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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

Common sense vs. miracle cures

I’ve seen this person, or someone like her many times before. On that occasion it was a demand for phentermine but it could have been antibiotics, ‘blood tests’, a ‘whole body scan’, benzodiazepines or opiates .

My doctor has prescribed it before. I need it again. So I just need a repeat script.

At a guess she had a BMI just shy of 30 and I noted that she had been prescribed this drug intermittently for a couple of years. She made it clear there was no room for discussion or argument. She had taken the day off work and wanted to get her diet underway. She wasn’t really interested in my opinion. If I’d prescribe it she’d leave. I explained politely that I don’t prescribe this drug (even though I could). I don’t believe it works and could actually harm her. But she persisted:

My professor prescribes it for me

In other words

What do you know about it? You’re ‘only’ a doctor.

I could explain lots of reasons why she shouldn’t be taking this drug. Phentermine is an amphetamine derivative that is used as an anti obesity agent it was approved by the US FDA in 1959 for short term treatment of obesity. It is the most commonly used anti-obesity drug on the US market and many US bariatric physicians use phentermine long term, ignoring the FDA guidelines that it be used for three months or less.

In a trial published in the British Medical Journal in 1968 it was concluded that phentermine has an anorectic effect ‘compared to placebo’. However according to a systematic review published in 2014:

No obesity medication has been shown to reduce cardiovascular morbidity or mortality. Additional studies are needed to determine the long-term health effects of obesity medications in large and diverse patient populations. JAMA

Like so many miracle cures discovered or unveiled decades ago we now know a bit more. Phentermine has been associated with psychosis. But there is precious little else to indicate major problems in the literature and the drug is still listed as available to prescribe. However patient experience is another matter:

I lost about 20 kg’s on [Phentermine] over about 6 months. I didn’t have any of the shaky or jittery, but these are common side effects. Even though my appetite was much less then it normally would be, I made a conscious effort to eat three small meals a day and a few snacks. I Used it in conjunction with a calorie tracker plus exercised. It can make the weight drop off quickly but if you don’t make the steps to eat correctly and exercise you can pick it up weight plus some again when you stop taking the tablets. Glowworm80

And another:

However, there are side effects. Lots of people say it makes their heart feel “racy”. This has not happened to me, but I suffered terrible insomnia. I wasn’t able to sleep before 3am in the morning, just lying in bed with thoughts racing around a million miles an hour. But then when you get up and take the next day’s pill, you get energised and you don’t feel like you’ve only had three hours sleep.

You can see how ridiculous this all is … eating next to nothing, sleeping only three hours a night but feeling no hunger and having boudless energy. It is not something that your body will thank you for in the long run. peckingbird

And this one:

I am sorry to say but I think any doctor who prescribes [Phentermine] as a first choice treatment for weight issues is being negligent. I really do understand the attraction when weight is needed to be lost quickly BUT..

I know many people who’ve taken it ( it was very readily available back in the 90s ) they have lost varying amounts of weight and have had varying side effects…some really dangerous and not one of them has maintained their weight loss beyond a couple of months after ceasing the drug. Soontobegran

This has also been my experience when I’ve prescribed it for patients in the past so I won’t prescribe it now. We need to exercise our right to refuse to prescribe treatments that promise more than they can deliver because they rarely do. We don’t need to wait for research evidence to catch up with common sense.

With regard to ‘diet pills’ I agree with this:

The allure of a pill – whether pharmaceutical or nutraceutical – that allows one to lose weight without requiring behavioural changes at the dinner table or in the gym is irresistible. a burgeoning market for both prescription and over-the-counter diet pills exists. Unfortunately to date, the dream of a thin-pill has largely failed to materialise due to unrealised efficacy, safety or both. Mark K Huntington & Roger A Shewmake

Picture by Baker County Tourism

How can medicine compete against the new normal?

Joanna was exactly the person we are being urged to help. In her forties, overweight verging on obese. Hypertensive, asymptomatic but well on her way to chronic diseases. We discussed her diet.

I like salt. So my food tends to be salty. Also most people in my house are my size. I thought about reducing my portions but I like meat, lots of meat. I’m a member of a gym but I rarely go there.

We talked about her risk of heart disease and encouraged her to banish the salt cellar from the table, perhaps think again about reducing the portion size and making time to go to the gym. She looked at me pityingly her eyes said

Well that ain’t gonna happen

This was not a teachable moment. She was not ready to make an investment in changing her habits. She could not see that she was at risk. She was ‘normal’ as far as she could see. So she was not going to change her diet to deal with a problem that she did not perceive as real.

There are many things that are regarded as ‘normal’.

