Picture by JD Lasica
Picture by JD Lasica
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
Significant proportions of people walk out of doctors’ clinics and disregard or fail to act on the opinion offered. The data reported in the literature does not make for encouraging reading. This behaviour has been observed in almost every clinical scenario and every speciality:
Medication compliance in pediatric patients ranges from 11% to 93%. At least one third of all patients fail to complete relatively short-term treatment regimens.
Of the 137 patients included in the study, 32% did not show up for their first appointment.
Similarly, although men receiving health education learned a lot about hypertension, they were not more likely to take their medicine.
We conclude that compliance with the once-daily regimen was best, but that compliance with a twice-daily regimen was very similar, and both were superior to dosing three times a day.
Seven hundred and two patients (14.5%) did not redeem 1072 (5.2%) prescriptions during the study period, amounting to 11.5% of men and 16.3% of women.
Eighty percent of 223 patients enrolled completed the study by returning their bottles. The rate of strict compliance with prescription instruction was 25%. The rate of noncompliance was 24%. Fifty-one percent used some intermediate amount of medication. There was no statistical difference in compliance by gender, presence or absence of symptoms, or site of enrollment.
Ultimately, this study suggests that health professionals need to understand reasons for non-compliance if they are to provide supportive care and trialists should include qualitative research within trials whenever levels of compliance may have an impact on the effectiveness of the intervention.
The fact that this happens is important because it is a costly waste of resources. There are many explanations for this phenomenon but they are all summarised in the findings of one study:
Studies have shown, however, that between one third and one half of all patients are non-compliant, but different authors cite different reasons for this high level of non-compliance. In this paper, the concept of compliance is questioned. It is shown to be largely irrelevant to patients who carry out a ‘cost-benefit’ analysis of each treatment, weighing up the cost/risks of each treatment against the benefits as they perceive them. Their perceptions and the personal and social circumstances within which they live are shown to be crucial to their decision-making. Thus an apparently irrational act of non-compliance (from the doctor’s point of view) may be a very rational action when seen from the patient’s point of view. The solution to the waste of resources inherent in non-compliance lies not in attempting to increase patient compliance per se, but in the development of more open, co-operative doctor-patient relationships. Donovan and Blake
What practitioners can do without waiting for policy change is to review their communication style. As Bungay Stanier has suggested it can’t be assumed that the first thing the person mentions is what is uppermost in their mind. Bungay Stanier’s suggested questions will reduce the rush to action. A rush that fails to identify the issue that the patient may feel is a greater priority than hypertension or diabetes.
Picture by Sergio Patino
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
Among the commonest tests ordered by doctors is a full blood count. The test presents signs of iron deficiency anaemia. The prevalence of that condition is reported as follows:
In Australia in 2011–12, around 760,000 people aged 18 years and over (4.5%) were at risk of anaemia, with women more likely to be at risk than men (6.4% compared with 2.5%). The risk of anaemia was highest among older Australians, with rates rapidly increasing after the age of 65 years. People aged 75 years and older were more likely to be at risk of anaemia than all other Australians, with 16.0% in the at risk range compared with 3.6% of Australians aged less than 75 years. Australian Health Survey
With regard to this blood test (AACC):
Therefore among the pathognomonic features of established iron deficiency anaemia (IDA) is a low Mean Corpuscular Volume (MCV). The sensitivity and specificity of a low MCV for a diagnosis of iron deficiency anaemia are quoted as 42% and 93%. Assuming a prevalence of 3.6% in the under 75 year old age group this means that if 100 adults in Australia had a full blood count then 3-4 will have iron deficiency anaemia. Screening these people for IDA with this test 8.3% of people will be told they have an abnormal test i.e. 8 people. Of these only 1-2 will be a true positive for IDA. On the other hand 6-7 may be misled into thinking they might have iron deficiency. 91 will be told they have a normal test in this case 2 may be incorrectly reassured. Of course there are other significant conditions which present with a microcytosis ( low MCV) although ‘treatment’ is not necessary in many such cases and also screening for IDA involves other and more sensitive tests.
If the prevalence of the condition was 20%, then even the modest sensitivity and specificity of this test would identify more people at risk of IDA even though it will also miss people with the condition.
