More on this from the Journal of Health Design.
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We do not gain weight steadily through the year. In fact, it is primarily from the end of November to mid-January that we find ourselves tempted and triggered to eat more than we need. With a seemingly endless round of invitations to partake in sugary treats most people succumb and add up to one kilo to their already growing girth.
The average BMI of males in their 40s in the West is 25.6 to 28.4. The numbers are similar for women. In other words, most are overweight. Researchers document that during this holiday season adults consistently gain weight during this period (0.4 to 0.9 kg).
Participants seeking to lose weight appeared to increase weight although this was not consistently significant and motivated self-monitoring people also appeared to increase weight. These results must be considered for registered dietitian nutritionists, other health providers, and policy makers to prevent weight gain in their patients and communities during this critical period.
Obesity is an epidemic with a rising tide of chronic and life-limiting illnesses in its wake. As healthcare professionals,
we need to be confident about raising the issue of overindulgence without putting a damper on the festivities.
Picture by jrchapoy
Joe and Brenda are now in their 60s they have a number of chronic healthcare problems some of which will put them at risk of life limiting pathology (hypertension) and others detract from their quality of life (low back pain). Everyone involved in providing healthcare to this couple wants the best for them. Best case scenario Joe and Brenda are satisfied every time they consult their doctor and improve from whatever ails them. It is also better if their use of the healthcare resources is minimised. But what predicts that outcome?
In 2001 the BMJ considered the issues. Paul Little and his colleagues approached three local practices that served 24 100 patients. They invited consecutive patients attending the surgery to participate. All patients able to complete the questionnaire were eligible. 661 participants completed a questionnaire before their consultation in which they were asked to agree or disagree with statements about what they wanted the doctor to do. A questionnaire after the consultation asked patients about their perception of the doctor’s approach. Both questionnaires were based on the five main domains of the patient centred model: exploring the disease and illness experience, understanding the whole person, finding common ground, health promotion, and enhancing the doctor-patient relationship
The post-consultation questionnaire included items about the reason for consultation and a positive and definite approach of the doctor to diagnosis and prognosis as well as sociodemographic details, the short state anxiety questionnaire, number of medical problems, and current treatment. The team also included questions relating to important patient related outcomes from the consultation: enablement (six questions about being enabled to cope with the problem and with life), satisfaction (medical interview satisfaction scale), and symptom burden (measure yourself medical outcome profile, which measures the severity of symptoms, feeling unwell, and daily restriction of activity). Patients were followed up after one month with the measure yourself medical outcome profile, and the team reviewed the medical records after two months for reattendance, investigation, and referral.The outcome measures of interest were patients’ enablement, satisfaction, and burden of symptoms. Factor analysis identified five components:
In return they will use healthcare resources less and their symptom burden will reduce. All this might be achieved without major policy reform and can be implemented locally to improve the patient experience and by corollary reduce the strain on healthcare resources.
Picture by Jenny Mealing
Every doctor in general practice/family medicine learns about the ‘models‘ of the consultation. My favourite is the Pendleton model. The thinking behind a map of the medical consultation is summarised by Pawlikowska and colleagues
A fundamental change in medical culture in this area has been the recognition and acceptance of the fact that the way in which health professionals communicate, on all levels, can be enhanced, irrespective of the innate and learned abilities they already possess.
In 2016 Michael Bungay Stanier published The Coaching Habit: Say Less, Ask More & Change the Way you Lead Forever. This comes at a time when the relationship between doctors and the people who seek their help is changing. With each passing generation, people expect to be actively involved in making choices in healthcare.
Women, more educated, and healthier people were more likely to prefer an active role in decision making…..Preferences for an active role increased with age up to 45 years, but then declined. Livenson
Doctors and the people who consult them will frame themselves as a team. At the same time, the major challenges relate to non-communicable chronic disease. Specifically to encourage people to stop smoking, eat and drink less, exercise more, and to be screened for early detection of malignancies. And for those who succumb to actively manage their chronic illness.
Therefore the interaction between the person seeking advice and the ‘expert’ is more likely to be akin to coaching. Given that people present to primary care with undifferentiated conditions the agenda for the meeting is set by the person who made the appointment. That’s why Bungay Stanier’s practical approach is a significant contribution. If we accept that the doctor is to be the ‘coach’ the author sets the scene in the very first chapter:
Only 23% of people being coached thought that the coach had a significant impact on their performance or job satisfaction. Ten percent even suggested that the coaching they were getting was having a negative effect. ( Can you imagine what it would be like going into those business meetings? ” I look forward to being more confused and less motivated after my coaching sessions with you.”)
