Tag Archives: Distress

Can the patient relay what was done for them?

A perennial source of dissatisfaction in healthcare (as documented here and here) is the poor flow of information from one sector to another. ‘Joe’ (speaking here– video from BMJ open) couldn’t tell me, his doctor, anything helpful about what had been done while he had been in hospital. That means we have to schedule several appointments to try to unpack it all. He was an in-patient for two weeks and someone had decided one Thursday morning that it was time for him to go home. It wasn’t really clear to Joe or to me why that particular morning or what was to happen when he got home other than that he should contact his ‘local GP’. A letter would follow some time in the future. There may have been good or bad reasons for sending him home. We could only guess what was in the mind of the person who made the decision:

We needed the bed. Joe was fine. His observations were normal, he was ambulant his wife was happy to take him home.

But of course Joe comes home with lots of questions, which I now struggle to answer without making phone calls to track down the busy medical team. The problem is articulated by several ‘stakeholders’ members of the ‘multidisciplinary team’ on the ward none of whom feel they own the problem of telling this man what he needs to know. There is only one constant in this story- Joe. If Joe can collect the information we need during the course of his hospital stay we might begin to improve the outcome:

In addition to increasing the burden on GPs, it engenders a need for a subsequent GP appointment; it limits GP capacity to respond to patient concerns and queries, at least on one occasion; it may result in a re-referral to the specialist; and it increases GP dissatisfaction with the care provided to the patient by the hospital. BMJ

The problem is Joe often does not know what he needs to know by the end of his hospital stay. It isn’t impossible to work out how to trigger questions for Joe to ask throughout his hospitalisation. What is far more difficult is to motivate every hospital ward and every discipline in a team to address this challenge consistently. It is ‘easier’ to nudge one individual than enlist the cooperation of the dozens of health professionals who will come into contact with Joe. Making people active in healthcare processes has achieved results before:

Influence at Work, a training and consultancy company that Cialdini founded, worked with the United Kingdom’s National Health Service (NHS) in a set of studies aimed at reducing the number of patients who fail to show up for medical appointments. They did this by simply making patients more involved in the appointment-making process, such as asking the patient to write down the details of the appointment themselves rather than simply receiving an appointment card. Sleek

Picture by Michael Coghlan

Change your reactions to change your results

In 2017 you can expect to be challenged because it is unlikely that everything will go to plan. As in everything in life you have a choice how to react but you may find it difficult to exercise that choice because of your habits. You can bear witness to these habits in your interactions at work next week. According to the Karpman drama triangle you are likely to be your own worst enemy.

When ‘bad things’ happen you may react in one of three ways initially:

Victim

‘Poor me!’

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One that is acted on and usually adversely affected by a force or agent

(1):  one that is injured, destroyed, or sacrificed under any of various conditions

(2):  one that is subjected to oppression, hardship, or mistreatment. Merriam Webster 

From the victim’s perspective it’s their fault. ‘They’ did it to you. It’s the government, the company, the patients, the clients, your  boss. If not them it’s the weather, the traffic, your genes. There is nothing you can do but complain.

Rescuer

‘Let me help you’ (and thus keep you dependent on me).

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A person who pretends to suffer or who exaggerates suffering in order to get praise or sympathy. Merriam Webster

From the rescuer’s (martyr’s) perspective they are surrounded by people who make unreasonable demands. Nobody can get the job done without their help. It may mean cancelling holidays and working weekends but there is nothing for it.

Persecutor

‘It’s all your fault.’

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 The Persecutor is controlling, blaming, critical, oppressive, angry, authoritative, rigid, and superior. Wikipedia

From this perspective it’s time to put your foot down. ‘Enough is enough’. ‘They’need to be brought into line.

It has been suggested that we move in and out of these roles. However everyone has a default position and in most cases it is the ‘rescuer’. This may be because:

It keeps the Victim dependent and gives the Victim permission to fail. The rewards derived from this rescue role are that the focus is taken off of the rescuer. When he/she focuses their energy on someone else, it enables them to ignore their own anxiety and issues. This rescue role is also very pivotal because their actual primary interest is really an avoidance of their own problems disguised as concern for the victim’s needs. Karpman Drama Triangle.

At this time as we launch on another round of New Year’s resolutions. Our results may already be predicted.