In practice the sensitivity and specificity of tests may be assumed closer to 90% in each case. Given these figures the numbers of people from 100 people test and correctly identified, incorrectly reassured or told they are ill depends on the prevalence. The prevalence of most pathology in the community is low often well below 1%. The figures are presented in the infographic below.
Prevalence 0.005% ( 5 per 1000 people, e.g. hypothyroidism ) 2% ( e.g. diabetes) 20% (e.g. common and plantar warts).
From these figures it can be seen that testing is more fruitful in circumstances in which the prevalence is high. The prevalence is higher in those who have signs and symptoms of a condition. One could argue therefore that the ‘prevalence’ is much higher in those who choose to consult a doctor as opposed to the ‘prevalence’ in the community. For iron deficiency anaemia these circumstances are well known. Which means an effective consultation in which the patient is heard and examined is crucial to interpreting test results. As can be seen from the calculations there is a substantial risk of labelling people as ill, or requiring yet more tests given the modest prevalence of most conditions in the community and where there might be an indiscriminate use of tests.
It is hard to disagree with Campbell and colleagues who considered this issue and noted that:
1) Diagnosis is based on a combination of tests and clinical examination and there is little research based on the sensitivity and specificity of the combination of different examinations as opposed to a one-off test, which is why GPs are unlikely to know the values.
2) It is unclear what is meant by the prevalence of asthma or diabetes for these GPs. It is not the proportion of people in the population with the disease, but rather the proportion of people who come to consult who have the disease (perhaps with similar age and clinical history). This proportion is likely to be quite high and so the issue of overestimating the positive predictive value is less important.
3) The prevalence of the disease will also depend on the severity of the disease being tested for and so this also muddles the calculations.
We might however equally reasonably expect doctors to have an understanding of the issue if only because the practice of medicine involves the most crucial of ‘tests’ the history and the examination and this issue highlights the importance of that activity. Tests that are not appropriately interpreted can be harmful if only because they become a source of anxiety.
Picture by Aplonid
The ideal innovation is inexpensive, readily incorporated into practice and has substantial patient benefits. In this context the humble physical examination is a strong candidate. However it is reported that in practice laboratory and or radiological tests are requested more often than not. Here is a quote from an editorial in the British Medical Journal (2009):
In the first camp are those who pine for the old days, bemoan the loss of clinical bedside diagnostic skills, and complain that no one knows Traube’s space or Kronig’s isthmus. In the second camp are those who say good riddance and point out that evidence based studies show that many physical signs are useless; some might even argue that examining the patient is just a waste of time. Verghese and Horwitz
Research suggests that most diagnoses are based on the history and examination:
In this prospective study of 80 medical outpatients ….in 61 patients (76%), the history led to the final diagnosis. The physical examination led to the diagnosis in 10 patients (12%), and the laboratory investigation led to the diagnosis in 9 patients (11%). The internists’ confidence in the correct diagnosis increased from 7.1 on a scale of 1 to 10 after the history to 8.2 after the physical examination and 9.3 after the laboratory investigation. These data support the concept that most diagnoses are made from the medical history. The results of physical examination and the laboratory investigation led to fewer diagnoses, but they were instrumental in excluding certain diagnostic possibilities and in increasing the physicians’ confidence in their diagnoses. Peterson et al
In only one of six patients in whom the physician was unable to make any diagnosis after taking the history and examining the patient did laboratory investigations lead to a positive diagnosis. BMJ 1975
Also the value of tests is contested in some cases:
Information from the history, physical examination, and routine procedures should be used in assessing the yield of a new test. As an example, the method is applied to the use of the treadmill exercise test in evaluating the prognosis of patients with suspected coronary artery disease. The treadmill test is shown to provide surprisingly little prognostic information beyond that obtained from basic clinical measurements. The JAMA network
A considerable number of plain abdominal films taken for patients with acute abdominal pain could be avoided by focusing on clinical variables relevant to the diagnosis of bowel obstruction. European Journal of Surgery
However the predictive value of the physical examination appears to depend on the clinical scenario. If the patient appears ill it is far more likely that they will have clinical signs:
In order to study the occurrence and positive predictive value of history and physical examination findings suggestive of serious illness in ill-appearing and well-appearing febrile children, 103 consecutive children aged ≤24 months with fever ≥38.3°C were evaluated from July 1, 1982 to Nov 24, 1982….The positive predictive values of abnormal physical examination findings for serious illness in ill-appearing (11 of 14, 79%) and well-appearing children (3 of 12, 25%) were significantly different (P = .02 by Fisher’s exact test). The trends for abnormal history findings in ill-appearing and well-appearing children were similar to those for abnormal physical examination findings but did not achieve statistical significance. The results, indicating an important interaction between a febrile child’s appearance and physical examination findings, are discussed in terms of probability reasoning in clinical decision making. McCarthy et al
In some common clinical scenarios it is difficult to find objective evidence in support of a diagnosis and tests are necessary. There are many examples including:
Irritable bowel syndrome
Individual symptoms have limited accuracy for diagnosing IBS in patients referred with lower gastrointestinal tract symptoms. The accuracy of the Manning criteria and Kruis scoring system were only modest. Despite strong advocacy for use of the Rome criteria, only the Rome I classification has been validated. Future research should concentrate on validating existing diagnostic criteria or developing more accurate ways of predicting a diagnosis of IBS without the need for investigation of the lower gastrointestinal tract. Ford et al
Differences in clinical parameters in heart failure patients with decreased versus normal systolic function cannot predict systolic function in these patients, supporting recommendations that heart failure patients should undergo specialized testing to measure ventricular function. Thomas et al
Thirty one consecutive patients with a first flare of shoulder pain were prospectively included in the study. All had a physical examination performed by two blinded rheumatologists. Ultrasonographic examination was carried out within one week of the physical examination by a third rheumatologist experienced in this technique who had no knowledge of the clinical findings. Ultrasonography was considered the optimal diagnostic technique. Naredo et al
Also relevant are the physician’s skill in eliciting and interpreting signs:
Agreement between 24 physicians on the presence or absence of respiratory signs was investigated. The physicians were divided into six sets of 4; each set examined 4 patients with well-defined chest signs. There was generally poor agreement about particular signs. Overall, the 4 physicians in a set were in complete agreement only 55% of the time. Some signs such as wheezing seemed to be more reliably elicited than others such as whispering pectoriloquy. Comparison of diagnoses based on the clinical findings with the correct diagnoses supported by investigations showed that 28% of physicians’ diagnoses were incorrect. The more often the examiners differed from the majority on the presence or absence of a sign, the more likely they were to make an incorrect diagnosis. The Lancet
In some cases physical signs are unreliable:
A review of published studies of patients suspected of having pneumonia reveals that there are no individual clinical findings, or combinations of findings, that can rule in the diagnosis of pneumonia for a patient suspected of having this illness. However, some studies have shown that the absence of any vital sign abnormalities or any abnormalities on chest auscultation substantially reduces the likelihood of pneumonia to a point where further diagnostic evaluation may be unnecessary. JAMA
Therefore always relying on physical signs without conducting tests is unsafe. However the value of the clinical examination as an integral part of the patient experience was eloquently articulated in the BMJ editorial:
A third view of the bedside examination, and one that we advocate, is that it is not just a means of data gathering and hypothesis generation and testing, but is a vital ritual, perhaps the ritual that defines the internist. Rituals are all about transformation. The elaborate rituals of weddings, funerals, or inaugurations of presidents are associated with visible transformation. When viewed in that fashion, the ritual of the bedside examination involves two people meeting in a special place (the hospital or clinic), wearing ritualised garments (patient gowns and white coats for the doctors) and with ritualised instruments, and most importantly, the patient undresses and allows the doctor to touch them. Disrobing and touching in any other context would be assault, but not as part of this ritual, which dates back to antiquity. Verghese and Horwitz
Common sense dictates that where the patient appears unwell the physical examination will have a higher yield. In those circumstances clinical examination is crucial:
Misdiagnosis of acute appendicitis is more likely to occur with patients who present atypically, are not thoroughly examined (as indexed by documentation of a rectal examination), are given IM narcotic pain medication and then discharged from the ED, are diagnosed as having gastroenteritis (despite the absence of the typical diagnostic criteria), and with patients who do not receive appropriate discharge or follow-up instructions. Rusnak et al
Therefore the physical examination has an incalculable value not necessarily obviating the need for tests but increasing patient satisfaction and reducing the risk of litigation. Click the link for an excellent video on examination.
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].
