The future of healthcareLearn More

Doctors need better tools to help people recognise danger

Doctors see it all the time. The fifty-year-old with a BMI of 28, the teenager who is developing a taste for cigarettes, the twenty-year-old who now binge drinks every weekend, the soon-to-be-mum who is ‘eating for two’. Small choices that may become habits and habits that lead to consequences. Where I have worked the average consultation lasts fifteen minutes. In that time we address whatever symptoms or problems have been tabled. The list may be long. Occasionally it’s possible during the conversation to bring up a subject that I’m worried about. The problem is the patient may not be worried about that issue.

Afterall doctor I don’t drink any more than my mates do or I don’t really eat that much.

What’s needed are tools that help frame the issue from the perspective of the patient, not the practitioner. Tools that help us address public health priorities that speak TO that person, not AT everyone. Before making any changes the person needs to agree that their choices might blight their hopes for the future. These are not inconsiderable challenges given the gloomy predictions for the future.

At the other end of the malnutrition scale, obesity is one of today’s most blatantly visible – yet most neglected – public health problems. Paradoxically coexisting with undernutrition, an escalating global epidemic of overweight and obesity – “globesity” – is taking over many parts of the world. If immediate action is not taken, millions will suffer from an array of serious health disorders. The World Health Organisation

Diabetes is likely to cement its place as the fastest growing epidemic in history. The Medical Journal of Australia

In addition, youthful drinking is associated with an increased likelihood of developing alcohol abuse or dependence later in life. Early intervention is essential to prevent the development of serious alcohol problems among youth between the ages of 12 and 20. NIH

Picture by Marcelo Nava

A small act that never goes unnoticed

Much can be said about the way we greet people. However nothing is more telling than the memory of the last time we were greeted when we were in need. Those who have travelled overseas know exactly what it’s like to be in an alien environment, where things are unfamiliar and a little threatening. Like pulling up at an immigration check point, passport in one hand and tired kids at your feet.

The one that sticks in mind was the experience at Italian passport control decades ago when we arrived in Rome with our then very young brood. The smartly dressed official eyed us all in turn from behind the tall counter, then made to count our children, smiled broadly at the parents, nodding as if in approval of the size of the family and waved us through. A charming start to the holiday. That was fifteen years ago and we still  talk about it.

Last week in Bali the receptionists stood up every time a guest passed the desk, bowed with hands clasped to heart smiling brightly. It set the tone for the whole day.

My favourite greeting is Malay.

“The traditional Malay handshake, known as ‘salam’, involves both parties extending their arms and clasping each other’s hand in a brief but firm grip,” advised Lew Wai Gin, the guest liaison manager at Tanjong Jara Resort. “The man can then offer either one or both hands, grasp his friend’s hands, and then bring a hand back to his chest, which means: ‘I greet you from my heart’.” Grantourismo

Having experienced the impact it has when I travel for work in that country it persuaded me that how we greet each other matters more than we might realise. It’s a small choice which costs nothing. In medicine the provider has the opportunity to set the tone for what follows which can be to agree or disagree, to give good or bad news. Whatever follows people remember the way they were made to feel when they were most vulnerable. They might even write about it decades later!

Picture by Ben Smith

Are we are obstructing the doctor with gadgets?

Despite billions of dollars of investment in technology the results in healthcare are disappointing.

Information Technology (IT) surrounds us every day. IT products and services from smart phones and search engines to online banking and stock trading have been transformative. However, IT has made only modest and less than disruptive inroads into healthcare. Nicolas Terry (2013)

This was predicted in a prophetic article by Gregory Hackett (1990) when he concluded that:

The primary reason is that technology alone does not determine corporate performance and profitability. Employee skills and capabilities play a large role, as do the structures of day-to-day operations and the company’s policies and procedures. In addition the organisation must be flexible enough to respond to an increasingly dynamic environment. And products must meet customer requirements. Investment in Technology-The Service Sector Sinkhole? SMR Forum Service

However, there are still those who seem enamoured of machines:

Rapid growth of robotic industry is leading to novel applications in medical field. Evolution of new terminologies like tele-presence, tele-medicine, tele-consultation, tele-diagnosis, telerounding, tele-health centers, tele-doctors, tele-nurses are overwhelming and required to be readdressed.  Iftikhar

That way leads to a nightmarish world in which we push vulnerable people onto an assembly line and healthcare looks like this but also includes the dehumanising impact of machines:

….. hospitalists care for sick inpatients and are charged with rapid throughput by their administrative overlords; nocturnists do this job as well — but at night; intensivists take over when work in a critical care unit is required; transitionalists step in when the patient is ready to be moved on to rehabilitation (physiatrists) or into a skilled nursing facility (SNFists). Almost at the end of the line are the post-acutists in their long-term care facilities and the palliativists — tasked with keeping the patient home and comfortable — while ending the costly cycle of transfers back and forth to the hospital. Finally, as the physician-aid-in-dying movement continues to gain support, there will be suicidalists adept at handling the paperwork, negotiating the legal shoals and mixing the necessary ingredients when the time comes. Jerald Winakur- The Washington Post

Technology now impinges on every interaction- for better and for worse:

There were the many quiet voices who urged circumspection as long ago as 1990:

Diagnosis is a complex process more involved than producing a nosological label for a set of patient descriptors. Efficient and ethical diagnostic evaluation requires a broad knowledge of people and of disease states. The state of the art in computer-based medical diagnosis does not support the optimistic claim that people can now be replaced by more reliable diagnostic programs. Miller

One could not argue against technology as a tool but the art of medicine requires that technology helps the doctor. People are not disordered machines and the promise of better health is not forthcoming as we throw money at machines hoping for greater access, efficiency, and safety. However, there is now mounting evidence that the patient is not responding and it’s time to pause for thought, again.

It’s not that complicated. Healthcare works when the doctor and her patient are on the same page. So to what extent does a gadget or gizmo allow that? Does it help them to:

  1. Work out what’s wrong together?
  2. Make it easier for them to work together?
  3. Make it easier for them to achieve a goal together?

If it becomes a substitute for the doctor it will disappoint. People respond best to human doctors. No ifs or buts. Medical school 101. Doctors also have choices in how they deploy and interact with technology. Turning to face the computer, ordering a test and recommending an app aren’t always the way to the best outcome.

Picture by Guian Bolisay 

It’s time to consider what we want beyond access to general practitioners

Ever since Adam was a boy the thing that has driven policymakers into a frenzy is ‘access’ to a GP. That’s good because they recognise that the work done by a general practitioner is very important. However, it sometimes feels like ‘access’ is the only thing that really matters in healthcare policy. Politicians and bureaucrats can’t look beyond the quantum of people being seen because that’s how they think their performance will be judged by the voter/shareholder.

Of course, it is important that the public is able to access a doctor trained to deal appropriately, effectively and efficiently with all that can happen in life. However, an ‘open’ sign doesn’t mean people will get that beyond those portals. To get what we imagine lies beyond the door we need to consider how those doctors communicate because the formula is: thoughts -> feeling and feelings ->action. Action is what is needed when someone is overweight, smoking, abusing, bleeding or worrying. The person who needs to take action or consent to treatment is the person now striding through the door.

The ability to help means being able to put the needs of the other first. It doesn’t happen quite so well, or in any sustained way when the person trying to help is troubled, anxious, tired or working in a hovel. There are two parties in the mix- the one who is dealing with the crisis and the one who is trying to help. The needs of both will impact on the outcome.

An older couple I know walk miles and wait hours to see their doctor. This doctor has been looking after them for years. Her clinic is open for long hours and everyone gets seen ‘eventually’ and on the same day. I know these people well and I know they are not taking the statins, the NSAIDS, the antibiotics and list of other things that are prescribed and that the innumerable scans and X-rays ordered every year are futile. What they crave most is to be heard, for someone to acknowledge that things don’t work as they used to, or help prepare to visit their beloved daughter overseas. That takes time, it takes a willingness to see people in context but for longer than 10 minutes at a time. It takes planning for what people will think after their visit because thoughts determine feelings and feelings drive actions.  Good feelings are engendered only when the doctor can invest- not just in what happens when she is face to face with her patients but at every touch point with her practice. Then she can communicate that she cares and that she can be trusted when she says that that ache or pain isn’t something that needs yet more tests or another prescription. What the practice needs is not just another doctor to churn through the waiting list but for those doctors to work their magic. For now, she is open for business- the question is what business and who really benefits from her efforts?