The book emphasises that ‘coaching’ is a habit. Something that needs to be valued for three reasons:
Building a coaching habit will help your team be more self-sufficient by increasing their autonomy and sense of mastery by reducing your need to jump in, take over and become the bottleneck.
There is already such a concern about over-dependence in medicine. Read Naomi Hartree’s summary ( Helping Patients Avoid Doctor Dependency)
2. To avoid getting overwhelmed.
Building a coaching habit will help you regain focus so you and your team can do the work that has real impact and so you can direct your time, energy and resources to solving the challenges that make a difference.
Being overwhelmed is a recognised problem in medicine. Read locumstory(Physician Workload)
3. To help people do more work that has impact and meaning.
Coaching can fuel courage to step out beyond the comfortable and familiar , can help people learn from their experiences and can literally and metaphorically increase and help fulfil a person’s potential.
Again this has strong resonance in healthcare specifically because of the limited predictive value of tests or the large number needed to treat. In addition, there is mounting concern about the variation in these outcomes across geographical areas. See John Newton.
The Coaching Habit emphasises seven questions in a specific order. The first question is arguably the most important. Bungay Stanier calls it the kickstart question: ” What’s on your mind?” He justifies it as follows:
Because it’s open, it invites people to get to to the heart of the matter and share what’s important to them. You’re not telling them or guiding them. You’re showing them trust and granting them autonomy to make choices for themselves. And yet the question is focused, too. It’s not an invitation to tell you anything or everything. It’s encouragement to go right away to what’s exciting, what’s provoking anxiety, what’s all-consuming, what’s waking them at 4 a.m., what’s got their hearts beating fast.
This question followed by the space to answer is one that creates the opportunity to find what is really bothering someone. It is not universally common in healthcare. There’s an eloquent summary of the data from Juliet Mavromatis
Why do physicians interrupt? In practical terms, throughout the course of a given day a physician may be tasked with listening to twenty to thirty patient derived histories and with solving difficult problems for each of these patients in a matter of ten to fifteen minutes. This is a tough, if not impossible job. Consequently, once a physician believes that the meat of the story is out there, he or she may respond and interrupt before hearing details that the patient (or colleague) feels are important. In more abstract terms interruption is a communication strategy that reinforces physician dominance in the hierarchy of the patient-physician relationship.
Picture by Allie Hill
In the wake of her book launch I had the honour to interview Dr. Halee Fischer-Wright President and CEO of MGMA. In her book: ‘Back to balance:The art, science and business of medicine’ the author asserts:
We have lost our focus on strengthening the one thing that has always produced healthier patients, happier doctors, and better results: namely, strong relationships between patients and physicians, informed by smart science and enabled by good business.
In a separate blog post Larry Alton, business consultant addressing the business community says:
In 2017, you’ll find it difficult – if not impossible – to be successful without strategizing around customer communications. Customers have become conditioned to expect interaction and service. Provide both and you’ll be delighted with the results.
Most people will interact only with primary care when they need healthcare. The average consultation in primary care is less than 15 minutes. Therefore efficient communication is a priority. Larry Alton goes on to advise:
Communication is at the heart of engaging and delighting customers. The problem is that, even with all of the new advancements in communication technology, very few businesses are taking this all-important responsibility seriously. This results in poor relationships and a bad brand image.
His four key action points are:
One area that seems to receive scant attention in medical practice is explaining technical concepts. And yet technical concepts are integral to medical practice:
Ours is a technologically proficient but emotionally deficient and inconsistent medical system that is best at treating acute, not chronic, problems: for every instance of expert treatment, skilled surgery, or innovative problem-solving, there are countless cases of substandard care, overlooked diagnoses, bureaucratic bungling, and even outright antagonism between doctor and patient. For a system that invokes “patient-centered care” as a mantra, modern medicine is startlingly inattentive—at times actively indifferent—to patients’ needs. Meghan O’Rourke
When explaining complex ideas there is a checklist:
Adapted from a post by Thorin Klosowski
Perhaps the neatest medium to communicate some aspects of a complex idea is the infographic. According to experts:
In the past 5 years, the term “infographic” has seen an impeccable rise in trend.In fact, the popularity of infographics is expected to see an increase of almost 5% by next year, meaning that anyone who isn’t yet riding the infographic bandwagon is bound to fall behind. The Daily Egg
Here are the data:
The Journal of Health Design has recently introduced the Infographic as a submission type. Communicating using this medium could reduce the time required to assimilate the information needed to make a decision.
