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Doctors need better tools to help people recognise danger

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

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

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

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

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

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

Picture by Marcelo Nava

Start the consultation as you mean to continue

What I consider this week requires no renovations, no insurance rebate or government subsidy. It does require clean hands. Yet the humble handshake has the power to catapult a meeting into an entirely different dimension.

Many of our social interactions may go wrong for a reason or another, and a simple handshake preceding them can give us a boost and attenuate the negative impact of possible misshapenings.  Dolcos

The importance of any act that makes for a more positive interaction is that doctors are more often than not in the ‘sales’ business. They ask us to ‘buy’ all the time:

  • Buy my advice
  • Buy the recommended tests
  • Buy this diagnosis
  • Buy the suggested lifestyle change
  • Buy these pills

On the other hand ( pardon the pun) some researchers have called for a ban on handshakes because they can spread infections. But are you more or less likely to ‘buy’ from someone who does not shake your hand?  The evidence that the simple handshake can make a huge difference to the outcome of a meeting is overwhelming but there is precious little written about it in the medical literature.  As recently as 2012 researchers at the University of Illinois noted that:

Despite its importance for peoplesʼ emotional well-being, the study of interpersonal and emotional effects of handshake has been largely neglected. Dolcos et al

We have all heard that handshakes have an impact on the outcome of job interviews. But perhaps more than any other literature consumer psychology has a lot more to say on the subject:

A successful sale depends on a customer’s perception of the salesperson’s personality, motivations, trustworthiness, and affect. Person perception research has shown that consistent and accurate assessments of these traits can be made based on very brief observations, or “thin slices.” Thus, examining impressions based on thin slices offers an effective approach to study how perceptions of salespeople translate into real-world results, such as sales performance and customer satisfaction….Participants rated 20-sec audio clips extracted from interviews with a sample of sales managers, on variables gauging interpersonal skills, task-related skills, and anxiety. Results supported the hypothesis that observability of the rated variable is a key determinant in the criterion validity of thin-slice judgments. Journal of Consumer Psychology.

We now have very sophisticated was to assess the impact of our behaviour on each other. And when functional MRI is deployed the data suggest:

A handshake preceding social interactions positively influenced the way individuals evaluated the social interaction partners and their interest in further interactions, while reversing the impact of negative impressions. Journal of Cognitive Neuroscience

David Haslam (Said by the Health Service Journal to be the 30th most powerful person in the British National Health Service in December 2013) wrote:

Touch matters. Really matters. It is a highly complex act, and touch has become taboo. Touch someone’s hand in error on the bus or train and both parties will recoil with hurried exclamations of ‘sorry’. To touch someone has become an intimate act–generally limited to family, lovers, hairdressers and healthcare professionals. The very word carries significance. We say we are touched by an act when it moves us in a strongly positive emotional way. And all manner of other phrases have connotations that link touch to emotion–giving someone a shoulder to cry on, or saying ‘you can lean on me,’ ‘hold on,’ ‘get a grip,’ ‘a hands on experience,’ ‘keeping in touch,’ ‘out of touch’ and so on. For doctors, touch can be a vitally important part of our therapeutic armamentarium. I’ve lost count of the times that I’ve leant over and held someone’s hand when they started to cry in the consulting room. The healing touch

In a small study now a decade old, Mike Jenkins suggests that a spontaneous handshake proffered by the patient at the end of the consultation is a very good sign:

This small study suggests that most handshakes offered by patients towards the end of consultations reflect patient satisfaction — ‘the happy handshake’. Indeed, many reasons were recorded using superlatives such as ‘very’ and ‘much’ representing a high level of patient satisfaction — ‘the very happy handshake’. Mike Jenkins

It cost nothing- although, in some cultures, it may be taboo to shake hands. In most cases, it can only help to establish trust and improve the outcome of the consultation. Of course, if you care enough to want to engage with the patient you would wash your hands thoroughly before sticking out your hand but failing to make physical contact at the outset comes at an enormous cost of reducing the ability to put the patient at their ease.

Whatever we decide patients notice:

I saw one of your doctors today, she didn’t shake my hand, listen to my heart, do any type of extremities tests to verify my condition. Just referred me to another doctor. Is this the kind of poor medicine I can expect from the rest of your professionals? Mark Roberts, Facebook

Picture by Rachel

No we can’t

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Oh yes doctor, we would like to have you present at our conference. In fact we would like you to run a three hour workshop and do a plenary. And sorry no we don’t pay speakers. We offer budget travel and basic accommodation.