  1. How many times over the past week, while you were allegedly on holiday,  have you responded to email or taken phone calls for work?
  2. How many times have you felt compelled to work even though you were on ‘holiday’?
  3. In how many conversations over dinner have you moaned about your job?
  4. What will be the first topic of conversation at work after the polite “How was your Christmas”?

The antithesis of a drama triangle lies in discovering how to deprive the actors of their payoff. Therefore if your default position is ‘rescuer’ you may want to consider whether, or perhaps which, of your own problems you are avoiding. Keep a close eye on your behaviour next week. That may be a better place to start making meaningful resolutions this year. For best results also consider reading: The Coaching Habit by Michael Bungay Stanier. You may also enjoy in praise of the quiet life.

Picture by Brandon Warren

Create your own working conditions or deal with the headaches

It was Friday morning. S/he looked well so I was surprised when s/he said:

I woke up with a headache this morning. I’ve taken paracetamol. I feel a bit better but I couldn’t go to work this morning.

What do you do for a living? I asked. Insert into his /her response:

Teacher/nurse/social worker/call centre operator/forklift driver

Is it busy just now? I asked. Wondering how his/ her boss would take the news of this absence. The smile slipped.

It’s been terrible this year. Lots of demanding (patients/ clients/ kids/shifts).

Then- tears.

I’ve got to hold it together. I’m only six months away from ( holiday/ long service leave/ wedding/ boss leaving)

Is this sustainable? Really?

How much time do you spend on things that are either distractions (not-urgent or important) or someone else’s emergency (urgent /not important)? How much time do you spend on the most valuable quadrant not urgent and important? Why are you always fire fighting (urgent and important) ? Icon made by Ocha from www.flaticon.com

What are you doing during the most productive time of the day? What do you focus on first in the morning? When you are fresh and rested? What are you leaving till later when you should be heading home? Icon made by Freepik from www.flaticon.com

 

It’s your responsibility to set limits to your accessibility. If your boss wants you to do this then s/he doesn’t expect you to do the other.  Are you sure you clarified the situation? YOU have created these unreasonable expectations because the word ‘no’ isn’t in your vocabulary. Icon made by Freepik from www.flaticon.com

 

Finally how much energy, stamina, good will or creativity is left in the tank? There is a limit- even for you. Icon made by Freepik from www.flaticon.com

You are not exempt even if you are a doctor. If you don’t create the life you want then one will be created for you. And it might just give you a headache. You have some thinking to do while you nurse that headache.

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Rehearse a plan for best care

It was a Saturday morning. Michael (43) popped in to get the results of his test as requested by the message left on his phone. He was told that the doctor who ordered the test wasn’t on duty that day so he asked to see whoever was available. That’s how I came to be involved.

From the records it wasn’t clear why the cortisol assay had been requested along with a battery of other tests all of which were normal. All the man could tell me is that he had asked for the test because:

It might explain a lot.

We had to start again. He was tired. He was stressed. He was working long hours at two jobs to pay a mortgage and service his debts. He had three young children and had been on antidepressants on and off for years. He wasn’t taking any tablets at the time. Didn’t smoke or drink. He was attending a counsellor.

There must be a reason I’m feeling so tired.

There was no obvious explanation for the borderline low result. Physical examination was entirely normal. No recent change in weight, normal blood pressure and no hint of major depression. No history of tuberculosis. No evidence of Addison’s disease.

I thought the ‘cortisol’ levels would be high I’m under a lot of stress.

We could now be on the way to more tests to determine what I suspected would be the final outcome that there would be no explanation. Life can cause people to feel this way with multiple physical symptoms including dysphoria, fatigue, insomnia, sexual dysfunction, weight changes and anxiety. Reasons may include poor choice of occupation, poor choice of partner, poor money management, poor time management, poor parenting. All of these can be associated with unfulfilling social interactions and or job dissatisfaction. Poor coping mechanisms then lead to physical sequela. People can be trapped in a spiral of increasing adverse consequences until lessons are learned and either alternative choices are forced upon them or circumstances conspire to offer the opportunity to start again.

People may not be ready to face their demons and that means they will ask to go searching for something more palatable than a need for a education,  honesty, economy or help.