It is now normal:

  1. To have to wear extra large clothes.
  2. To be offered larger portion sizes when we dine out
  3. For more than one in three Australians aged 14 years and over to consume alcohol on a weekly basis
  4. For friends or acquaintances to be the most likely sources of alcohol for 12–17 year olds (45.4%), with parents being the second most likely source (29.3%)
  5. For more than one in three Australians aged 14 years and over to have used cannabis one or more times in their life
  6. For more one in ten people to drink and drive
  7. For one in three people to lose their virginity before the age of 16 ( i.e. before the age of consent) and also to have multiple partners
  8. For 66 percent of all men and 41 percent of women to view pornography at least once a month, and that an estimated 50 percent of internet traffic is sex-related.
  9. For most people who join a gym to never use it

These and many other trends dictate what is ‘normal’ to the average person. It’s OK to eat and drink far too much because everyone else does. It’s OK to be promiscuous, watch pornography and take risks because that’s what people see happening all around them.

Against these trends the challenge is to seek opportunities when ‘normal’ is seen as risky and hopefully before that risk has manifested as pathology.

Picture by Mario Antonio Pean Zapat

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

Work with employers to improve health

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Annual profits confirm whether the staff of a company performed well. Profit margins, and the rate of innovation, closely reflect the health of the people who deliver that success. Employers are, and perhaps always have been, a key partner in the drive to improve the health of the nation. What has become a greater imperative to forge a partnership is the threat to profit margins from the looming spectre of chronic illness in epidemic proportions. Work is a vitally important aspect in most of our lives:

The average working American spends the majority of his or her waking hours on the job. Some of us live and breathe our work. Others of us work to pay our mortgages. Either way, the workplace has become an important source of social capital for millions of Americans – a center of meaning, membership, and mutual support. More than ever, we find our close friends and life partners on the job, we serve our communities through work-organized programs, and we use the office as a forum for democratic deliberation with people different from ourselves. Countless studies show that a workplace with strong social capital enhances workers’ lives and improves the employer’s bottom line.The workplace and social capital.

Similarly in Australia people spend most of their waking time at work. On average 34 hours a week . Sixteen percent of us work more than 50 hours per week. In contrast we spend 6-9 hours  per week doing house work and 6 hours and twenty seven minutes per day asleep. The impact of the working environment on health ranges from physical to psychological and can be both harmful and beneficial. Employers in most developed countries are therefore legally obliged to provide:

  • safe premises
  • safe machinery and materials
  • safe systems of work
  • information, instruction, training and supervision
  • a suitable working environment and facilities.

However there is much more that can be done to optimise the health of employees. The economic argument for this is clear and closely related to the rising incidence of chronic and complex illness among the working population. In 2002 approximately 59 per cent of global death was attributable to chronic, non-communicable diseases and the toll is projected to increase to 66 per cent by 2030.  The other outcomes that should worry employers is the prospect of premature retirement from the workforce.

It was found that individuals who had retired early due to other reasons were significantly less likely to be in income poverty than those retired due to ill health (OR 0.43 95% CI 0.33 to 0.51), and there was no significant difference in the likelihood of being in income poverty between these individuals and those unemployed. Being in the same family as someone who is retired due to illness also significantly increases an individual’s chance of being in income poverty. Schofield et al

A report by the Australian Institute of Health and Welfare in 2009 outlined the consequences of chronic illness and early retirement on the entire Australian economy. It concludes that:

  • People with chronic disease had, on average, 0.48 days off work in the previous fortnight due to their own illness, compared with 0.25 days for those without chronic disease.
  • The annual loss in workforce participation from chronic disease in Australia was around 537,000 person-years of participation in full-time employment, and approximately 47,000 person years of part-time employment.
  • For people participating full-time in the labour force, there was a loss of approximately 367,000 person-years associated with chronic disease, approximately 57,000 person-years in absenteeism associated with chronic disease and 113,000 person-years were lost due to death from chronic disease.
  •  Estimates of loss do not take into account lower performance while at work. Similarly, the effect of loss from participation in the unpaid labour force (carers, parents and volunteers) has not been accounted for. The estimates, therefore, underestimate the loss in workforce participation associated with chronic disease.

Therefore employers who wish to retain an effective workforce, and by corollary their profitability, need to invest in the well being of their workers. This responsibility extends beyond ensuring the physical safety of their workforce. A workforce that is under threat from an ageing population and an alarming incidence of retirement through ill health. If employees spend most of their waking hours at work then the following might concern the employer (click the links for the literature):

I believe health innovators who address these issues in their dealings with industry will discover an open door with massive potential for mutual benefit.