According to the Royal College of General Practitioners, UK:
The consultation is at the heart of general practice… As a general practitioner, if you lack a clear understanding of what the consultation is, and how the successful consultation is achieved, you will fail your patients. RCGP
The impact of the consultation varies because of the different perspectives between doctors and their patients:
…. in the consultation the patient is most commonly construed as a purely “biomedical” entity—that is, a person with disconnected bodily symptoms, wanting a label for what is wrong and a prescription to put it right. Even under this guise the patient still sometimes fails to report their full biomedical agenda. Not all symptoms were reported and not all desires for a prescription were voiced. Barry et al BMJ
Much of what transpires in the consult is a ritual. Over the course of a professional lifetime most doctors will greet the patient in the same way, say the same sort of thing, prescribe similar drugs and order the same sorts of tests. This occurs for a variety of reasons perhaps because a doctor learns to present herself and behave in a specific way but also because the doctor’s training and experience has a significant impact on their clinical practice. There is ample evidence that how doctors interact with their patients is crucial to the outcome of the consultation and ultimately to outcomes in healthcare:
An increasing body of work over the last 20 years has demonstrated the relationship between doctors’ non-verbal communication (in the form of eye-contact, head nods and gestures, position and tone of voice) with the following outcomes: patient satisfaction, patient understanding, physician detection of emotional distress, and physician malpractice claim history. Although more work needs to be done, there is now significant evidence that doctors need to pay considerable attention to their own non-verbal behavior. Silverman BJGP 2010
With this in mind, if you are a doctor you may want to consider seven components of your interaction with patients that warrant occasional re-evaluation:
Our health is a cause for concern.
Someone must be to blame for all this- if only they would do their job and tell us to eat and drink less, exercise more and slow down. But wait there are industries profiting from our bad choices. We are influenced by more than our doctor. We have known this for decades. It is known as the Bronfenbrenner’s Ecological Model:
At the core of Bronfenbrenner’s ecological model is the child’s biological and psychological makeup, based on individual and genetic developmental history. This makeup continues to be affected and modified by the child’s immediate physical and social environment (microsystem) as well as interactions among the systems within the environment (mesosystems). Other broader social, political and economic conditions (exosystem) influence the structure and availability of microsystems and the manner in which they affect the child. Finally, social, political, and economic conditions are themselves influenced by the general beliefs and attitudes (macrosystems) shared by members of the society. Wikipedia
Most Australians (13 Million) spend over 18 hours a day online. One in every five minutes (3.6 hours) a day is spent on social media. On the other hand time spent with general practitioners (GPs) is declining:
The proportion of GPs providing ‘Level C’ consultations (longer than 20 minutes) is substantial (96%) and constant; however, the number of long consultations provided per GP decreased by 21% between 2006 and 2010. The proportion of GPs providing Level D consultations (longer than 40 minutes) decreased from 72% in 2006 to 62% in 2009, while the number of Level D consultations provided per GP decreased by 26%. AHHA
Secondly the number of problems presented to doctors in increasing. In one survey of the 8707 patients sampled from 290 GPs, approximately half (47.4%, 95% CI: 45.2–49.6) had two or more chronic conditions.
Junk food is cheap and readily available. It is advertised to children. Fresh fruit and vegetables are less available, more expensive and of poorer quality in rural and remote Australia. These areas are also among our most economically disadvantaged and residents generally have less disposable income to spend on expensive, healthier food options. According to one report a multinational fast food company paid $500 million in taxes to the Australian government and might be due to pay more.
A 2017 poll found that most Australians (78 per cent) believe Australia has a drinking problem, 74 per cent believe our drinking habits will worsen over the next five to ten years, and a growing majority (81 per cent) think more should be done to reduce alcohol harm. A price increase of 10% on alcohol has been shown to reduce consumption by an average of 5%. Similarly for every 10% increase in price, consumption of tobacco reduces by about 4%. Finally a significant proportion of people are unhappy at work and this has been associated with snacking and weight gain.
So it seems that we are choices are triggered by far more than a doctor informing us that we are making bad choices. Doctors can make a huge difference to the individual who seeks advice in a teachable moment and can be triggered to make better choices. This requires more time with the patient and a greater focus on the needs of that individual patient rather than the distraction of a public health agenda. At a public health level doctors’ impact is miniscule because of the much more powerful and ubiquitous drivers of poor choices that are fueled by those who profit from our dubious behaviour. A summary:
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