Tag Archives: lean medicine

Perspective is crucial when considering changes in healthcare policy

It was summer of 2010 in Australia. I had been working hard in the garden one Sunday afternoon. Feeling the need for a little mindless entertainment I suggested to our then 14 year old that we might rent a sci-fi movie. It was around 7pm and  getting dark. My son jumped into the car beside me and we took off toward the video shop. That’s when I noticed that the car headlights were far too dim. I turned on full beam- but it didn’t help. I ranted for a good five minutes about how difficult it was going to be to get a mechanic to look at the car so close to Christmas. I was also a bit put out that our teenager was showing no concern for my predicament. At this point he quietly reached across and took my sunglasses off my face.

There. Problem solved dad.

I learned something that day not least what it would cost me if that story was not be retold to his brothers.

I love the work of Deana McDonagh and Joyce Thomas, especially their thinking on empathic design. Deana and Joyce begin their sessions on empathic design by inviting participants to try on their designer glasses- the ones that demonstrate what it must feel like to have tunnel vision. They’ve written about it in the Australasian Medical Journal. I keep those glasses in my office to remind myself and visitors of the valuable insights they offer but also as a treasured momento of a fun workshop generously organised by a brilliant team.

Their work came to mind later when we were investigating the attitude to self-management of a condition that is progressive and for which there is no cure. Patients and doctors in an Asian setting were interviewed. We recorded poignant stories about the impact of this condition on people’s lives- resulting in social isolation, self loathing and a need to feel supported by a health practitioner:

Both patients and doctors were against the adoption of self-management strategies. This is contrary to recommendations for the management of COPD by many studies and guidelines. However, another study has similarly shown that self-management skills were not rated as important by patients. Furthermore, the psychosocial impact of their disease such as fear limited their ability to manage their own symptoms. A lack of knowledge may also contribute to their dependence on doctors and health care providers.

We concluded:

In reality, patients have to conduct self-management daily and it is not feasible for physicians to provide all of the management needs that patients have during their day-to-day lives. Therefore, self-management remains an aspect of overall COPD care. However, it should not be the only focus and future interventions should also examine ways to improve access to health care.

On reflection we noted something similar with patients in Australia. Those who had an established medical condition were much more likely to ‘trust’ their doctor than those who were not currently unwell or those from higher socioeconomic groups. Innovating requires the ability to see people as heterogenous having very different perceptions on the need to be in charge of their own health, perceptions that are liable to change with circumstances. I also wonder if policy makers consider what it must be like to implement their big ideas from this perspective:

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Why doctors say ‘it depends’.

She looked harassed. She flung herself into the chair.

I’ve just about had enough. This cold is driving me mad. I’m coughing all day. Nothing helps. I’m still working for that pig of a man and we are short staffed this winter. I’m not sleeping at night. The kids are all down with this bug and my husband is on night shift. I can’t go on like this.

She left with a prescription for amoxycillin and a seven-day course of hypnotics. She also agreed to come back the following week to report on her progress. The consultation included a conversation about the natural history of viral illnesses and advice to defer the antibiotics, a discussion about her job as a reluctant telemarketer who left school without any qualifications and how to promote restful sleep. The only part of the consult that could be easily audited were the prescription data. The ‘real’ issue was not a microbe it was the milieu.

It is possible to publish papers in prestigious journals demonstrating that clinicians deviate from the evidence base. The list of misdemeanours is not insubstantial:

If you were a clinician you might say:

I never do that.

In which case you might reasonably be asked to outline your goals for consultations. If we accept that it is to be celebrated that people are free to make choices good or bad then we must accept that people smoke, eat more than they need, work in occupations that make them miserable or under bosses who are tyrants. They may choose to remain in abusive relationships or be addicted to drugs, alcohol, pornography or gambling. They are free to make choices but they must also live with the consequences of those choices. Eventually in most cases people will consider alternatives. The role of the clinician is to try to make that sooner rather than later whilst keeping channels of communication open.