Picture by Vase Petrovski

Twenty minutes every three months

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I recently said goodbye to my patients when I moved to another job. One of my general practitioner friends also said goodbye to his patients, albeit it temporarily. He has been visiting Australia this week. I am pleased to recount his story.  For him the light bulb moment came when he noticed that people were concerned that he ‘might never return’. He wondered if he could deploy this connection to encourage his patients to be more active and or stop smoking.

Two months before Dr Klein left ( for one year), he wrote to his patients, challenging them to set 1 health-related goal to work on while he was away. He suggested they consider a lifestyle change, such as losing weight or quitting smoking.

Two of his colleagues offered to support the patients in their efforts to achieve any goals they set in Dr. Klein’s absence.

About 1 in 8 adult patients (48 out of 350) set goals, including losing weight, exercising so many times per week, and quitting smoking; some set more than 1 goal.

The ‘intervention’ took only a few minutes to initiate and 20 minutes of staff time every 3 months. This was essentially a reminder letter every 3 months. The results were impressive.

Among the participants, 18 (38%) did not achieve their goals; another 15 (31%) could not be reached, so their results were unknown. The remaining 15 patients (31%) succeeded, 8 completely and 7 partially reaching their goals, and some meeting more than 1 goal. The successes included 3 patients who quit smoking, 7 who increased physical activity levels, 7 who lost weight, 1 who reported decreased shoulder pain after exercising more often, and 1 who made an overall lifestyle change.

It sounds as if the reminder letters were triggers to keep working towards the goal. This ‘lean innovation’ did not require a research grant or a large team to complete. No drugs were prescribed, no tests were required. It was rewarding and demonstrated the value of the social capital in the doctor patient relationship. A relationship that defines the role of the medical practitioner even in 2015. The same relationship that creates tangible results. Medicine is a people business. We do well to remember that at a time when there is an obsession with quantified self.  You can read more about Doug Klein’s experience here.

Picture by Kellan.

Don’t curse the dark, light a candle

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Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light.

Dylan Thomas

My young colleague recently received the following note from the editors of a well known primary care medical journal:

Thank you for submitting your manuscript, [ Title here], manuscript number XYZ-601-14 Version 1, for consideration by the Most Important Journal of Family Medicine. The editors have completed their evaluation and we regret that we are unable to accept the paper for publication. This decision reflects a variety of factors, including the large number of manuscripts competing for limited space and the paper’s priority relative to others we are considering.

She was especially disappointed because the paper was summarily dismissed. Her submission was a painstaking review of the literature that demonstrates the equivocal evidence for the successful management of obesity in general practice. The paper was co-authored by two senior colleagues and she had been encouraged to submit it as a quality piece of writing. I could show her my collection of similar letters. I have kept them all. It seems, ‘space’ is lacking rather than the value of this young researchers offering. A researcher who will one day become a leader in her profession. Her paper will be published of that there is no doubt but not in that journal. An experience that is all too common for those trying to make an impression in the early part of their career.

Five years ago a team of us decided we’d like to make a small difference to people in this position and so, in 2008,  the AMJ was launched. We administered the journal on a shoe string budget and brought it to the attention of medical students via face book. In the early days it was hard work. In fact it was an expensive and time consuming hobby. Today the AMJ is an established and recognised peer reviewed medical journal, it is listed on most of the major databases and is entirely self sustaining. Some of the papers the AMJ has published have made an enormous impact.  It makes a small but reasonable contribution to the work of people who often find themselves sidelined because editors of the ‘far too important’ journals can’t see the value of their ideas or care how their dismissive and impersonal tone can crush their junior colleagues. And so we say to our colleagues, there is no point cursing the darkness because today with global access a mouse click away, with a little tenacity, it is possible to reach out to many. If only a few like minded people respond what started as a small candle in the gloom may one day become a beacon. At a time when primary care in so many parts of the world seems to be undervalued we need to do a small thing to assist our cause rather than whinging about how unfair it all is.

Picture by Justin McMurray

Personal choice versus social responsibility- compassion before all.

9363012140_4304b8498b_zAt 52 years of age Suzy knows better. She is unemployed and divorced, again. She takes her antihypertensive only very occasionally. She is obese. Often sleeps rough, drinks far too much especially when flush with social security payments and is frequently at the emergency department with injures following a binge drink or a fight. Her destiny is to become a statistic.

