Tag Archives: creative thinking

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:

 

Picture by algona81

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:

Picture by Erich Ferdinand

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

Picture by ReSurge International

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.

Picture by Rene Passet

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

Picture by astrid westvang

Triggering better health outcomes

The first piece of data we collect in healthcare is: date of birth. Could it be used to trigger better habits?

50th birthday bashes have overtaken 21st celebrations as 50 now considered the “peak” age to throw a party, sales figures for cards and party paraphernalia show.

Sales of 50th birthday cards have for the first time eclipsed the number of 21st birthday cards sold, according to data from Clintons, the UK’s biggest cards retailer.

With 50th birthdays now leading on the birthday league table and accounting for 16 per cent of all card sales, 21st birthday cards now make up 14.1 per cent of all cards sold. Katie Morley. The Telegraph Oct 2017

I explore the possibilities.

Picture by synx508

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