In 1999 Mainous and colleagues published a paper in the American Journal of Public Health which reported data suggesting that access though necessary was not sufficient to make a real difference to patients in primary care:

OBJECTIVES: This study examined a private-sector, statewide program (Kentucky Physicians Care) of care for uninsured indigent persons regarding provision of preventive services. METHODS: A survey was conducted of a stratified random sample of 2509 Kentucky adults (811 with private insurance, 849 Medicaid recipients, 849 Kentucky Physicians Care recipients). RESULTS: The Kentucky Physicians Care group had significantly lower rates of receipt of preventive services. Of the individuals in this group, 52% cited cost as the primary reason for not receiving mammography, and 38% had not filled prescribed medicines in the previous year. CONCLUSIONS: Providing free access to physicians fills important needs but is not sufficient for many uninsured patients to receive necessary preventive services.

Picture by dmon_21

 

Aren’t general practitioners already working hard enough Mrs May?

Right on cue in 2017 one government has made public pronouncements that the healthcare service is failing people because doctors, and specifically general practitioners, are not working hard enough. And their prime minister is prepared to penalise them:

Mrs May wants GPs to provide services 8-8pm, seven days a week, unless they can prove there’s no demand.

Her three point plan would see extra funding for docs slashed unless they provide weekend and evening appointments when patients need them– not when they offer them.

Practices getting extra cash for opening outwith core 8-6.30pm hours during the week will also be asked to expand online services. Lynn Davidson

It is as if the health of the nation can only be managed in one way- increase the number of people who consult a GP. It implies that the quality of those consultations couldn’t possibly suffer because tired doctors are forced to work longer hours. The government appears to be armed with a hammer and to them, everything looks like a nail. If these are the public pronouncements of the UK government, and there is a GP shortage how are they making a career in general practice an attractive option? Five experts presented their views on the subject of the current crisis in another article in a different national newspaper:

Nursing: Poor strategic decisions and budget cuts to care services have exacerbated pressures on emergency care.

Think Tank: More people attending hospitals and more of them are older and sicker. In many hospitals, beds are fully occupied, making it difficult to admit patients and causing waiting times in A&E to lengthen

Medical association: Demand is so great that hospitals are now full all year around, meaning there is no spare capacity to deal with a seasonal spike in demand

General practice: Cold weather inevitably brings more illness. But while we hear a lot about the crisis in our A&E departments, the explosion in demand for GPs is being overlooked or ignored.

Emergency medicine: It is not inappropriate patient attendances that are causing this; it is simply the volume of ill, elderly people made more complex with the wide range of existing medical conditions many suffer from.

The answer according to each expert is to ask for more money. But there are hints of an understanding that there is a more fundamental problem:

More money on its own will not help when the current system is fundamentally flawed and needs to be redesigned from scratch. Admissions should be prevented through early intervention and supporting people in their homes by anticipating their needs before they experience a crisis. Chris Ham

If that is so what does a ‘redesigned from scratch’ health service look like? In the UK there has been reform of the National Health Service by every government in the past thirty years. We have known about the coming tsunami of chronic and complex conditions for decades. How then is it that at least one developed country has woken up to this nightmare seemingly unprepared?  What happens in the interaction that matters the most- the one involving only two people- the health practitioner and the patient? What is needed to prevent a crisis in the patient’s life? In a society where autonomy is a fundamental right who makes the choices that lead to the need for medical intervention? How can we redesign the system so that we are turbo-charging the very interaction that has the most potential to prevent the crisis? It surely isn’t to ask doctors to work hours that are unsustainable.

Picture by Damian Gadal

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!’

Icon made by Freepik from www.flaticon.com 

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).

Icon made by Freepik from www.flaticon.com

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.’

