The future of healthcareLearn More

A cough is not minor in any sense

 

 Acute cough, which often follows an upper respiratory tract infection, may be initially disruptive but is usually self‐limiting and rarely needs significant medical intervention. Thorax

In adults or children with acute cough, the evidence does not support the effectiveness of over the counter preparations. Cochrane Review

On the other hand:

Oral syrups segment is expected to expand at 2.9% CAGR (Compound annual growth rate) over the estimated period and be valued more than US$ 10 Bn by the end of 2026. The segment is expected to create absolute $ opportunity of a little more than US$ 300 Mn in 2017 over 2016. The segment is the most acceptable dosage form for cough, cold, and sore throat medicines due to ease of administration and pleasant taste. The oral syrups segment dominated the global cold, cough and sore throat remedies market in terms of revenue in 2016 and the trend is projected to continue throughout the forecast period. Oral syrups segment is the most attractive segment, with attractiveness index of 1.5 over the forecast period. FMI

Cough, cough, cough. Every hour on the hour. There appears to be no end to it this season. No symptom is driving more people to seek treatment than the misery of upper respiratory tract infections (URTIs). The impact of the URTIs season on the population is massive as has been demonstrated in data from the US:

More than half (52%) of Americans reported that their cold impacted their daily life a fair amount to a lot. Productivity decreased by a mean 26.4%, and 44.5% of respondents reported work/school absenteeism (usually one to two days) during a cold. Overall, 93% of survey participants reported difficulty sleeping. Among all respondents, 57% reported cough or nasal congestion as the symptoms making sleep difficult. Drug Store News

One issue that appears to be bound up with the epidemic of URTIs is rates of prescribing of antibiotics. Here the available data are encouraging:

Professor Bell suggests that 20–25% of acute URTIs are likely to need antibiotics…..We have shown that over the last 13 years GPs in Australia have decreased their level of prescribing of antibiotics for acute URTI and to a lesser degree, for ‘other RTIs’. Britt et al

However there is an opportunity here over and above the treatment of an annoying self-limiting infection. Most people who seek help want more than anything else to feel better. By 2026 they will spend $10Bn in the attempt. The conversations in consulting rooms and pharmacies around the country focus on symptoms that will improve, eventually. Antibiotics won’t help. But, in the end what people want is to feel better not a lecture on virology. There is an opportunity for a ‘set play’.

Yes, you have a nasty infection and I see that it is making you miserable. Here’s what you can do to help your self.

There is an opportunity to forge a relationship with the patient. The ritual of the consultation complete with examination has the potential to create enormous deposit of social capital. Something that might be critical when the patient presents later in life with life-limiting pathology. There is the chance to understand a lot more about the patient for whom a cold is the final straw. But what’s the context? Be curious, very curious that’s why it’s called the art of medicine.

Picture by Rebecca Brown

Healthcare will do better when Joe accepts that he is in trouble

There is nothing especially remarkable about Joe. At 49 he works as an administrator for a company in the city. He walks to work from the station having taken a train from the suburbs. He weighs 78Kgs and is 170cm tall (BMI 27). To stay that way he needs to consume no more than 1900 calories per day. He has a bowl of cereal for breakfast, a  panini sandwich for lunch and a home cooked dinner with a glass of wine. That’s about 1900 calories. Joe isn’t inspired at work but he earns a reasonable living. They bought a new car last year and Joe is tied to a hefty car loan, his wife Bridgette gave up her job as a nurse when they had their children ten years ago. They now have three children under 10. The youngest has asthma but he seems so much better since he was put on a steroid inhaler. Joe and Bridgette have had their ups and downs. They worry about money.  Mostly they work hard and are doing their best to raise their boys. At the weekend Joe goes to a football match but since his mid-twenties doesn’t play any sport. With the kids doing sport and music lessons there isn’t time. Joe has never smoked a cigarette.

During the week Joe goes for coffee with his colleagues at 10.30 every morning. He also enjoys a small muffin. Then he has a banana at 2 pm and a couple of small biscuits while he is watching television in the evening. He doesn’t think too much about it. He is consuming 500 calories more than he needs per day and in 6 months when Joe is 50 his BMI will put him over the line into obesity.

Joe rarely sees his doctor. In winter he occasionally gets a chesty cough and makes an emergency appointment with any doctor who is available because Bridgette says he might need an antibiotic. Once or twice since his thirties, a doctor checked his blood pressure and it is always normal. He had a medical as part of his mortgage application when he was 35 and everything was ‘normal’. Most of Joe’s friends are heavier than Joe and he still thinks of himself as ‘healthy’.  After all, he walks to work, has a healthy banana as a snack in the afternoon and he makes sure his evening meal is a healthy one.

Joe doesn’t see any problem. There is really time to talk to the doctor about why he likes that large cup of coffee and the muffin or to say that he is stuck in a dead-end job with a mortgage to pay and children to raise. Joe doesn’t admit that he is bored. The coffee break is the highlight of an otherwise long day of drudgery.  Joe’s trousers are getting a little bit tighter. Bridgette has noticed but his friends are all so much bigger and Joe doesn’t think she’s worried about it. She herself has gone up three dress sizes since the children were born so she doesn’t tease him too much. Besides, he just got a bigger size recently and he still thinks he looks good.

Joe is at risk of becoming a statistic in the epidemic of Globesity. All that stands in the way is the ingenuity and interest of those who care to find a way to help Joe turn things around.

Picture by Khuroshvili Ilya

She’s furious but what does your reaction say about you?

Where there is anger there is fear. Health issues are frightening. They pose a real and sometimes imminent threat to our basic needs. Sometimes even a threat to life itself.

There is a strong relationship between anger and fear. Anger is the fight part of the age-old fight-or-flight response to threat. Most animals respond to threat by either fighting or fleeing. But, we don’t always have the option to fight what threatens us. Instead, we have anger. Psychology 

Anger is an emotion that doctors encounter often. Unfortunately they may also find themselves getting annoyed at that angry patient who has been kept waiting, that angry mother who thinks her child’s test results should be available today, that angry young man who says he will be fired unless he gets a backdated certificate, that angry Boomer who is convinced her cancer can be cured if only this doctor arranges an appointment for coffee enemas.

Doctors can choose how to respond. How to interpret that emotion. Doctors too can be angry. Angry about having to work in a healthcare system where one sector doesn’t coordinate with another, a payment schedule that doesn’t reward for time spent waiting on the phone, a system where people come with undifferentiated problems and can’t give a clear history of their symptoms. They can choose whether or not to express this emotion during a heated conversation.

At the end of the day, doctors can go home- for the mother of the child with cystic fibrosis, the young man with the heartless employer, the old lady with bowel cancer there is no such escape. A response that may help is to acknowledge the anger but address the fear. It may even reduce the frequency with which people might see the doctor standing in the way of something they think will immediately reduce the threat. It may also help when doctors are angry that those who are the target of that anger confront the issues rather engage in recrimination.

Picture by Petras Gaglias 

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

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 work the average consultation is fifteen minutes. In that time we address whatever symptoms or problems have been tabled. The list may be long. Occasionally it’s possible to raise a topic 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).

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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.’

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