Much of what we do in healthcare is communicate ideas. That is far more common than ‘doing’. Executive control over decisions are the purview of the patient. It is a basic tenant of medicine that the patient has autonomy.
Often armed with little more than a stethoscope doctors must communicate to the patient that:
When communication about the evidence base is effective the patient, the practitioner and ultimately the economy benefit. How we communicate such ideas is where innovation has the brightest future. It gives us hope that we can improve outcomes in health without recourse to major policy change or curbing freedom of choice.
We communicate in words, pictures, video, audio and using models. Yet so much of how that is done in the doctor’s office hasn’t changed over the decades. ‘It’s just a virus’ doesn’t cut it any more.
We experience the power of effective communication everyday and in every other area of our lives. Look at your credit card statement this month- does it all make sense? What pressed your ‘purchase‘ button?
What if this extraordinary power deployed so effectively in commerce was unleashed in the clinic?
Picture by Dan Moyle
The duration of consults in medicine has been a bone of contention for years. Nowhere has the issue received more attention than in the UK where the issue of access to general practice has been the subject of debate and discussion since at least since the late nineties. The following graph depicts the duration of consults in one data set:
The accompanying commentary summaries the position well:
The shape of the curve highlights the extent of variation, though the mean is just under 12 minutes … In the GP contract 2014 the requirement for a 10 minute consultation has sensibly been dropped. Some clamour for 15 minutes – and they are right, but for only a small minority of patients. Many more need under 10 minutes, also right. What is inefficient is allocating the wrong time – too short, and rework results. Too long, throughput falls and waits rise.
Therefore the issue is not merely the ‘duration’ of consults but what actually transpires in those meetings. Decades of research have identified the tasks for both parties in the consult (the paper below may not have been written by someone whose first language was English but they make their point):
For example: patients face the issues of how to put their concerns on the floor (Robinson and Heritage 2005); how to show themselves to be properly oriented to their bodies (Halkowski 2006, Heritage and Robinson 2006, Heath 2002); how to direct the doctor’s attention toward and away from certain diagnostic possibilities (Gill and Maynard 2006, Gill et al. forthcoming, Stivers 2002b); and how to deal with diagnoses and treatment recommendations that may or may not correspond to their own views and preferences (Heath 1992, Stivers 2002a, 2006, Peräkylä 2002).
From the point of view of doctors, issues include eliciting all of a patient’s concerns (Heritage et al. 2007, Robinson 2001) and designing solicitations that are fitted to the concerns that patients are likely to have (Heath 1981, Robinson 2006); preparing patients for no-problem diagnoses (Heritage and Stivers 1999) as well as difficult diagnostic news (Maynard 2003, Maynard and Frankel 2006); and securing patient agreement in regard to diagnoses (Peräkylä 2006) and treatment recommendations (Stivers 2006, Roberts 1999). Pilnick et al
We know that the doctor will be taking notes or referring to the patients records during the consultation.
Conversation analytic studies have shown that participants of a conversation constantly monitor each other
and the unfolding speech in order to be able to perform the relevant next action when the present speaker has ﬁnished his turn of talk (Sacks, Schegloﬀ & Jeﬀerson, 1974). The direction of gaze is of utmost importance here, as gazing at the speaker constitutes a display of attention by the recipient (Goodwin, 1980, 1981; Heath, 1986; Robinson, 1998).
In addition to direction of gaze, the engagement framework may be created and maintained by shifting one’s posture (Kendon, 1990; Schegloﬀ, 1991; Robinson, 1998), or gesturing in the visible ﬁeld of the intended recipient (Goodwin, 1986; Heath, 1986). Shifts in posture that may be treated as displays of attention or disattention can be analyzed as shifts of ‘home position’ of the body (Schegloﬀ, 1991)
As in everyday conversation, in doctor– patient interaction the participants constantly monitor each other’s movements and direction of gaze (Heath, 1986; Robinson, 1998)
Johanna Ruusuvuor’s research, quoted above also suggests that there are four circumstances in which the consultation becomes dysfunctional insofar as the patient’s narrative is inhibited.