Icon made by Freepik from www.flaticon.com

 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

Will patients ever benefit from dubious surveys published in academic journals?

Untitled

The headline in the newspaper was provocative:

One in 10 parents do not trust GPs with their child’s healthcare: survey

Three questions arise:

  • Is it new?
  • Is it true?
  • So what?

It didn’t resonate. Children under the age of fifteen constitute at least one in ten encounters with General Practitioners (Family Physicians). That means there are at least 12 million consultations with children in Australia every year. The notion that parents don’t trust their GPs is questionable. Even in the study reported by the newspaper most parents (91%) had a regular GP and more than one in three children had visited a GP at least five times a year. The conclusions reported by the journalist were based on a study in which 666 parents were approached in a paediatric outpatient clinic to participate in a survey by a ‘trained research assistant’ and offered $10 for participating.  The context is important given that the conclusions as reported in the newspaper headlines were about people’s views on GPs.

100 parents in each of five specialties and 50 parents in each of the subspecialties was the ‘target number’- but we are given no justification for that number. The validity of the survey depends, in part, on the sample size which is governed by what was anticipated to be the likely response.

The questionnaire was ‘developed’ by the research team and pilot tested with 39 parents across both hospitals. We are not told how the questionnaire was developed and refined or how the validity and reliability of the responses were tested. Nor are we told why piloting ceased at 39. No scientific framework is cited. Without this information the interpretation of the findings is speculative.

It is reported that only half of the new patients seen in the paediatric speciality clinics were referred by a GP. The remainder were referred by other doctors. Therefore these participants were receiving their care from specialists and hospital doctors and it is reasonable to assume that their views were influenced by this experience.

If we are to read on notwithstanding the limitations evident early in the paper we note that only 45% of respondents were ‘completely confident’ that ‘a GP’ can provide general care to their child. From the way the question is posed we don’t know why the respondents were not ‘completely confident’. It could be because they think:

  • A GP doesn’t have access to the resources their child might need
  • Their child has had an illness that requires specialist to monitor their care
  • A GP doesn’t offer appointments when it suits them
  • A GP doesn’t do blood tests, X-rays, scans or prescribe the drugs they think their child needs
  • A GP isn’t qualified to look after their child
  • Someone they trust told them their child should see ‘specialists’ every time

Our understanding of this paper depends on which of these was meant by the respondent but the question was never posed in a meaningful way. The paper does not report the perspective of either the referring doctor or the specialist about the need for that specific referral. Without that information we can only draw conclusions based on our perspective on the issues. We certainly cannot conclude that GPs need more training in paediatrics unless we were looking for an excuse to come to that conclusion. Why publish a survey that cannot be interpreted meaningfully?  The concept explored is not new, the data can’t be safely interpreted and the only question is so what? Who benefitted from this ‘research’?

Picture by KristyFaith

Practitioner income as a function of Freakonomics

According to headlines this year more than one in three GPs in Australia report feeling somewhat or very dissatisfied with their income. Two things determine health practitioner income:

  1. What is a (funder / government / insurer) willing to pay?
  2. What is a (patient / customer / client) willing to contribute?

What is beyond doubt is that when it comes to their pet’s healthcare the Australian public is very willing to pay. In fact Australians would alter their spending habits rather than compromise their pet’s quality of life.

Of the 2,500 Australians, aged between 18 and 65 that were surveyed in the 2015 Financial Health Barometer, only 14 per cent of pet owners would reduce spending on their pets if their income dropped Remarkably, almost half (48 per cent) of respondents would take steps to minimise their power usage. We’d be more likely to reduce spending on essentials (47 per cent), switch to using cheaper products (35 per cent) or look for additional work (16 per cent) rather than curb spending on our furry friends. Hayley Williams.

Similarly spending on beauty treatments is remarkable:

The online survey of close to 1300 Australian women was conducted by Galaxy Research and commissioned by at-home hair removal brand Veet.
And, while 10 per cent of the women surveyed spent $5000 on average and and almost 60 hours in the beauty salon annually, 40 per cent admitted to putting their beauty regimens ahead of sleeping, shopping and their social life, with 4 per cent of those women also choosing a salon visit over their sex lives.