The clinician advocates for the patient. In which case the answer to the question ‘would you do this’ is more likely to be:

It depends on the circumstances

You aim ‘never’ to cause harm. To avoid that which will diminish the patient’s choices by engendering physical or psychological adverse outcomes. Technological medicine can and does harm. However what is seldom reported is how the practitioners of the art of medicine help people to cope with life, not just today or tomorrow but in the longer term. That precludes slavery to ‘evidence’ that was never indicated for the very specific circumstances in which a person presents on one occasion. Compassion is not weakness. There is a narrative behind decisions in practice and simply reporting data does not present the whole story.

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Profiting from vanity- they may be targeting someone you love.

Where I live you’d be forgiven for thinking that you will be reported for child abuse if your teenager has less than perfectly straight teeth. Kids are growing up believing they need to be physically perfect.  So when the first crop of zits appears there is a hasty and often expensive trip to the chemist. Treating acne is a $3 billion industry in the United States alone.

..but i just feel so ugly when i see pretty girls with perfect skin around me.. it just makes me feel terribly disgusting, honestly. like i’m less of a person. it’s not fair. at my age there’s so much pressure to look beautiful constantly. even though i know most people don’t care how good you look a lot of them are secretly judging inside… everyone does it, even me..Nyla

Those in the age group 15-24 account for 7.6%  of consultations in general practice. Significant or life limiting pathology is unlikely in this age group but for many these meetings with their doctor will set the tone for a life long relationship with their main healthcare provider. For young people acne and eczema are the reason for almost one in three consultations with a GP. Sadly it has been reported that some teenagers get a very poor deal when they pluck up the courage to see a doctor:

It’s not that he doesn’t listen … sometimes he doesn’t fully comprehend that he’s talking in a way you can’t understand … it would help if they talked to teenagers. ( As reported by Jacobson et al in the BJGP)

This could be a missed opportunity to forge a relationship with the patient. If you are a doctor it may be worthwhile rehearsing a lucid explanation of common problems presented to you, including and especially acne. There is a bewildering array of opinions on this problem. Indeed the conclusion of research on this topic was that the majority of young people are getting information from non physician sources and there may be a need to evaluate the resources they are using to make sure they are receiving appropriate, helpful information. That includes parents who would rather their teenager would learn to live with her spots and expect you to endorse that view.

For those who want a ‘cure’ the opportunity for to profit from their distress makes them vulnerable to the most unscrupulous practices. $3 billion USD represents a substantial market for lotions, potions and diets that don’t work.

Substantial numbers of those surveyed had ideas about cause, treatment, and prognosis that might adversely affect therapy. Rasmussen and Smith

The truth is acne is a manageable condition, it’s just a matter of finding a treatment that works for an individual. For most people, it may take few attempts at find something that works. For some, over-the-counter topical creams are fine, for others, oral antibiotics or hormonal treatments work better, and yet others only respond to drugs prescribed by a dermatologist, with multiple courses required in relatively rare circumstances. The goal of having clear (or at least totally acceptable) skin is not unreasonable. This is a teachable moment in the interaction with young people.

Picture by Caitlin Regan

Why people will sack a plumber but won’t sue their doctor

Everyday somebody somewhere summons a plumber. The drain is blocked, the boiler isn’t working, there’s a leak under the sink. The problem is obvious the solution is technical and everyone knows when the job is done. If it’s not fixed asap the plumber is sacked.

That’s rarely what it’s like in medicine. Not everything is a blockage or a break. Not everything can be fixed by sitting quietly with a tool box and following the instructions in the manual.

Many of the commonest problems in healthcare don’t have an easy fix.

  1.  The pain of ‘tennis elbow’ can last for months despite treatment

Patients with tennis elbow can be reassured that most cases will improve in the long term when given information and ergonomic advice about their condition. Bassett et al.