Nothing is more evident in the statistics of public health than the role played by individual health behavior in contributing to accidents, illness and disease. Daniel Callahan

In a now classic series of studies Lester Breslow and his associates revealed that men who successfully adopted seven good personal health habits had lower morbidity and mortality rates than those who followed six; those who followed six of the habits had better health and mortality outcomes than those who followed five; and so forth. Kayman, Bruvold, and Stern demonstrated that individuals who develop their own diet and exercise plans are more successful at achieving and maintaining weight loss that those who play a more passive role. Each year, millions of smokers successfully quit the habit (albeit usually after several attempts), and most who do quit do so on their own.  Individuals have a fundamental right, based on the principle of autonomy, to choose health-related behaviors. Yet, with this right, so it is argued, comes a responsibility to make wise choices. Herein lie the strongest case for innovations targeted at the individual.

It is often supposed that given information people will make the right choices. Suzy knows that when intoxicated she is likely to injure herself, she has been advised that she is at significant risk of cardiovascular disease and is aware that her junk food diet is likely to maintain her BMI at 35. She has had bariatric surgery but she had the surgery reversed. Knowing is not enough. So one point of view says:

Being ill is redefined as being guilty. MH Becker

At the same time epidemiologists such as S. Leonard Syme have pointed out that people at progressively lower socioeconomic status (SES) levels have correspondingly less opportunity to control the circumstances and events that affect their lives. Conversely, for individuals at higher levels, factors like higher income and greater discretion, latitude, and control over their lives may contribute to a more generalized sense of “control over destiny, ”which, in turn, may translate into enhanced health behaviours and health outcomes. Suzy  could be, and is, stigmatised. Conservative governments have used the rhetoric of personal responsibility for health to justify cutbacks in needed health and social programs. Only this week the Australian Government was urged to consider a proposal in which

about 2.5 million welfare ­recipients on “working-age ­payments”, including disability support pensioners and carers, would be forced into a cashless world where 100 per cent of their payments were income-managed and they were banned from purchasing “prohibited” goods. The Australian.

Meanwhile concerted efforts have been made to support Suzy to lose weight, drink less and take more exercise. Clearly none have succeeded so far. Suzy may turn things around despite previous failures. On the other hand if she is forced to use her social welfare payments for food she may trade food for alcohol, and it’s unlikely to be a fair trade. Suzy’s response to life, may be a factor of the attitudes she comes across on the street. How do you innovate against disdain?

There is no question that her poor choices have landed Suzy in trouble. But no one who takes the time to listen could possibly believe she doesn’t want better. One day we might find the trigger for a radical change. In the meantime what Suzy needs most is someone on her side. She needs continuity of care, someone who understands the complexities of her deeply troubled life, someone who knows the actors and can interpret her cries for help, often couched in somatic terms. As her clinician she deserves my undivided attention anything that comes between us would detract from the chance that she will one day reinvent herself. ‘Suzy’, as described, doesn’t exist- but the elements of her story are true for many who seek help from their general practitioner.

Picture by Kat N.L.M.

Health Innovation: lessons from the past

What lessons can innovators learn from the experience of a medical practitioner born in 1749? Here is a summary of what happened:

  • He was a curious and prodigious innovator who based his ideas on his observations.
  • He built and twice launched his own hydrogen balloon.
  • He published the observation that it is the cuckoo hatchling that evicts the eggs and chicks of the foster parents from the nest. Something that many naturalists in England dismissed as pure nonsense until it was proven beyond doubt in 1921.
  • He devised an improved method for preparing a medicine known as tartar emetic (potassium antimony tartrate).
  • He worked as a doctor and noted that dairymaids were protected from smallpox naturally after having suffered from cowpox.
  • In 1797, he sent a case report to the Royal Society describing how a boy who had been inoculated with cox pox subsequently became immune to small pox. The paper was rejected.
  • Many years later he published another paper outlining his hypothesis. The publication of the Inquiry was met with a mixed reaction in the medical community.
  • In the course of his life he not only received honors but also found himself subjected to attacks and ridicule.

In summary 80% of people exposed to small pox contracted the disease. Almost 1-7 died. Many thought it was innate to humans. Others thought it was an infection attributed to menstrual blood or something caused by the putrefaction of the umbilical cord. A host of remedies were proposed at the time, including special diets and enemas.  There is a remarkable parallel between the variety of proposed “cures” for smallpox and the treatments for many modern maladies foisted on a long suffering public by those looking to make a profit. The discovery of the small pox vaccine by Edward Jenner was arguably one of the greatest leaps in medical science. It was made by someone who observed the effect of the innovation at first hand. His ideas were rejected and ridiculed by many but recognised by those with sufficient insight to ensure that humankind would benefit for generations to come. How do we recognise those most likely to offer a genuine step forward in our search for a better way?