In contrast national statistics document that a significant proportion of Australians are reticent to seek healthcare because of the perceived cost. It was not surprising that a proposed $7 co-payment proposal for general practitioner visits in Australia was dumped before it was enacted.  It is evident that some doctors get paid far more than others. Secondly some parts of the country attract more doctors but as a general rule where there is a scarcity, by dint of geography or specialisation, it is more likely that doctors will earn more.

What people are willing to pay for health care is a function of economics, or perhaps “Freaknonomics” (study of economics based on the principle of incentives.) From this perspective “incentives matter.” Consumers try to maximize total satisfaction, while providers try to maximize profits. Whenever there are a lot of people willing and able to perform a job, that job doesn’t pay well. In a capitalist society, intense competition will drive prices down. When a technological advance occurs, it results in a shift of the supply curve to the right. All other things equal, this will lower the equilibrium price of a good, which then increases demand. Both producers and consumers need to be fully informed regarding their consumption or production decisions for a market to be efficient.

So how might this apply to primary care? 

  1. There are more doctors per head of population than ever before- in other words more people willing and able to perform the job- especially in primary care.
  2. There is a global trend in developed economies for “alternative providers” for primary care services- including vaccination, cancer screening and treatment of ‘minor’ illnesses.
  3. Technology offers new ways to ‘consult’ a practitioner other than by having practitioner and patient in the same room.
  4. Because of the internet doctors no longer hold the monopoly on information.

So doctors’ incomes in primary care experience downward pressure because suppliers of the services are increasing. We might therefore consider what people would consider paying for a consultation at a doctors’ clinic. Research published in 2008 (Annals of Fam Med) offers one perspective:

  • Overall, patients were willing to pay the most for a thorough physical examination ($40.87).
  • The next most valued attributes of care were seeing a physician who knew them well ($12.18),
  • Seeing a physician with a friendly manner ($8.50),
  • Having a reduction in waiting time of 1 day ($7.22), and
  • Having flexibility of appointment times ($6.71).
  • Patients placed similar value on the different aspects of patient-centered care ($12.06–$14.82).

It seems that two sectors (Pets and Beauty) appear to have no difficulty with their income. What might they have to offer by way of advice?

  1. The art of creating added value starts with the ability to see your business through the eyes of your customers.
  2. Although the debate over whether the customer is always right (or not!) continues, lack of customer satisfaction is a sure-fire way to keep people from coming back.
  3. Implement marketing models into your strategy.
  4. Most importantly, memorable customer experience models aim to deliver unexpected intangible value that cannot be packaged or sold. This includes personalized service, attention to detail, and showing a sense of urgency to address concerns as they arise.
  5. Whether it’s a free guide, a printable PDF, or a company branded calendar, free resources are a great way to create added value and showcase your brand’s ability to offer ‘a little something extra’ to customers.

In the case of healthcare the ‘customer’ is not just the patient but also the pay master. These ideas may need to be translated for this sector. In many cases it probably already has been. However for others there is something to learn from how successful businesses add value that translate into better rewards.

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The chasm between patient experience and clinical practice

Can you guess what this abstract relates to without clicking on the link:

ABC is advisable if the patient does not show sustained improvement after a year of active treatment by other indicated means. The operation often represents the turning point in effective treatment. After the first year of ineffective treatment valuable time is being lost, with danger of fixation and deterioration. Then it is safer to operate than to wait. Calif Med. 1958 Jun; 88(6): 429–434.

That operation was last carried out in the 1960s. 40-50,000 were performed in the USA alone. This is what was reported about one person post op:

The reason for Dully’s lobotomy? His stepmother, Lou, said Dully was defiant, daydreamed and even objected to going to bed. If this sounds like a typical 12-year-old boy, that’s because he was.

What is being described below in 2011?

Remission of diabetes mellitus occurs in approximately 80 percent of patients after XYZ. Other obesity-related comorbidities are greatly reduced, and health-related quality of life improves. Complications and adverse effects are lowest with laparoscopic surgery, and vary by procedure and presurgical risk. Am Fam Physician. 2011 Oct 1;84(7):805-814.