2. Plantar warts don’t always respond to cryotherapy

Little evidence exists for the efficacy of cryotherapy and no consistent evidence for the efficacy of all the other treatments reviewed. Gibbs et al

3. Lung cancer is incurable in most cases

Lung cancer is the main cancer in the world today, whether considered in terms of numbers of cases (1.35 million) or deaths (1.18 million), because of the high case fatality (ratio of mortality to incidence, 0.87). Parkin et al. 

4. Anti hypertensives aren’t guaranteed to prevent stroke

Our analysis indicated that the absolute benefits of antihypertensive therapy depended on BP as well as the presence or absence of additional cardiovascular disease risk factors and the presence or absence of preexisting clinical cardiovascular disease or target organ damage. Ogden et al

5. Mild depression can be hard to treat

The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. Fournier et al 

6. There is no cure for the common cold ( You don’t need a link for this)

These and most other problems in healthcare cannot be ‘fixed’. They can be diagnosed and they can be ‘managed’ but they can’t be fixed in the way that faulty plumbing can be fixed. Therefore that queue of people in the waiting room is saying something more than ‘I’m here to be fixed.’ Patients are saying:

  1. I am in pain
  2. I am anxious
  3. I am unhappy
  4. I am bored
  5. I am angry
  6. I am confused
  7. I am lonely
  8. I don’t like my job
  9. I can’t pay my bills
  10. I need tablets or surgery

The job of the doctor is to work out which and then to fix what can be fixed and help the patient to live with the rest until their perspective or their circumstances change.

  1. Most people won’t take their tablets as prescribed.

    Because non-compliance remains a major health care problem, high quality research studies are needed to assess these aspects and systematic reviews are required to investigate compliance-enhancing inteventions. Let us hope that the need will be met by 2031. Vermeire et al 

  2. Most people won’t benefit substantially from health promotion advice.

Exercise-referral schemes have a small effect on increasing physical activity in sedentary people. The key challenge, if future exercise-referral schemes are to be commissioned by the NHS, is to increase uptake and improve adherence by addressing the barriers described in these studies. Williams et al

3. Most people get better in spite of treatment and not because of it.

Disease mongering can include turning ordinary ailments into medical problems, seeing mild symptoms as serious, treating personal problems as medical, seeing risks as diseases, and framing prevalence estimates to maximise potential markets. Moynihan et al

But then most people will be deeply grateful to their family doctor because they don’t have to respond a certain way to be treated with respect and they don’t expect a ‘cure’ and won’t ask for their money back when things don’t work out. The doctor’s role is to be there, to encourage, to educate, to accept and to walk with their patient through all the challenges that life has to offer.

Picture by Vicki

Doctor now that my ears are older I can hear you so much better

He was much more willing to listen than the twenty nine year old who was only interested in his sprained ankle. The attitude that millennials consider themselves invincible might explain it. Dave on the other hand wanted a certificate for work. Bit of a headache that morning. Didn’t go to work.

So, we got talking. He coaches a local football team. Now 50 can’t keep up with the young blokes on the field. Can still drink ten pints of beer on Saturday night at the club but most other nights happy to settle for two and some nights doesn’t drink at all. He snores. His trouser size gone up to 36 for the first time ever. Feels too stiff and breathless to do any real exercise. His blood pressure is borderline though be feels well enough.

Just under 1 million Australians were born between 1962 and 1966. Even though birthdays at each decade are usually marked by a special celebration, those for 50 are often unusually large. Being fifty is a bid deal.

It is in their 50’s, for example, that most people first think of their lives in terms of how much time is left rather than how much has passed. This decade more than any other brings a major reappraisal of the direction one’s life has taken, of priorities, and, most particularly, how best to use the years that remain. NY Times

  • 50 year olds are now officially “middle aged” technically ‘Generation X’.
  • Retirement benefits are only going to be available when they reach 67 and the money may have to last another 20-30 years.
  • At 50, many couples still have kids in the nest, with educations to be financed, teaching them to drive with attendant expenses , and, perhaps, weddings and helping with house purchase.
  • They may have parents in their 70s and 80s. They are watching mum and dad and their worries about healthcare and long term care expenses.
  • At 50 the majority of people are over weight or obese, the risk of hypertension begins to rise at this age, some men suffer erection dissatisfaction, many may start to have problems seeing clearly at close distances, especially when reading and working on the computer, the prevalence of hearing loss ranges from 20 to 40 percent. Things just don’t work like they used to!

