Tag Archives: creative thinking

The infographic bandwagon rolling in to your clinic

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:

  1. Hire empathetic employees
  2. Leverage the right communication mediums
  3. Use analogies to explain technical concepts
  4. Become a good listener

One area that seems to receive scant attention in medical practice is explaining technical concepts. And yet technical concepts are integral to medical practice:

  1. What pathology brought me here today?
  2. Why has my physiology responded in this way?
  3. What is the prognosis?
  4. Why do need this therapy?
  5. What are the risks?

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:

  1. Does the patient want all the information?
  2. What are the implications of the prognosis?
  3. How can you explain with reference to something they are already know?
  4. What details can you leave out that would only serve to distract from an understanding?
  5. How can the patient assimilate this information actively?

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.

Picture attribution

Designers will rescue the health sector

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

For best results engage the entire decision making apparatus

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:

  • Use multiple formats, because no single representation suits all members of an audience.
    Illuminate graphics with words and numbers.
  • Design graphics to allow part-to-whole comparisons, and choose an appropriate scale, possibly with magnification for small probabilities.
  • To avoid framing bias, provide percentages or frequencies both with and without the outcome, using frequencies with a clearly defined denominator of constant size.
  • Helpful narrative labels are important. Compare magnitudes through tick marks, and clearly label comparators and differences.
  • Use narratives, images, and metaphors that are sufficiently vivid to gain and retain attention, but which do not arouse undue emotion. It is important to be aware of affective responses.
  • Assume low numeracy of a general public audience and adopt a less-is-more approach by reducing the need for inferences, making clear and explicit comparisons, and providing optional additional detail.
    Interactivity and animations provide opportunities for adapting graphics to user needs and capabilities.
  • Acknowledge the limitations of the information conveyed in its quality and relevance. The visualization may communicate only a restricted part of a whole picture.
  • Avoid chart junk, such as three-dimensional bar charts, and obvious manipulation through misleading use of area to represent magnitude.
  • Most important, assess the needs of the audience, experiment, and test and iterate toward a final design.

The last offers a call to arms for innovators.

Picture by Alan

Is your motto reflected in every interaction?

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:

Cum Scientia Caritas

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:

  1. I’m not paid to do that
  2. I don’t have the resources
  3. That’s not how things are done
  4. Where’s the evidence?
  5. It’s not my fault
  6. It’s not in the protocol
  7. Too idealistic
  8. It’s not me it’s them
  9. I didn’t know
  10. We didn’t negotiate that in the contract
  11. People expect too much
  12. We never promised that
  13. We might do that in the future
  14. We would never get through the day if we did that for everyone
  15. I don’t care
  16. I only work here
  17. Too busy
  18. Maybe next time
  19. What about me?
  20. It doesn’t matter

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

 

Your words are potent medicine


A principle of medical ethics is beneficence:

A moral obligation to act for the benefit of others. Not all acts of beneficence are obligatory, but a principle of beneficence asserts an obligation to help others further their interests. Obligations to confer benefits, to prevent and remove harms, and to weigh and balance the possible goods against the costs and possible harms of an action are central to bioethics. Med Dictionary

In saying that the business of medicine is not so different from many other forms of commerce where someone might offer a solution to what appears to be a problem. What we have learned from studying human interactions is that what is said, how and when it is said has a crucial impact on what the person with the problem decides to do. In medical research the hopes of improving outcomes sometimes seem to focus on labs manned by people in white coats funded by a research grant. What is often overlooked is that it may be possible to change outcomes in healthcare (for better or for worse) by working on the dialogue in the consulting room. What in previous posts I have dubbed the ‘script’ in the ritual that is the consultation.