In the same abstract the authors, Schroeder et al say:

The family physician is well positioned to care for obese patients by discussing surgery as an option for long-term weight loss…. Patient selection, pre surgical risk reduction, and postsurgical medical management, with nutrition and exercise support, are valuable roles for the family physician.

What do we know about this surgery?

According to the Schroeder:

Complications and adverse effects are lowest with laparoscopic surgery, and vary by procedure and presurgical risk…. Overall, these procedures have a mortality risk of less than 0.5 percent.

Here are some videos of what we are talking about. So what’s the patient experience?

Immediately post op:

Days 7-10: Now, at this stage, I shall only eat 4-6 Tablespoons of food each “meal” and I should have 5-6 meals a day. I can add mashed potatoes, custard, and pudding, but I must be VERY careful to keep it really low sugar and really low fat. Otherwise, my tiny pouch will rebel and make me regret it. Big Fat Blog

After a couple of years:

I had a lap-band. Then I had it removed after 2 years. The restrictions on drinking meant that exercise was difficult. And while I’ve felt emotionally broken for years, those two years were the only time I’ve felt physically broken. The experience was miserable. Big Fat Blog

Years later:

….almost 12 years later, there are still foods I have trouble eating. It still takes me 30 to 45 minutes to eat a meal, even if it’s just a sandwich and some chips. I have to stay away from anything that has a lot of sugar or a lot of grease in it (explosive diarrhea is not something you want to deal with in a public space, take it from me, been there done that). Big Fat Blog

Here are reflections from another blogger:

  • A few months after my surgery I started to have significant hair loss.
  •  It is important to take your vitamins.
  • There have been times that I have forgotten and do drink after I have eaten and when I do this I become quite uncomfortable and this is the occasions I may feel the need to vomit.
  • My taste buds have changed.
  • After I eat most of my meals or have a drink I get a little burppy. Not sure if it’s because I have eaten my meal too quickly (which I do), but it’s a side effect that hasn’t gone away.
  • This is really hard, everybody knows I have had the surgery but what they don’t understand is how little I can eat. I have to remember to ask for a small plate of food and I feel awful when I can’t eat all they gave me.
  • I hit a dark place about 2 weeks in, as I could only drink soups, watered down gatorade, sorbet etc. I really struggled with people eating around me being that I couldn’t eat.
  • I have tuckshop arms, which only recently have started to bother me like this morning when I saw them wobbling when I was drying my hair. It also does get me down a little when I lift my arm up and I notice people noticing my arms. I have an apron fold on my stomach from my pregnancy with the twins. When I have lost all my weight I would like to get the excess skin on my stomach removed. I will only do this when I have lost all my weight though. The organised housewife 

Experience of referral:

A few years later I moved and had to find a new primary care physician. She suggested Weight Loss Surgery… I asked her if she was familiar with WLS research regarding success (lack thereof), mortality rate, etc. After she answered, no, I asked her how she could recommend such a surgery when she was ignorant of its effects. She had no answer. Big Fat blog

So back to the literature (note the dates):

Undergoing laparoscopic sleeve gastrectomy induced efficient weight loss and a major improvement in obesity-related comorbidities, with mostly no correlation to percentage of excess weight loss. There was a significant weight regain and a decrease in remission rates of diabetes and, to a lesser extent, other comorbidities over time. JAMA Surg 2015

And

Not all bariatric patients, however, experience mental health gains from weight loss surgery, which is likely attributable to patients’ reactions to common undesired physical outcomes postsurgery: lack of weight loss, weight regain, and undesirable skin changes. Patients’ expectations that bariatric surgery will undoubtedly change their life may also set them up for psychological failure if expectations are not met. Journal of Obesity 2013

Finally we might reflect on the lobotomy as per Gregory Myers:

  1. The surgeon who introduced the world to the lobotomy was awarded the Nobel prize
  2. Some thought it was better than the alternative
  3. There was poor patient follow up
  4. It had significant adverse effects
  5. There was inadequate patient information and consent
  6. It destroyed people’s lives
  7. It was often a rushed procedure
  8. The indications for this invasive surgery were not limited to severe illness
  9. It was replaced by drug treatment

Is history repeating itself? It may by relevant that the global bariatric surgery market size was valued to be over USD 1,300 million in 2014.