Gen X has to stay healthy because in this economic climate early retirement is not an option. Within this context Dave and I began the work of focusing on his physical well being. The conversation was much more satisfying. This ‘teachable moment’ allowed us to engage in some simple strategies- reducing portion size, drinking less, taking up gentle exercise and keeping an eye on his blood pressure. Now Dave is earnest in his desire to invest in his health. That’s a good thing because at 50 one in 15 men will have heart disease by the time he is 60 one in four men will have developed that condition. Now is the time to invest. For his sake if not for the economy.

The average age of GPs in Australia is also about 50. We will make the journey together because that’s what general practice is all about. No gadget, gizmo or app was required to forge the connection, no research grant or policy. Just doing what we are trained to do.

Picture by Rene Gademann

Why hardly any medical invention is better than a six inch wooden stick

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A timeless and effective innovation:

  • Can be deployed in any setting
  • Cheap and easily available
  • Familiar
  • Requires minimal training
  • Acceptable to all
  • Unobtrusive or at least does not impact negatively on the consultation
  • Changes how we feel

The best one yet is the humble tongue depressor. How does your gadget, gizmo or app compare?

I recall our then 14 year old returning from a visit to his GP.

Dad, he didn’t even examine me!

It seems the doctor did not look into his sore throat and somehow the patient felt ‘cheated’.

But son, it wouldn’t have made any difference if he did look in your throat, doctors can’t tell if a sore throat is cause by a virus or something else just by looking at it.

I know that dad but the ‘magic’ is in the examination.

That from a 14 year old! A few months later an older woman consulted me with the ‘worst sore throat ever!’ I took a history of what sounded like a upper respiratory tract infection and the examined her very unimpressive throat with said wooden spatula. As I turned away to put it in the bin she said:

There’s one more thing doctor. For the first time in ten years I haven’t been able to afford books for my kids going to school. So I’ve been working as a prostitute.

It is possible or even probable that she would have told me this anyway. However I posit that the an examination with a wooden spatula is a profoundly intimate act. It changes the dynamic in the consultation when your doctor is able to see your sore red throat, is able to notice what you had for your lunch, whether you clean and floss your teeth and smell your bad breath. These intimate details are not shared with everyone or even with our most trusted confidantes. Indeed breath odour has been associated with a very significant impact on self image:

…smell from mouth breath odour can connect or disconnect a person from their social environment and intimate relationships. How one experiences one’s own body is very personal and private but also very public. Breath odour is public as it occurs within a social and cultural context and personal as it affects one’s body image and self-confidence. McKeown

In that context further disclosures can follow an examination of the mouth in a way that can change the diagnosis and management.

That is a truly valuable innovation.

Picture by USMC archives

What drives people away from doctors?

3661194585_438071ddc6_zInnovation is most effective when it enables a health practitioner and his patient or client to communicate. The ‘consumer’ if that’s what we choose to call them has a problem, they are in pain or have some other symptom. They are anxious or can’t see how they will ever recover from whatever it is. Their problem may be caused by a virus, or some other pathogen, it may be related to their diet or lifestyle or it may be a manifestation of  inheritance or an accident. It may be temporary, persistent or fatal. Whatever the problem the consumer must leave the building feeling that they have been heard and that the practitioner has taken this into account in his or her prescription.

What they don’t want is for the practitioner to be distracted in the process of attending to those needs. They crave empathy which is best expressed by ensuring that the patient is in no doubt that the doctor is listening, hearing and cares enough to want what’s in that person’s best interests. A recurring theme in this blog is that there are ten precious minutes, in the case of general practice when the practitioner can ensure that this first and essential goal is achieved. Everything else that happens in and around that consultation needs to support that objective.