Health innovations are not always intuitive, but rather are made by innovative thinkers who are brave enough to try something new and think outside the box. Colin Farrelly

My colleague Ori Gudes drew my attention to this post by Chris Dixon. Chris brings the Jenner experience into the 21st Century. His post outlines three key features of those with a winning idea:

  1. Know the tools better than anyone else
  2. Know the problems better than anyone else
  3. Draw from unique life experience

However, having said that he points out that these characteristics are not immediately successful in getting their innovations to market because:

  • Powerful people dismiss them as toys
  • They unbundle functions done by others.
  • They often start off as hobbies.
  • They often challenge social norms.

So how do you spot a good idea? Pose one question: Does the founder have technical expertise, problem/domain expertise or experience? My colleague Oksana Burford and I observed the reaction of young women who were shown photoaged images of their wrinkled faces after a lifetime of smoking. What we observed persuaded us that this reaction would trigger determined attempts to stop smoking. Despite numerous applications Oksana couldn’t get her project funded. Potential funders couldn’t see what we had witnessed in the consulting room. So she committed to it as a self funded PhD. Oksana delivered the intervention as part of brief professional smoking cessation advice in a randomised controlled trial. As per the published results we observed 1 in 7 successful quit attempts, which is better than most other interventions. Oksana will soon be working with colleagues targeting Parisian smokers. Meanwhile Gemma Ossolinski and I are using a similar intervention in obesity– the preliminary results are also very encouraging.

Semiotics and the placebo

It has long been acknowledged that the ‘doctor’ can have a therapeutic effect without ever ordering a test, prescribing a medicine or performing surgery. Indeed the earliest thinkers about the the role of the doctor talked about the ‘drug-doctor‘. But what are the constituent parts of this most powerful of placebos and what impact does this have on our attempts to improve outcomes?

The placebo pill, the saline injection, and the invasive procedure or device that works by virtue of a placebo effect are each signs, or sets of signs, that convey information to patients or research subjects. Additionally, the placebo intervention, like a standard treatment, is delivered within and surrounded by a context, which includes a host of other signs that convey information with the potential for producing therapeutic (and also counter-therapeutic or nocebo) responses. These include the clinician’s white coat, diagnostic instruments, the appearance of the doctor’s office or hospital room, the words communicated by the physician, the physician’s disposition in listening and responding to the patient, gestures, and touch. The patient does not come to the clinical encounter as a blank slate but with a history of experiences and memories evoked by prior responses to signs related to the milieu of therapy, some of which may influence the way in which the patient processes the information from signs emanating from the present clinical encounter. Franklin G. Miller and Luana Colloca

More recently evidence has emerged that hints at more specific ways in which these elements might be improved. When I was training our mentors recommending that we should never be casually dressed when consulting patients. This was based on their impressions of patient expectations. Later in my career my wife who was a staff nurse at our local hospital was amused that the patients I had admitted overnight were  impressed that their doctor was wearing a neck tie even at 2am. I’m not sure whether that was by design or accident.

Rehman and colleagues conducted a study of patient preferences about how they preferred their doctor to dress. Within a North American context it was clear that patients preferred their doctor to wear a white coat, whether the doctor worked in a hospital setting or not. According to the respondents to the survey doctors in white coats were more likely to be knowledgable, competent, caring compassionate, responsible and authoritative. It was evident from this study as well as a study from the UK that older patients in particular prefer their doctor to wear a white coat. There are differences in attitude based on geography and culture. However it is important to consider the importance of this question if only because patients who trust their doctors are more likely to take advice. It is argued how much of a difference attire makes to patient trust but the consensus appears to be that business wear and formal clothing generally inspire more confidence than tee shirts and shorts.

A second issue has recently become relevant. Research has documented negative stigma by health providers toward overweight and obese patients, but it is unknown whether physicians themselves are vulnerable to weight bias from patients. Puhl and colleagues surveyed 358 adults. Respondents were less trusting of physicians who were overweight or obese, were less inclined to follow medical advice, and were more likely to change providers if the physician was perceived to be overweight.  Normal-weight physicians elicited significantly more favorable reactions. These weight biases remained present regardless of participants’ own body weight. A more recent study from Johns Hopkins University School of Medicine suggests that although patients might trust their doctor regardless of his or her weight, those seeing obese primary care physicians, as compared to normal BMI physicians, were significantly more likely to report feeling judged because of their weight.

Therefore attending to how we come across to patients might be an important place to start improving the chances that they will trust us. This is based on intuition and a little bit of evidence, it doesn’t require a grant or a change in government policy. If you think it needs work- start today.