As for doctors ordering tests could add to the complexity of the situation. Rare causes of fatigue are legion.  However typically people will ask if their fatigue is caused by some malfunction of their ‘hormones’ or if they are anaemic or diabetic.

In the case above there was no hint in the records what the patient had been told to expect after the test. His understanding of hormones was not recorded. He had read that cortisol is related to stress but not what the results might mean.

Because of the very low prevalence of pathology the Positive Predictive Value of ‘abnormal’ tests for middle aged patient without any positive history or examination findings is low for example:

Therefore the probability that one simple test will make the diagnosis is unlikely. People will need multiple tests and possibly a referral to a specialist once we embark on the hunt for the elusive physical cause. The likelihood of finding one when the patient doesn’t have any physical signs is vanishingly low. In sporting terms what’s needed is a set play. The question can be anticipated and the response to the initial request for tests needs to be crafted in advance. There is no better start then taking a full history and examining the patient before looking for the needle in the haystack.

Picture by Henti Smith

An illness is never minor when you’re ill

After 20 years in practice I’d never seen one of these in my career. Until that day. It’s called a quinsy. Essentially an abscess deep in the throat. Not really surprising because according to a recent review:

Most patients with quinsy develop the condition rapidly, and many do not present with a respiratory tract infection to their GP first. BJGP

The incidence is estimated to range from 10-41 cases per 100,000 per year. It’s unusual to see a case in practice. Given Australia’s 23 million people you’d expect an incidence of about 2,300 cases per year nationwide. Similarly I consulted a young child with nephrotic syndrome, similar incidence (3.6 per 100,000). Both cases were referred to hospital as emergencies. The odds of seeing one of these is in the same order of magnitude as being struck by lightening in your lifetime.

On the other hand in the same week I saw several people with:

I also saw a victim of domestic violence:

Just under half a million Australian women reported that they had experienced physical or sexual violence or sexual assault in the past 12 months. Domestic violence prevention centre.

And a drug seeker:

Australian GPs write more than 15 million prescriptions per year for drugs known to be misused, with the main prescription drugs misused currently being narcotic analgesics and benzodiazepines, as well as stimulants, barbiturates and other sedative–hypnotic agents. Martyres et al

So apart from quinsy and nephrotic syndrome (both of which I recognised) I spent most of my week managing conditions that didn’t need to be referred to specialists.  And yet the people who were offered reassurance or simple and effective treatment for their ailments were immensely grateful. Every day general practitioners provide this service to the community. They save lives by identifying people who need urgent care but much more than that they make the lives of the community so much more tolerable. There is no such thing as ‘minor illness’.

The last word has to be on pityriasis rosea:

I finally found out what the rashes on my back, arms, torso, and now my foot are. I have herolds patch too. I hate it! I can’t stop scratching. It took 1 hospital visit and a trip to my doctor to find out what this thing was. The doctor at the hospital thought the big round patch was a ringworm and he thought all the other small rashes that had just appeared was scabies. I was terrified..did some research on scabies and tried to treat that myself. Then I decided to just go to my doctor and he told me it wasn’t scabies…and showed me a picture of hereld’s patch. He knew what it was right off the bat. I guess there is no cure for it and it just goes away by itself. I just wish I could take something so I can stop scratching. SkinCell forum

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Biomedicine falters when it ignores our messy lives

What this mum needed most was a good nights sleep. I proceeded to examine her smiling, curious, well fed, active infant. He reached up and grabbed my stethoscope than raised an eye brow and looked into my eyes and cracked a gummy smile the way babies do.

But he never cries doctor and today he hasn’t settled at all.

She was tired, she was a first time mum. She couldn’t see what I could see a content baby with a viral upper respiratory tract infection.

My sister says he could have a seizure when his temperature goes up. Both her boys have fits.

She needed me to tell her her baby was well, that he wasn’t going to have febrile convulsions and that one day soon, preferably today,  he would stop being wakeful at night. I mused that the child’s grandparents might have been helpful, but they lived in another city on the other side of the country. I had ten minutes to convince this mum that an immediate visit to the emergency department, ‘just in case’  was not warranted. She needed me to be calm and reassuring. She needed me to be confident. Anything else would reinforce the nightmare of visits to an emergency department every time the child had a fever.