Don’t introduce a new gadget, gizmo or policy that will detract from that experience. Don’t force the doctor to spend time on some other agenda. Those few minutes, in many ‘systems’  is the only time that is available to facilitate healing through human connection. If your innovation serves to enhance that exchange then it becomes part of the healing process. If it doesn’t it becomes yet another distraction in a failing healthcare system and the consumer will choose to go elsewhere or refuse to take the medicine. When it comes to seeking alternatives, research tells us that:

Five factors were identified, in order of importance: a positive valuation of complementary treatment, the ineffectiveness of orthodox treatment for their complaint, concern about the adverse effects of orthodox medicine, concerns about communication with doctors and, of less importance, the availability of complementary medicine. Vincent and Furnham

Not all medicines will work. Not all prognosis are favourable. However the business of doctoring is most constrained by the fact that our patients need to feel seen and heard. It’s astonishing how often policy makers and even innovators ignore this fact and make a bad situation worse.

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Why wearables don’t work and people don’t floss their teeth

Wearable devices are now a billion dollar business:

Fitbit Reports $712M Q415 and $1.86B FY15 Revenue; Guides to $2.4 to $2.5B Revenue in FY16. Press release.

In a wonderful article from the Washington Post the author reports:

Another friend, a woman in her 40s, explained: “I realized that there were a couple weeks where I took it off because it was making me feel bad when I was ‘failing,’ so why do that to myself?” Steven Petrow

Associated Press pointed out that:

One research firm, Endeavour Partners, estimates that about a third of these trackers get abandoned after six months. A health care investment fund, Rock Health, says Fitbit’s regulatory filings suggest that only half of Fitbit’s nearly 20 million registered users were still active as of the first quarter of 2015. Anick Jesdanun

This is consistent with what my patients are telling me. I’ve seen the same trend with relatives. But it is all very predictable because these devices fail on one fundamental count. People are not logical. Information alone does not lead people to make choices. Humans are driven by emotion and not just information. If that were not the case people would floss their teeth, not text while driving or borrow more than they can afford to pay.

Innovations that rely on people acting on information to improve healthcare outcomes have no longterm future. If we want people to change their choices we need to accept that information alone does not lead to behaviour change. Functional Magnetic Resonance Imaging studies of the human brain have identified that our brains are resistant to change even when the change might be in our best interests. Habits drive our behaviours and are as an old pair of slippers, comfortable, familiar and easy. Change requires us to activate other parts of our brain, expend energy, learn and adopt new habits. Change requires effort which most people find uncomfortable. As a result, change is avoided and the easiest thing is to refuse to heed the message and bin the device.

There are three stages to adopting new behaviours:

  1. Unfreezing current patterns/unlearning old behaviours.
  2. Changing/applying new behaviours.
  3. Embedding new behaviours.

Of these wearables provide information that might get us underway with the first step by getting us to question the status quo. However that is far from what is required to get us to adopt a diet and exercise regimen. This so-called ‘disconfirming data’ is not enough – we can easily dismiss it, ignore it, or deny its validity. Which most people seem to be doing because it isn’t enough to generate new habits. Two other factors that are also essential to get us to the next stage:

  1. We need to accept that something is wrong and
  2. We need to believe that we can do what is necessary.

The ‘something wrong’ is the problem. Many people who are overweight or obese don’t see themselves are having a problem because in most cases the condition is asymptomatic. They may be surrounded by people who are of a similar body habitus and are therefore resistant to any notion that this body shape is in any sense abnormal. Finally for many people the idea that they might be able to change their shape is hard to swallow as in many cases they do not see results after weeks of effort.

For innovators a fundamental message is that there is no quick fix to healthcare problems because fundamentally humans are feeling not thinking creatures and therefore not responsive to messages that only tackle part of the drivers for change.

Picture by Philippe Put

Please don’t ask for my time as refusal may offend

In an article from the Economist, the authors advise that we appear to perceive ourselves as short of time. Every minute of the day can be filled ‘doing’ something or several things simultaneously, often badly. We are also increasingly wedded to the demands of our mobile devices. People spend time texting while eating, driving and even on the loo. In fact it is estimated that we spend one third of our waking hours interacting with our phone.