Beneficence dictates that we act to present the autonomous individual with options in a way that leads them to act in their best interests. That may include having the operation, taking the pills, accepting the referral or the test. But also steering away from  those options if they are not in their best interests. The art of communication received a boost in Robert Cialdini’s book Pre-Suasion. Cialdini catalogues the research on the subtle ways in which we are triggered to make choices from the options on offer. It is hard to summarise this extraordinary book but there are at least four essential lessons:

  1. There are ‘Privileged Moments’.  ‘Influence practitioners’ should target such moments before the interaction to greatly increase their effectiveness. It is possible to speculate what these might be for patients: pregnancy, diagnosis of a significant illness, receipt of worrying test results, significant birthday etc.
  2. During verbal exchanges leading questions try to get you to respond with certain answers and influence your later decisions. For example: “Given the recent cases of death from influenza, how dangerous do you perceive the threat of flu to be?” The way the question is posed is loaded with pre-suasion. By reminding you of these deaths the questioner draws attention to the recency of the topic, and thus the patient will evaluate the danger as high and be primed to accept the offer of vaccination.
  3. Whatever grabs our attention, we think is relevant. As Cialdini says:

All mental activity is composed of patterns of associations; and influence attempts , including pre-suasive ones , will be successful only to the extent that the associations they trigger are favourable to change.

In other words in any situation, people are dramatically more likely to pay attention to and be influenced by stimuli that fit the goal they have for that situation. In medicine being presented with information that suggests that someone might be ‘at risk’ of an illness might lead them to act to reduce the risk. However also in this context the heightened anxiety due to fear messages against for example smoking causes people to be delusional in order to dampen the anxiety effect. We also know that the public has a very poor understanding of numbers. In a study of laypersons published in Health Expectations it was concluded that:

Most participants thought of risk not as a neutral statistical concept, but as signifying danger and emotional threat, and viewed cancer risk in terms of concrete risk factors rather than mathematical probabilities. Participants had difficulty acknowledging uncertainty implicit to the concept of risk, and judging the numerical significance of individualized risk estimates. Han et al

Cialdini offers another insight:

The communicator who can fasten an audience’s focus onto the favourable elements of an argument raises the chance that the argument will go unchallenged by opposing points of view, which get locked out of the attentional environment as a consequence.

It isn’t just the facts but how the facts are presented. There are ways in which to engage if not by pass the logic. The three ‘commanders’ of attention that are highly effective are: the sexual, the threatening and the different. When an issue is presented in the context of these considerations their impact is boosted significantly.

    4. Our word choices matter a lot more than we think, because words get us to do things. The main function of language is not merely to  express or describe, but to influence. Something it does by channeling recipients to sectors of reality preloaded with a set of mental association favorable to the communicators view. Doctors may want to illuminate connections to negative associations and increase connections to positive associations. People also prefer things, people, products, and companies that have an association with themselves. This again emphasizes the vital importance of knowing what matters to the person whom you may wish to influence.

Finally and in medicine very significantly Cialdini draws our attention to the following:

Those that use the pre-suasive approach must decide what to present immediately before their message. But they must also have to make an even earlier decision: whether, on ethical grounds, to employ such an approach.

Every day patients consult doctors. Words are use. These words are designed to influence choices. In medicine the options presented may not take into account factors that the patient may not have disclosed and therefore the choice on offer may not be in their best interests. Nor do those choices take account of the practitioner’s own limitations in evaluating the choices offered. Therefore the first and most important aspect of communicating persuasively is to listen. As Cialdini suggests first determine identifiable points in time when an individual is particularly receptive to a communicator’s message.

Picture by Andreas Bloch

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


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

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

There are five elements to this ritual:

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

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

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

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

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

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

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

The team go on to conclude that:

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

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

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

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

Picture by US Army Garrison Red

To stem healthcare costs offer more time in the consulting room

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

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

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

What has been shown to reduce costs is General Practice.

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

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

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

These goals are easier to achieve when:

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

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

1. Telehealth.

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

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

2. Wearable technologies.

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

3. Genetic testing.

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

4. Electronic medical records.

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

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

a. Slow down

b. Active communication

c.  Minimise competing agendas

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

Image by Roswell Park

Road map to better health outcomes

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

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

 

Image attribution

Why our jobs are making us fat

We spend most of our time at work.

  • Expressed as terms of a percentage of your life, this 39.2 hours a week spent working is equivalent to:
  • 14% of your total times over the course of a 76 year period (based on the average projected life expectancy of 76 for people born in the year 2000 according to the ONS’s National Life Tables for the United Kingdom.)
  • 23.3% of your total time during the course of a 50 year working-life period
  • 21% of your total waking hours over a 76 year lifespan, assuming 8 hours of sleep a night.
  • 35% of your total waking hours over a 50 year working-life period assuming 8 hours of sleep a night
  • 50% of your total waking hours during any given working day. ReviseSociology

This is a significant chunk of our lives. Yet we note that many people are disengaged at work.

