Tag Archives: obesity

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.

Innovating to save precious time

When I was at medical school Pendleton’s book on the consultation was required reading. Pendleton maintained that one of the tasks in the consultation was to consider ‘at-risk factors’. It’s one item on an otherwise long list of tasks to be completed. Today it is often the case  that a discussion of  those ‘at-risk factors’ take over the focus of the consultation. Doctors are urged, even rewarded for moving the agenda to- diet and exercise, responsible drinking, colorectal, breast and cervical screening, hypertension, safe sex….the list is endless. The impact of having the doctor’s agenda up front and central in the consult is what has been described as

High controlling behaviours.

Ong et al.

The resultant style of consultation is described thus:

It involves… asking many questions and interrupting frequently. This way the doctor keeps tight control over the interaction and does not let the patient speak at any length.

Recently medicolegal defense organisations have taken to issuing advice against this pointing out that when the patient does not feel they have been heard they are more likely to complain. Research has shown that patients don’t ask for much. They won’t take long to spit out the reason for their visit. In one study:

Mean spontaneous talking time was 92 seconds (SD 105 seconds; median 59 seconds;), and 78% (258) of patients had finished their initial statement in two minutes.

Langewitz et al.

Allowing the patient to speak first is a good start. Then how do we support practitioners to earn a living by also attending to those topics for which they must tick a funder’s check box? Tasks introduced by policy makers as if the primary care consultation was replete with redundant time. In some ways it’s like what happens when you buy a new television, it’s not long before the sales assistant wants to sell you insurance and other products- ‘just in case’ but really because their commission depends on it. What we need in medicine is to stop eating into the time it takes to explore a patient’s ideas, concerns and expectations, time needed to examine the patient and express empathy. We need cheap, agile, intuitive and creative solutions that will quickly offer the patient an indication of their risk from whatever the latest public health issue happens to be- smoking, influenza, prostate cancer…but also the benefits and why they might want to consider ‘taking the test’, accepting ‘the jab’, or changing the habit.  My colleague Oksana Burford invested three years testing one such innovation. What Oksana realised is that in the end it’s the patients choice and the key is to introduce the idea of change in a way that speaks to her but only when she is ready to hear the message.

The reasons why primary care is selected to relay public health messages is that people trust their health care provider and are more likely to comply if that practitioner recommends it. However that does not mean that we should assume the patient can only get the necessary information from one source. What the practitioner can do is sign post where that information can be found and effectively convey why the choice being recommended is better than the status quo. I recommend the food swap app– its downloaded free and saves a lot of time which can then be used to deal with the reason the person had come to see me in the first place. There is lots of room for innovation but it should meet the needs of the patient and the practitioner.

Why aren’t healthcare providers doing more to tackle the biggest health problem?

Obesity is the single biggest health problem facing our generation and the generations to come. It’s already killing, disabling, disfiguring and demoralising more than half of the population in most developed countries. By 2025 the majority in the developed world, and a growing proportion in the developing world will be overweight or obese. We have seen it coming, the warnings have been around for decades and yet we have done very little to combat it. Now it’s reported that doctors can’t see what they can do about it.

Until more effective interventions have been developed GPs may remain unconvinced that obesity is a problem requiring their clinical expertise and may continue to resist any government pressure to accept obesity as part of their workload.

—Laura Epstein and Jane Ogden

The reality about the problem of obesity is:

1. We are all aware that being overweight is harmful and yet we are legally bombarded with subliminal messages that promote unhelpful lifestyle choices .

2. It may be counter productive to raise the issue with someone who already feels a sense of shame and guilt.

3. Simply being offered dietary advice by a health practitioner isn’t making a difference to most people. We already know what we shouldn’t put in our mouths, that an apple is better for us than a chocolate bar.

4. People find it hard to do what needs to be done to tackle the issue—eat less and exercise more. It’s hard to sustain the effort over a period of time and to make permanent lifestyle changes.

5. Our current healthcare interventions and innovations with regard to obesity are not working.

6. In Australia the cost of dealing with the effects of obesity has reached $120 billion. We are not doing enough to tackle the root cause.

7. We must find a sustainable solution to this problem. Handing out diet sheets and making referrals to dieticians is not enough.

The challenge, for the practitioner is to present information that’s hard to hear in a way that it is likely to be taken on board and acted on. To appeal to how people feel about making changes, not just what they know. To provide information that is motivating and affirming. To reduce the time burden on health practitioners to deliver that advice efficiently. To put the tools into the hands of the person who may have to change life long habits. We just need the collective will to make it happen.