In an experiment carried out at the University of Toronto, two different groups of people were asked to listen to the same passage of music. Before the song, one group was asked to gauge their hourly wage. The participants who made this calculation ended up feeling less happy and more impatient while the music was playing. Participants reported experiencing greater impatience while listening to the music when prompted to think about their time in terms of money.

This has some important resonance in healthcare where practitioners who earn a living through fee for service may, and often do, become impatient about engaging with researchers or academics. This is a significant problem because in countries where primary care is the first port of call for most people we desperately need research to ensure that the service offered is both evidence based and cost effective. But what is the order priority: appointments with patients, results of tests, administrative paperwork, continuing medical education, family commitments, surveys or recruitment to research? There is an opportunity cost to all of these activities.

Research in primary care is challenging not least because as has been observed repeatedly it is very difficult to recruit participants to trials in primary care. Practitioners are not funded by the paymaster to do research. Costing the recruitment to adequately compensate for the time taken to seek informed consent is prohibitive and the medical defense organisations do not indemnify doctors to do research.

Therefore, it is often if not almost always, very challenging to conduct randomised clinical trials in that setting. Other methodologies, such as prospective observational studies may be more likely to yield data whilst at the same time acknowledging that this would not be classed as level one evidence. Nonetheless, we need to work within a paradigm in which neither patient nor practitioner is likely to participate or if they do attrition is substantial and threaten the validity and generalisability of the data.

We need more creative ways to test hypotheses and collect data in primary care. Methods that capture data from a substantial number of representative participants. Methods that generate a minimum disruption to the business of doctoring. Traditional research approaches are failing or are only really possible where doctors and patients have unlimited funded time. I don’t know where that is, meantime remain sceptical about results of trials that appear to have recruited and retained thousands of participants but where the practices were involved in a significant effort to recruit to research. In that scenario somebody has paid, always ask who and why.

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Tailoring lifestyle advice as per patient experience design

16821469876_8d062d433d_zLots of people stop smoking every time the tax on cigarettes is raised. It has been said that:

‘A 10% increase in the price of cigarettes in developed countries will result in a 3 to 5% reduction in overall cigarette consumption.’

And in one study only 6% of people were confirmed as non-smokers one year after receiving advice in general practice.

So if we can dissuade enough people from compromising their health with financial disincentives what is the role of the doctor and primary care? What can a health professional do to help when a smoker with a nasty cough seeks advice, and or treatment? It could be argued that the person is aware that their habit has a bearing on the symptoms. Or that by drawing attention to the link with cigarette smoking that the doctor is heightening a sense of shame, self-loathing and guilt.

So what is the role of general practice or primary care in tackling the big issues —smoking, obesity and alcohol abuse? Are brief interventions delivered in this setting more harmful than necessary? What if innovations delivered by practitioners were even more effective than the modest 6% recorded in the past?

An innovation that I was involved in evaluating led to one in seven smokers quitting. An innovation we subsequently developed as an adjunct to the treatment of obesity may well be more effective than diet and exercise regimens used alone. However if these innovations are delivered in a primary care setting then there is a risk that some patients who access them might feel challenged by the having it drawn to their attention that their results are a reflection of their own efforts. Those who fail to achieve the desired results may become disheartened.

It takes an effort to give up a harmful habit and it is now possible to predict and demonstrate the results of our lifestyle choices in ways that appear to matter to us the most. The key for innovators in the’ patient experience design’ space is to ensure that we minimise the harm that could be done by ensuring that such innovations do what they say on the tin and that they are designed with safeguards. What is beyond dispute is that the prevalence of obesity is increasing at an unprecedented rate and every health care professional has a role in combating this issue, not just those with a public health perspective. Some people respond best to health messages that are tailored to their personal circumstances, and as healthcare practitioners, we have a duty to make those options available to them. If you are interested in staying abreast of innovations developed along these lines click here.

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