I couldn’t believe what I was hearing. The preparation for this would take weeks. According to the glossy brochure the conference was to be held at an expensive venue overseas and the delegates would be paying handsomely to attend. The young man who called me couldn’t see anything wrong with asking me to work on his business at the expense of my employer in order to make a profit for his company. My response as far as he was concerned was unexpected. Which means he was probably used to hearing:

Yes

Academics give it away for a plane ticket and a cheap hotel room. They are just so pleased to be noticed.

The word for 2016 has to be:

No

  • No to urgent and not important
  • No to someone else’s priorities
  • No to time wasters
  • No to projects that don’t serve the mission
  • No to lack of self respect

If you are being asked, as you will be daily, to give up your time and pay an opportunity cost to be distracted then your boss has the right to ask difficult questions at your annual appraisal.

  • What did you accomplish today?
  • How does this work towards the mission of your team?
  • What tangible can you show when you reflect on progress this week?

Learn to say

No.

Here are some different ways to say it. Practice today. Say it politely but say it emphatically.

No, Nein (German), Non ( French), Hapana (Swahili), Naheen ( Hindi).

If you practice it judiciously then you are less likely to hear it said to you.

Picture by Michael Sissons

First we have to agree that there is a problem

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In order to make progress when we are trying to help someone we have to understand their world view. This was wonderfully portrayed in the Dove commercial. To understand a person’s perspective we have to try to see them as they see themselves but also to accept that as health professionals we may have less influence on people’s choices then we like to think.

It was also underlined in a research paper which concluded:

Overweight and obese youth were significantly more likely to misperceive their weight compared with non-overweight youth (P<0.001). Multilevel modeling indicated that greater parent and schoolmate BMI were significantly associated with greater misperception (underestimation) of weight status among children and adolescents. Maximova et al

Large proportions of the population are now overweight or obese. It may be hard to believe this if you live in affluent suburbs where salad bars, gym membership, jogging and cycling are the norm. In other parts of town it might be routine to eat fast food and wear XL or XXL sizes. As health professionals we have to compete with the messages from ‘healthy’ juice bars where sugar is added to sweet fruit and sold to the public as a better choice than a Mcdonald’s smoothie. Supermarkets sell cereal bars as a healthy snack even though most are loaded in sugar and salt. But all of these pales compared to the gluten-free fad. It is reported that 90 million Americans now follow a gluten-free diet because they believe (despite the lack of research evidence) that it is healthier, or as a weight loss strategy or in some cases to treat extra-gastrointestinal symptoms like a ‘foggy mind’.

Unpacking these beliefs in the course of a routine consultation in primary care is challenging. The belief has to be volunteered and the context understood. The associated behaviours have to be outlined and if there are sufficient grounds challenged without engendering the impression that the health professional does not accept the person’s right to make a choice, even when that choice is dubious or could even be harmful. People have the right to follow a gluten free or lactose free diet whatever their reasons. They have a right to drink too much alcohol and or to smoke cigarettes. However for many such people the consequences may include chronic morbidity and a shorter life expectancy. It is therefore incumbent on health professionals to communicate effectively with those who seek help. This may include demonstrating the outcomes in a creative way. The task is to help people to decide what outcomes they would prefer. However in the first instance we have to understand the ‘why’ as well as the ‘what’ of the decisions they make. That means creating the conditions in which people will feel inclined to share. That only happens when they believe that their perspective as well as their right to choose matter to you.

Picture by Will Temple

Funding creativity

The organisations or institutions most able to fund and promote creative solutions have the resources but it is unusual for them to embrace novel ideas. Perhaps because they are accountable to stakeholders, risk averse and have rigid governance structures enforced by people with no stake in the outcome, rewarded instead for enforcing process. Decisions taken by such organisations are vulnerable to influence. Here are ten ways competitors stem funding for novel ideas:

1. Nominate: Get nominated as a grant reviewer on a funding committee on the basis of ‘expertise’ in their field.
2. Spook: Express concern that the applicants don’t seem to be aware of other funded projects on the same topic. Committees are easily spooked by the idea that applicants might be generating ideas that compete with something that has already been funded. The details don’t matter as long as whatever the committee ‘expert’ cites sounds like it might be relevant.
3. Foster doubt: Express concern that in their ‘expert’ opinion the project won’t succeed especially if the applicant could be accused of being unfamiliar with the context in which they intend to operate. Committees will be relying on their member’s special ‘expertise’ and are unlikely to disagree.
4. Cast aspersions: Note that the applicants don’t have the relevant expertise. It needs some imagination but always possible. No one is accomplished in every facet.
5. Magnify: Make much of reports that the pilot studies were inconclusive and by corollary risky. Novel ideas usually are. If the pilot studies showed promising results they make the remark that further research of this untested, risky idea is therefore probably unnecessary.
6. Argue: Present arguments why the budget requested is too high- in the current economic climate there is always room for economy. If the grant is approved having the budget slashed should slow competitors down.
7. Impugn: Comment that the chief investigator doesn’t have a strong enough track record to deliver on this project. Innovators doing something new are unlikely to have done anything exactly like this before. It spooks committees who might worry about any possibility that the money will be wasted. Sexism and racism, when it is subtle makes this easier.
8. Choose: Find another project on the list, led by someone who isn’t a threat, that is ‘so much better’ and of course less risky and would make a ‘big’ difference in practice. Committees would be happy to hear that the subject expert thinks they’d be funding something that would be so much more likely to meet a need.
9. Gossip: Express concern that even though they don’t ‘know’ the applicants personally, they’ve heard rumours that the applicants don’t produce good work. The doubts should generate enough anxiety to make some reviewers rethink their enthusiasm for a project.
10. Ambush: If such attempts at heading off the applicants at the pass fails and the committee funds the project- there’s always a chance for a competitor to stop them publishing their results later on. There’s lots of scope to recommend rejection of any paper- inadequate literature reviews, debated methodology, concerns about sample size, participant attrition, conflicting ideas about analysis of the data, failure to acknowledge the limitations of the methods. If all else fails someone can always find typographical and formatting errors that cast doubt on the whole manuscript- after all there is ‘lots of competition for space’ and the best journals receive ‘so many more papers than they can publish’.

On the other side of the fence if you are a determined innovator there is an opportunity buried here. On whom does your future depend if not on yourself? How do you innovate in a world that is viewed by some as being so small that if you have even a little then they don’t have enough? How are you being so resourceful that this doesn’t matter? A lean medicine approach is not about big projects nor reliant on big grants. Lean medicine is fuelled by the imagination and resourcefulness of champions.

You don’t need permission to begin innovating

imageLast weekend I spent four hours in the air sitting bolt upright crammed next to a fidget on a budget airline. The plane was full of sunburnt youngsters flying back from Bali. Years from now they’ll turn up at the doctors convinced that a mole has changed. Sadly malignant melanoma is the commonest malignancy in this part of the world.

Maybe much sooner they’ll be worried that the insect bite on their shoulders is infected. Spots, sores, moles if I had a cent every time someone wanted reassurance about one of those I’d be doing well. I’m sure many of my colleagues would agree that it would be great to have a reliable way to keep an eye on skin lesions that change when the doctor isn’t there to inspect them. It’s also hard to look between your shoulder blades. On the other hand the doctor in me wouldn’t want you to use your phone to make a diagnosis, it has been shown that technology can’t do better than a doctor with a good eye. Nonetheless we need something to track changes in our skin, to alert us if things aren’t looking the same. It would also we helpful to have a record of lesion changes to show when we turn up at the clinic.

Taking photos on a smart phone might help but tracking symptoms and measuring changes in the appearance of something that might need to be removed is a good idea. iMockApp is a free app that enables anyone to create wireframes. I used it on my iPad mini (on that flight from Bali) to develop the idea for an app that could monitor skin lesions. Of course it would need a lot more work before it was made available to the public, but it was a start and spending time on the idea stopped me reaching across to strangle my fellow passenger who had just managed to punch me, accidentally I think, in the side.

The point is that as an innovator you are rarely without the tools to create—diaries, iPads, laptops, note books, napkins, pens, pencils, whatever. You don’t need a whiteboard, a ‘team’, a budget, grant or a mandate from the ‘boss’ to create something new. The world appears divided into two simple typologies- creators and consumers. Will you wait for someone to give you the permission to innovate, or have you taken out pen and paper and begun sketching your design already?