Gallup

This is a problem because being disengaged at work is also associated with other behaviours that are problematic. Faragher and colleagues reported in the BMJ:

A systematic review and meta-analysis of 485 studies with a combined sample size of 267 995 individuals was conducted, evaluating the research evidence linking self-report measures of job satisfaction to measures of physical and mental wellbeing. The overall correlation combined across all health measures was r = 0.312 (0.370 after Schmidt-Hunter adjustment). Job satisfaction was most strongly associated with mental/psychological problems; strongest relationships were found for burnout (corrected r = 0.478), self-esteem(r = 0.429), depression (r = 0.428), and anxiety(r = 0.420). The correlation with subjective physical illness was more modest (r = 0.287).

There is increasing evidence for an association between job dissatisfaction and the most significant health challenge we face in the next decade- namely obesity. A survey of nurses in Ohio concluded that:

..disordered eating differed significantly based on perceived job stress and perceived body satisfaction. Nurses with high levels of perceived job stress and low levels of body satisfaction had higher disordered eating involvement. King et al

A more recent paper in BMC obesity reported that obesity rates varied across industries and between races employed in different industries:

Obesity trends varied substantially overall as well as within and between race-gender groups across employment industries. These findings demonstrate the need for further investigation of racial and sociocultural disparities in the work-obesity relationship to employ strategies designed to address these disparities while improving health among all US workers. Jackson et al

Lui and colleagues suggest a possible explanation:

Study 1 sampled 125 participants from 5 Chinese information technology companies and showed that when participants experienced higher levels of job demands in the morning, they consumed more types of unhealthy food and fewer types of healthy food in the evening. In addition, sleep quality from the previous night buffered the effect of morning job demands on evening unhealthy food consumption. Study 2 used data from 110 customer service employees from a Chinese telecommunications company and further demonstrated a positive association between morning customer mistreatment and evening overeating behaviors, as well as the buffering effect of sleep quality. J Appl Psychol

Possibly a very useful question we can ask people seeking medical advice with weight management: ‘ What do you do for a living and how do you feel about it?’. It may be that they are eating their feelings. Review what people are eating at their desk or during breaks. Snacks have become the fourth meal of the day — accounting for 580 extra calories per day, most of which come from beverages — and may be a primary contributor to our expanding waistlines. Here’s why employees become disengaged at work. A summary:

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What’s the shortest route to where you want to go?

As the conference season begins we note that response rates in the order of 10-20% are not unusual in primary care research. Hardly generalisable. And yet we need sustainable and workable solutions that will promote health and well being in an ageing demography with increasing multimorbidity. Researchers take note the traditional gatekeeper in primary care, the general practitioner is occupied just keeping up with demand. There is no time to recruit, to seek informed consent or to deliver interventions that are being tested in a traditional randomised trial. At one time membership of networks with ‘committed’, well meaning practitioners were considered essential to successful research. In 2017 relying on anyone or any organisation that purports to guarantee recruitment rates or ‘collaboration’ seems at best naive and at worst risky.

Health requires people to make different choices. Eat better, drink less, take more exercise, jettison bad habits, consider when and where to seek medical advice. The traditional model of healthcare is evolving. The evolution is driven by technology that has fundamentally changed our experience of many if not all things. People consider themselves more time poor than they ever were.

The ability to satisfy desires instantly also breeds impatience, fuelled by a nagging sense that one could be doing so much else. People visit websites less often if they are more than 250 milliseconds slower than a close competitor, according to research from Google. More than a fifth of internet users will abandon an online video if it takes longer than five seconds to load. When experiences can be calculated according to the utility of a millisecond, all seconds are more anxiously judged for their utility. The Economist

The lesson for those hunting for better ways to reach people is to consider the least that can be done to get there. The answer may be waiting in all of our pockets.

Picture by Toshihiro Gamo