The doctor is seated facing the a desk away from the patient and does not make eye contact with the patient as they start to disclose the reason for the consultation.
2. Disengagement with manifest shift in orientation:
The home position of the doctor is towards the desk with his head in torque towards the patient. He releases his torque simultaneously as he withdraws his gaze from the patient.
3. Disengagement at critical point of description:
Turning away at a moment when maintaining mutual involvement in a common focus of interest has been made speciﬁcally relevant, and when the utterance is still incomplete with only the very core of the complaint pending, seems to be interpreted by the speaker as a disengagement from the role of the recipient.
In the last two examples the postural orientation of the doctors, and the way in which the doctors turned away from the patient to the records within the patients’ turns were enough to convey a disengagement from interaction with the patient
4. Disengagement at critical point of story-telling:
The doctor’s home position is towards the patient. From time to time he turns his upper body to torque towards the desk, making notes. The doctor disengages when the patient is about to reach the completion of her/his turn.
There are speciﬁc moments in which disengaging from interaction with the patients hampers a good outcome because it interrupts the narrative and the conversation becomes disjointed. Therefore it may pay great dividends to note where you are looking and how you are positioned during the consultation.
I’ve been sick for two days. I have a runny nose, headache, cough and I’m tired.
We agreed that it was very unpleasant having these symptoms when you are moving boxes around a warehouse all day. I examined him and found signs of an upper respiratory tract infection but nothing worse. Now comes the crucial part. If you are a doctor what do you say in the circumstances? You must have your speech ready because you will almost certainly consult someone like this every day, probably more than once a day. In an essay published in the BMJ Trisha Greenhalgh and colleagues wrote:
Evidence users include clinicians and patients of varying statistical literacy, many of whom have limited time or inclination for the small print. Different approaches such as brief, plain language summaries for the non-expert (as offered by NICE), visualisations, infographics, option grids, and other decision aids should be routinely offered and widely used. Yet currently, only a fraction of the available evidence is presented in usable form, and few clinicians are aware that such usable shared decision aids exist. BMJ 2014
What she appears to be hinting at is that words are not enough and may not efficiently convey what this man needs to make a decision for himself. He has already decided for whatever reason that he needs to see a doctor. He was probably able to ‘self-care’ by taking ‘over the counter’ symptomatic measures. Setting aside the notion that he might have presented to get a medical certificate to claim time off what else may be on his agenda? If we postulate that he might want prescribed medicines believing that they will hasten this recovery then there is the prospect of a disagreement with you as the ‘evidence’ suggests otherwise. He probably has a viral illness. But as David Spiegelhalter and colleagues wrote in Science:
Probabilities can be described fluidly with words, using language that appeals to people’s intuition and emotions. But the attractive ambiguity of language becomes a failing when we wish to convey precise information, because words such as “doubtful,” “probable,” and “likely” are inconsistently interpreted. Science 2011
What the person with the cold needs to know is that we cannot be sure what precise ‘bug’ has caused his symptoms. That the most likely cause is a virus but that his symptoms now do not predict the duration or severity of his illness. However most people get better within 10 days and he is probably suffering the most he will through this illness today. The worst symptoms are those he now describes. the cough may linger for a couple weeks. Symptomatic treatment might help him feel better and that people who have been prescribed antibiotics do not get better any faster (that last bit is my team’s research which hasn’t yet seen the light of day in a peer-reviewed journal). However he may not factor all of this information into his thinking without pictures. We need to consider how he makes the decision to take your advice. Scientists have studied this and come up with some helpful advice recently. For a start the patient is unlikely to make a decision based on logic alone.
Behavioral economic studies involving limited numbers of choices have provided key insights into neural decision-making mechanisms. By contrast, animals’ foraging choices arise in the context of sequences of encounters with prey or food. On each encounter, the animal chooses whether to engage or, if the environment is sufficiently rich, to search elsewhere. Kolling et al
There are three treatment options; prescribe an antibiotic now, defer prescribing for a couple days or prescribe nothing. The latter is the appropriate course however a goal in this situation is to reach consensus with this person. To present the data to him in a way that engages his entire decision making apparatus. You are able to usher him out the door without anything only to find that he has lost faith in you. How he feels about the matter is critical:
A few years ago, neuroscientist Antonio Damasio made a groundbreaking discovery. He studied people with damage in the part of the brain where emotions are generated. He found that they seemed normal, except that they were not able to feel emotions. But they all had something peculiar in common: they couldn’t make decisions. The big think
The more challenging approach is to communicate respectfully, appropriately and effectively. Pictures can now assist as never before. Yet the habit of using pictures is neither taught nor practised consistently in clinics. Spiegelhalter again:
The most suitable choice of visualization to illustrate uncertainty depends closely on the objectives of the presenter, the context of the communication, and the audience. Visschers et al. concluded that the “task at hand may determine which graph is most appropriate to present probability information” and it is “not possible to formulate recommendations about graph types and layouts.” Nonetheless, if we aim to encourage understanding rather than to just persuade, certain broad conclusions can be drawn, which hold regardless of the audience.