The literature presents an interesting perspective on the issues:

  1. Acute illness in infants: a general practice study– Of the 126 consultations reviewed, 106 (84per cent) included at least one major symptom. None of the illnesses resulted in hospital admission or had a fatal outcome. It was concluded that this classification of symptoms into ‘major’ and ‘minor’ categories is not sufficiently discriminating to use in general practice. More specific definitions are required. No significant relationship was found between the reported presence of major symptoms at a consultation and maternal age, number of siblings, social class, unemployment, single parent family or proximity of maternal grandmother. Wilson et al.
  2. Non-urgent Use of a Pediatric Emergency Department: A Preliminary Qualitative Study– These visits ( to hospital) appear to be driven more by consequences of system design and structure than by family members’ decision making. Mistrust of primary care services was not a strong family decision-making factor; the study’s setting may have limited its ability to capture such data. Recommended system changes to lower barriers to primary care include expanded office hours, subsidized staffing for offices in medically underserved areas, and lowering barriers to sick care. Chin et al 
  3. New mother groups as a social network intervention: consumer and maternal and child health nurse perspective– The groups ran for approximately eight sessions and provided infant- focussed parent education and social contact. Women who joined the groups were followed up 18 months to two years later to determine the degree to which these groups continued to meet on their own accord and the extent to which they had become self-sustaining social networks. The study found a very high level of continuation, suggesting that providing such programs may be an important vehicle for enhancing social support during the transition to parenthood and thus a useful primary prevention strategy. Scott et al

I seems it is not possible to provide guidance based on a list of symptoms- ‘if this’ then reassure, ‘if that’ then refer. This makes it even more difficult for new parents to be ‘taught’ to seek care ‘appropriately’ and proximity of grandmothers makes no difference. Essentially the advice that if you are concerned then seek help is reasonable. Secondly when parents end up taking their infant to hospital there isn’t unequivocal evidence that it’s because they don’t trust their family doctor but rather it’s because they didn’t have access to one when needed.  Finally it may be possible to offer new mums more support at a time when access to extended families is reduced and becoming the exception rather than the rule.

Every day colleagues will be consulted about a child as a cry for help. We need an approach that crafts a solution in the context of these consultations rather than a mechanistic biomedical approach that ignores the messiness of our lives.  Family practice provides that approach and effectively reduces the cost of healthcare to our economy.

Picture by Sandor Weisz

How improving the experience of hospital death can help redesign healthcare

 

The residents always approached my father as if he was a person and there weren’t any divisions between them. They didn’t come in and say, “I’m Doctor so and so.” There wasn’t any kind of separation or aloofness. They would sit right on his bed, hold his hand, talk about their families, his family, golf, and sports. From Steinhauser et al.

The chances are when the times comes you will die in hospital. It may be sudden or it may be expected and either you will die a good death or the experience for you and those who are left to grieve will make a bad situation worse. Charles Garfield put it like this:

A good death is no oxymoron. It’s within everyone’s realm of possibility. We need only realize its potential and prepare ourselves to meet it mindfully, with compassion and courage

John Costello concluded his research on patient experiences of death as follows:

The findings also challenge practitioners to focus attention on death as a process, and to prioritize patients’ needs above those of the organization. Moreover, there is the need for guidelines to be developed enabling patients to have a role in shaping events at the end of their lives. John Costello

Therefore, the needs of the ‘organisation’ may impact adversely on the experience of death. These might include the need to adhere to routines such as ward rounds, meal and medication time on open wards which may make it difficult to cater to the needs of the family when the patient dies.

A good place to start with innovation is to consider what, how and when things go wrong. Costello’s interviews with nurses identified several determinants of a bad death:

  • Sudden, unexpected or traumatic deaths especially soon after admission
  • Death other than on the ward
  • Family not aware of impending death or family conflict a major feature
  • Lack of dignity or respect
  • Diagnosis uncertain

Therefore, the key features are the circumstances surrounding the death. The consequences are far from trivial:

Dying patients with unresolved physical and psychological problems, such as pain, nausea, vomiting or spiritual distress, and who were unresponsive to treatment or nursing care, were invariably regarded as experiencing bad death. John Costello

This begs the question why not prepare for death in every hospital admission especially where death is a less than distant possibility. The majority of hospital deaths occur in those over 75 years of age. How is the team prepared if there is a death on the ward expected or otherwise, whether it’s convenient to the routines or not?