Picture by rossodilbolgheri

How to get your doctor to do what you want

I had no idea who he was other than a name in the appointment book and an address on some street I had never seen. What did he do for a living? Who was his partner? What was his home like? Where had be been before with this complaint? What was he told? What were his hopes and expectations?

I could take his pulse, his blood pressure and his temperature. I could listen to his heart sounds and palpate his abdomen. But his ideas, concerns and expectations were a mystery other than what he honestly shared with me.

We know little or nothing about the people who come to see doctors in many parts of the country. It is said that almost one in three Australians choose to see many GPs.

It would be foolish to assume people haven’t asked someone for advice before they present. A google search for ‘patient health advice sites’ yields 124 million results in 0.46 seconds. People are talking to each other even if they don’t always tell us what’s on their mind when they finally consult.

  1. Getting a sick certificate when you are not actually sick:

Usually if you say anything in regards to the gastro-intestinal area, they can’t really say no. It’s too hard to find out what the issue might be, plus it could just be something bad you ate the night before, so they usually just give you the certificate.

2. Hypothroid testing: what you need to know and ask for.

Please help!!! I feel like im going crazy! Im tired all the time. I’ve gained over 30 pounds in the last year. Dont get me wrong i have always been big but never gained weight this fast. I had my gallbladder out in March of this year due to a very large stone. My doctors and I contributed my symptoms to the gallstone but nothing changed after surgery. I feel like something is just off with my body. My GP did a blood panel and said everything came back normal. I feel sick all the time. Very fatigued with brain fog. What do I need to do to get this under control? I’m 34 years old and I feel like I’m falling apart. I need help and the doctors seem to think that it’s in my head because all my tests come back normal. What should i demand to be tested or done?

3. How to talk to Dutch Doctors so that they’ll listen

I don’t know how many times I went to the doctor with a sick child only to be told to go back home and give them Paracetamol. My husband, however, always gets medicine when he needs it. I’ve been wondering how he does it. Many times, I send him to the doc’s office with whichever child is sick at that time and he comes back home, waving the prescription for antibiotics at me. For a long time, I wondered, how does he do it? What am I doing wrong? So I asked him. The insights he gave me are just too precious to keep secret. Apparently, Dutch doctors require a special mode of communication…

4. Will my Doctor prescribe me Duromine??

Theoretically you have to have a Bmi of 30+ to be able to qualify(?) for a script in Australia. However many doctors don’t like it at all and won’t prescribe. Mine said it was evil and caused more problems than it solved. Refused.  I ended up going to a bulk billing clinic as figured if this doctor said no at least I wouldn’t be out of pocket.  Said my Bmi nudging 30 and weight making me sad and depressed. Losing confidence. Also that I had signed up at the gym with a series of personal training sessions to start me off. (True). And would like to use it to kickstart losing weight, a healthier lifestyle and better eating habits. (True) And that I had used Duromine in the past and not had any issues re blood pressure or heart etc. (not true). Initially this doctor said no, hates the stuff, banned in America, very bad drug etc etc. After some discussion he ended up writing me a script for 1 month.

5. How to convince your GP to refer you to a specialist?

You feel like you don’t have the right to make your GP listen. What they say goes. That is not the case, and sometimes you really have to push the issue or go elsewhere. You may have to be pushy, and you may have to be blunt and pretty much say “I don’t think you are taking me seriously and I think you are making excuses”. If the doctor you have still isn’t listening, then you have a right to a second opinion. Exercise this right. Go to another doctor if necessary.

It is more than likely that some people will present with ideas about what they think they need to get better. It could be a day off, or a blood test, drugs or a referral. For each of the examples above we need to consider how to facilitate the best in consultations. From what is said on such websites it appears that people come armed with arguments why their will should prevail even against expert advice.

Picture by bo.peter