate, calorie expenditure and sleep patterns. Detect cardiac arrythmias and abnormal brain electrical activity. It sounds good, but so what? If you experience a significant drop or severe rise in blood pressure you are going to notice even before you check the readings- you will feel very unwell. Similarly low blood sugar and dysfunction of the respiratory or cardiac system. Do we really need our smartphone to tell us we aren’t taking enough exercise and eating too much? Or that it’s time to see a doctor urgently? I agree with Jay Parkinson:

The exclusive-to-human part of our brain evolved so we can be creative and manipulate the world around us so we can invent things like the iPhone. And now, the creators of the iPhone want to give us the tools we need to badly do what evolution solved for us hundreds of millions of years ago.

Here’s the problem with this technology in practice:

About 10 percent are “quantified selfers” with an affinity for this kind of feedback; just by looking at the numbers, they are motivated to be more active. An additional 20 percent to 30 percent need some encouragement in addition to tracker data to effectively change their behavior. Kamal Jethwani

Therefore the vast majority of people who buy a wearable device right now will not benefit from that purchase. Those who do, might be amenable to other interventions. Unfortunately much of the data is meaningless or has no impact on long term decisions about health and well being. Sure, a trend in high blood pressure over a few weeks might indicate a need for treatment but a single high reading might be an anomaly or simply confirm that you are excited. Worrying about every little bleep on the chart is not going to add to your quality of life but will detract from it. For a sustained and beneficial change in life style people need more than data. They need motivation and help to workout the benefits of making different choices. They need the undivided attention of a practitioner who understands their needs and assists with a bespoke plan.

Information that we need right now, which our built in human senses may not already have alerted us to is another issue; microscopic haematuria (blood in the urine) proteinuria (protein in the urine), faecal occult bleeding (blood in the faeces), raised intraoccular pressure (high pressure in the eye ball) and changes in moles, breast or testicles will prompt doctors to investigate for sinister causes. Investigations that might lead to the early diagnosis of some costly and treatable or life limiting condition. Acquiring this information doesn’t require you to wear a device continually for a year. The business case for manufacturing devices to do that isn’t as compelling because of a limited market. Enthusiasts for wearables argue that:

Studies are beginning that examine the data from wearables, which is much more granular data about human activity than scientists have been able to access previously. This will answer questions like: how much of an increase in activity, of what type (moderate or cardio-challenging) leads to what degree of health benefit? Todd Hixon

What we may also discover is that there are probably side effects associated with wearable devices. Psychological harm may be associated with prolonged and heightened anxiety and obsession with self. What we won’t discover (and this is a guess) is that there is a short cut to losing weight that doesn’t require any significant effort. We might also discover that there are limited indications for wearable devices and that the market for them is much smaller than we envisage. Parallels exist with some parts of the pharmaceutical industry which has begun to promote ‘illnesses’ that would benefit from it’s offerings. So called disease mongering. We may well find ourselves being circumspect about wearables in the way that we have misgivings about drugs:

…drugs approved for devastating illness, such as clinical depression, are indicated for milder conditions, such as shyness, which is now dubbed ‘social phobia’. Howard Wolinsky

Data is no more the answer to all problems than are drugs. The indications for collecting data have parallels with the indications for prescribing drugs and how and why that data is collected merits thought. Those who promote the use of wearables need to question a trend which isn’t without a downside.

Why aren’t healthcare providers doing more to tackle the biggest health problem?

Obesity is the single biggest health problem facing our generation and the generations to come. It’s already killing, disabling, disfiguring and demoralising more than half of the population in most developed countries. By 2025 the majority in the developed world, and a growing proportion in the developing world will be overweight or obese. We have seen it coming, the warnings have been around for decades and yet we have done very little to combat it. Now it’s reported that doctors can’t see what they can do about it.

Until more effective interventions have been developed GPs may remain unconvinced that obesity is a problem requiring their clinical expertise and may continue to resist any government pressure to accept obesity as part of their workload.

—Laura Epstein and Jane Ogden

The reality about the problem of obesity is:

1. We are all aware that being overweight is harmful and yet we are legally bombarded with subliminal messages that promote unhelpful lifestyle choices .

2. It may be counter productive to raise the issue with someone who already feels a sense of shame and guilt.

3. Simply being offered dietary advice by a health practitioner isn’t making a difference to most people. We already know what we shouldn’t put in our mouths, that an apple is better for us than a chocolate bar.

4. People find it hard to do what needs to be done to tackle the issue—eat less and exercise more. It’s hard to sustain the effort over a period of time and to make permanent lifestyle changes.

5. Our current healthcare interventions and innovations with regard to obesity are not working.

6. In Australia the cost of dealing with the effects of obesity has reached $120 billion. We are not doing enough to tackle the root cause.

7. We must find a sustainable solution to this problem. Handing out diet sheets and making referrals to dieticians is not enough.

The challenge, for the practitioner is to present information that’s hard to hear in a way that it is likely to be taken on board and acted on. To appeal to how people feel about making changes, not just what they know. To provide information that is motivating and affirming. To reduce the time burden on health practitioners to deliver that advice efficiently. To put the tools into the hands of the person who may have to change life long habits. We just need the collective will to make it happen.