His team’s recommendations:
The last offers a call to arms for innovators.
Picture by Alan
Every interaction with patients should reflect the motto of the healthcare organization serving their needs.
Motto: A sentence, phrase, or word expressing the spirit or purpose of a person, organization, city, etc., and often inscribed on a badge, banner, etc. Dictionary
I like the motto of the Royal College of General Practitioners, UK:
Compassion with knowledge. So here are a list of unacceptable explanations when someone interacts with a service provider and things deviate from whatever noble aim is adorned above the front door:
Every interaction should reflect what we say and what we believe the patient /customer/ colleague is entitled to from our service or our staff. The response when deviations are reported should also reflect the motto. Choose your motto with care.
Picture by Adrian Clark
In general practice patients generally present with undifferentiated conditions. People come for help with a cough and not ‘pneumonia’, back pain and not ‘metastatic prostatic cancer’, fatigue and ‘not diabetes’. In a study published in 2015 it was reported that a diagnosis is not established in 36% of patients with health problems. According to the research team half of the symptoms were expected to resolve or persist as ‘medically unexplained’. In their summary the team concludes that:
The study highlights the need for a professional and scientific approach to symptoms as a phenomenon in its own right. Rosendal et al
We also know that the commonest symptoms relate to the musculoskeletal system, respiratory system and the digestive tract. As long ago as 1984 Gordon Waddell and colleagues made a similar point in the BMJ :
The amount of treatment received by 380 patients with backache was found to have been influenced more by their distress and illness behaviour than by the actual physical disease. Patients showing a large amount of inappropriate illness behaviour had received significantly more treatment (p <0 001).
We know that a standard medical history and examination provide a wealth of information not only about the disease from which the patient is suffering but also about how that particular person is reacting to and coping with his or her illness. What is necessary now is to devote as much time and effort to the study and understanding of illness behaviour as we do at present to the investigation of physical disease. Only thus can we put the art of medicine on to a sound scientific basis.
Decades later these words are prophetic and we find that the thrust of research is on the diagnosis and treatment of specific pathology rather than on how to help people to cope with persistent back pain, acute cough or ill defined abdominal pain. This continues to be a bone of contention between doctors and patients as was illustrated in a classic paper by Joe Kai writing about the management of illness in preschool children in general practice:
Parents expressed a need for more information about children’s illness. Advice about the management of common symptoms was insufficient. They sought explanation and detail that was specific and practical to help them make decisions about the likely cause of an illness, how to assess severity, and when to seek professional advice. They wanted to know of any implications of the illness or its treatment and the potential for prevention in the future. Most thought that being more informed would reduce rather than increase their anxiety.
In a literature review published in 2002 in the BJGP Hay and Wilson charted the progress of children under 4 who develop an acute cough:
At one week, 75% of children may have improved but 50% may be still coughing and/or have a nasal discharge. At two weeks up to 24% of children may be no better. Within two weeks of presentation, 12% of children may experience one or more complication, such as rash, painful ears, diarrhoea, vomiting, or progression to bronchitis/pneumonia.
The authors conclude that:
Illness duration may be longer and complications higher than many parents and clinicians expect. This may help to set more realistic expectations of the illness and help parents to decide when and if to reconsult.
By implication, as well as knowing when and how to investigate symptoms, it would help patients if doctors also routinely communicated the natural history of the commonest symptoms including and especially:
For example it has been demonstrated that the experience of individual doctors on this issue is unreliable. Writing on acute low back pain researchers from New Zealand suggests that 91% of patients stop consulting their doctor at 3 months after the pain starts and long before their symptoms have resolved. Also that only 1:5 patients are free of pain or disability one year after an acute episode of low back pain.
Picture by Tina Franklin