Achieving seven goals appear to mark a ‘good’ death:

  1. The patient should be physically, psycho-socially, and spiritually pain-free
  2. Recognize and resolve interpersonal conflicts.
  3. Satisfy any remaining wishes that are consistent with their present condition.
  4. Review their life to find meaning.
  5. Hand over control to a trusted person, someone committed to helping them have the kind of death they desire.
  6. Be protected from needless procedures that serve to only dehumanize and demean without much or any benefit.
  7. Decide how social and how alert they want to be.

Many of these goals are in the purview of the doctor and her prescription pad, others require all those involved to help prepare for an event that will impact on everyone associated with the patient. Healthcare is now a team effort and nowhere more than at the end of life.

When physical symptoms are properly palliated, patients and families may have the opportunity to address the critical psychosocial and spiritual issues they face at the end of life. Steinhauser et al

The point is if we prepare every hospitalised patient who may conceivably deteriorate and die as if we were preparing them and our units for that experience we will treat all patients with greater dignity. That’s the foundation of good outcomes for healthcare staff and the dying.

Picture by Alyssa L. Miller

Are medical students already healers?

I recall the awkward silence when I couldn’t decipher the carotid angiogram thrust at me on Monday morning. As a newly qualified doctor who’d spent the weekend on-call, I would not have been able to describe my route home much less recognise the stenosis in the relevant cerebral artery. Never mind ‘doctor’ spat my boss. Tell us is the patient I’m about to operate on a nice man? He said winking at the gathered retinue.

Actually professor he is. Trouble is he asked me the same question about you and as you can see I’m not a very good liar.

That cheeky reply probably spelled the end of my surgical career. This style of ‘education’ was known as pimping and that day I had just refused to accept it. Among the legions of would-be doctors, there are a few who will go on to be brilliant in the course of their careers. There are those who will one day discover the cure for Alzheimer’s or cancer. There are those who will perform surgery to save life against impossible odds. There are those whose pills or devices will earn fortunes. But brilliant are also those who will reassure and revive. They will be the unsung heroes whose name won’t appear on any honour’s list. They will offer that undefinable quality that helps us to prime our regenerative capacity and immune systems, more often than not in spite of the limitations of technical fix-its. Those who will be the healers of tomorrow already have the qualities within them even before their first anatomy or physiology lecture. They are intelligent and resourceful but also have an innate sense of what to do when faced with a human being in distress. Our job is to hone those qualities and help them to recognise the precious gift that lies dormant until it is needed on the wards, in the clinics and at the bedside. It is truly a privilege to be part of their journey to nurture their talent despite the many disappointments and frustrations that are part of the landscape of any medical career.

We conclude that compassion is everyone’s business and that learners require early and sustained patient and client contact with time for reflection to enable the delivery of compassionate care. Davin and Thistlethwaite

What the world needs is healers, not technicians because doctors care for people and not machines. So in answer to my boss’s question the man he was about to operate on was an incredibly nice person. He would hail us over in the middle of our shift and insist that we took the fruit that his family had brought knowing that we were unlikely to have made it to the canteen before closing time. My boss really was an excellent technician. What helped the patient through this episode wasn’t just this technical skill, it was the compassion and concern that was lavished on him by the dedicated team of nurses and doctors who would ensure that he was pain free, that his questions were answered, his wounds were dressed and that his family were informed of his progress through intensive care and on the wards as was his wish. I’m sure he remembers his surgeon fondly as the brusque, brilliant and efficient man who helped keep him from a stroke but I’m sure he also remembers the junior doctors who would come to him in the middle of the night when his temperature spiked and the staff nurse was worried that his wound was infected. Without this care what was a difficult time for the family would have been a nightmare and the outcome may not have been as good. There were many times during that illness that we came close to losing that patient except that he had the resilience to hold firm to life and we were in his corner.

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Are you borrowing money to pay for someone else’s healthcare?

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I didn’t think I could have heard her right.

Oh yes doctor $2000. The vet lets me pay it back in instalments. He did the same a couple of years ago. He is very kind.

This old lady had visited me umpteen times. I knew she didn’t have a lot of money and that on occasion she would go without her pills because things were tight. She tried to make ends meet by working as chef at a greasy spoon. Her boss was a bit of a bully and often refused to pay her overtime. I had seen her through oesophagitis, osteoporosis and breast cancer. Each time she couldn’t afford to expedite the investigations and insisted on waiting months to be seen as a ‘public’ patient. But that weekend her dog had been paralysed and the vet had been authorised to carry out emergency surgery. Something she would be paying for months into the future.

Australia has one of the highest rates of pet ownership in the world. The pet care industry in Australia is estimated to be worth $8.0 billion annually. 39% of households own a dog. In fact 50% of Aussies live in a household with at least one cat and or dog in it, whereas only 35% share their household with at least one child under 16.  Companionship is the driving reason behind pet ownership. Australians are showering pets with gourmet food, protecting them with insurance and pampering them with reflexology, acupuncture and hydrotherapy. Pet food has been compared to baby food in terms of resilient market performance. I notice that one of the major supermarket chains has half an isle now stocking chilled pet food.

Most pet owners consider their pets to be members of the family and this has a powerful impact on how and what people buy. Julie Power

This trend has taken medicine by surprise. It may be prudent to enquire if your patient has a pet and if that pet is well. This is especially the case for pensioners whose dog or cat may be the only company they have. The impact of pet ownership on health continues to be debated. On the one hand it is considered to be beneficial, for reasons unknown. On the other hand being responsible for a pet may negate all the benefits. It is stressful worrying about the dog barking and annoying neighbours or damaging property.

Health care practitioners might ponder the impact of these surrogate family members on the lives of people. For pensioners in particular:

High levels of grief may also be experienced in the event of a pet’s death. Other aspects include cost, time, and behavioural problems that may lead to further stress, anxiety and loneliness. Bradley Smith

It is helpful to know if the person who is consulting you smokes tobacco or drinks alcohol. We think nothing of asking other intimate details. However we often fail to ask if the person has a pet. It might explain a lot.

Picture by Malcolm Payne

The power of the pregnant pause

313238312_3c0b16565f_zJohn made an appointment recently. Never seen him before. He shook my hand enthusiastically as he strode into the room. A forced smile. Lots of eye contact. A need to look brave. I remember noticing his hand was a bit wet and his deodorant was working hard. He had flu like symptoms, runny nose, dry cough, sore throat. He had taken a few days off and needed a certificate for this employer. That didn’t explain his anxiety.  He seemed to have come to the right conclusion about his symptoms. I examined his throat, listened to his chest, took his temperature and agreed it was probably ‘a virus’ and that he should be fit for work before the end of the week. Then he hesitated. A pregnant pause. Seemed a bit unsure and blurted out those immortal words

There is just one other thing.

I was expecting it. I’ve seen this before. Adult males who exhibit signs of anxiety in a seemingly ‘routine’ consultation. If I’d looked closely I’d have noticed the dilated pupils and slightly rapid pulse. Sometimes ‘John’ comes with a request for a ‘full body check up’. Nonchalantly declaring that he’s getting older. Occasionally he brings his wife or partner, or perhaps they bring him. But when he comes alone the potential agenda is quite short- an embarrassing problem- impotence or sexual indiscretion and a need to be screened for ‘those other infections’, prostatism or something like what brought John in.

I have a very itchy sore bottom.

A life long problem it seems. Been using creams for years. Not helping. Bleeding a bit too. He knew what was coming. Hence the anxiety. The erythema and excoriations around his perineum verified the history. He left with a prescription for a steroid cream and a request to make a review appointment. It wasn’t as difficult as he had imagined. I clearly had heard all this before and he was pleased to be congratulated for being brave enough to ‘do the right thing’. The smile was now genuine. The prescription tucked away into his top pocket. It doesn’t take a lot to work out that there is more to the patient’s need for medical attention then meets the eye. The ‘Flu thing’ is what he tells people why he needs to see a doctor. In reality it’s a lot more serious- not the eczema that remains undiagnosed but the fear that the ‘itch’ is never going to go away and can’t be brought up in polite conversation despite ruining his life. It’s worth offering every man the pregnant pause. They might spit it out, if you’ve done your job right till that point.

Traditional masculine traits intersect with other physiological, sociological and cultural aspects of men’s lives when deciding to seek help. Andrology Australia

Often the patient wears the hidden agenda on their sleeve. No data or app necessary, just be interested enough to notice.

Picture by Drew Leavy