Tag Archives: personalised care

Designers will rescue the health sector

Much of what we do in healthcare is communicate ideas. That is far more common than ‘doing’. Executive control over decisions are the purview of the patient. It is a basic tenant of medicine that the patient has autonomy.

Often armed with little more than a stethoscope doctors must communicate to the patient that:

When communication about the evidence base is effective the patient, the practitioner and ultimately the economy benefit. How we communicate such ideas is where innovation has the brightest future. It gives us hope that we can improve outcomes in health without recourse to major policy change or curbing freedom of choice.

We communicate in words, pictures, video, audio and using models. Yet so much of how that is done in the doctor’s office hasn’t changed over the decades. ‘It’s just a virus’ doesn’t cut it any more.

We experience the power of effective communication everyday and in every other area of our lives. Look at your credit card statement this month- does it all make sense? What pressed your ‘purchase‘ button?

What if this extraordinary power deployed so effectively in commerce was unleashed in the clinic?

Picture by Dan Moyle

For best results engage the entire decision making apparatus

I’ve been sick for two days. I have a runny nose, headache, cough and I’m tired.

We agreed that it was very unpleasant having these symptoms when you are moving boxes around a warehouse all day. I examined him and found signs of an upper respiratory tract infection but nothing worse. Now comes the crucial part. If you are a doctor what do you say in the circumstances? You must have your speech ready because you will almost certainly consult someone like this every day, probably more than once a day. In an essay published in the BMJ Trisha Greenhalgh and colleagues wrote:

Evidence users include clinicians and patients of varying statistical literacy, many of whom have limited time or inclination for the small print. Different approaches such as brief, plain language summaries for the non-expert (as offered by NICE), visualisations, infographics, option grids, and other decision aids should be routinely offered and widely used. Yet currently, only a fraction of the available evidence is presented in usable form, and few clinicians are aware that such usable shared decision aids exist. BMJ 2014

What she appears to be hinting at is that words are not enough and may not efficiently convey what this man needs to make a decision for himself. He has already decided for whatever reason that he needs to see a doctor. He was probably able to ‘self-care’ by taking ‘over the counter’ symptomatic measures. Setting aside the notion that he might have presented to get a medical certificate to claim time off what else may be on his agenda? If we postulate that he might want prescribed medicines believing that they will hasten this recovery then there is the prospect of a disagreement with you as the ‘evidence’ suggests otherwise. He probably has a viral illness. But as David Spiegelhalter and colleagues wrote in Science:

Probabilities can be described fluidly with words, using language that appeals to people’s intuition and emotions. But the attractive ambiguity of language becomes a failing when we wish to convey precise information, because words such as “doubtful,” “probable,” and “likely” are inconsistently interpreted. Science 2011

What the person with the cold needs to know is that we cannot be sure what precise ‘bug’ has caused his symptoms. That the most likely cause is a virus but that his symptoms now do not predict the duration or severity of his illness. However most people get better within 10 days and he is probably suffering the most he will through this illness today. The worst symptoms are those he now describes. the cough may linger for a couple weeks.  Symptomatic treatment might help him feel better and that people who have been prescribed antibiotics do not get better any faster (that last bit is my team’s research which hasn’t yet seen the light of day in a peer-reviewed journal). However he may not factor all of this information into his thinking without pictures. We need to consider how he makes the decision to take your advice. Scientists have studied this and come up with some helpful advice recently. For a start the patient is unlikely to make a decision based on logic alone.

Behavioral economic studies involving limited numbers of choices have provided key insights into neural decision-making mechanisms. By contrast, animals’ foraging choices arise in the context of sequences of encounters with prey or food. On each encounter, the animal chooses whether to engage or, if the environment is sufficiently rich, to search elsewhere. Kolling et al

There are three treatment options; prescribe an antibiotic now, defer prescribing for a couple days or prescribe nothing. The latter is the appropriate course however a goal in this situation is to reach consensus with this person. To present the data to him in a way that engages his entire decision making apparatus. You are able to usher him out the door without anything only to find that he has lost faith in you. How he feels about the matter is critical:

A few years ago, neuroscientist Antonio Damasio made a groundbreaking discovery. He studied people with damage in the part of the brain where emotions are generated. He found that they seemed normal, except that they were not able to feel emotions. But they all had something peculiar in common: they couldn’t make decisions. The big think

The more challenging approach is to communicate respectfully, appropriately and effectively. Pictures can now assist as never before. Yet the habit of using pictures is neither taught nor practised consistently in clinics. Spiegelhalter again:

   The most suitable choice of visualization to illustrate uncertainty depends closely on the objectives of the presenter, the context of the communication, and the audience. Visschers et al. concluded that the “task at hand may determine which graph is most appropriate to present probability information” and it is “not possible to formulate recommendations about graph types and layouts.” Nonetheless, if we aim to encourage understanding rather than to just persuade, certain broad conclusions can be drawn, which hold regardless of the audience.

His team’s recommendations:

  • Use multiple formats, because no single representation suits all members of an audience.
    Illuminate graphics with words and numbers.
  • Design graphics to allow part-to-whole comparisons, and choose an appropriate scale, possibly with magnification for small probabilities.
  • To avoid framing bias, provide percentages or frequencies both with and without the outcome, using frequencies with a clearly defined denominator of constant size.
  • Helpful narrative labels are important. Compare magnitudes through tick marks, and clearly label comparators and differences.
  • Use narratives, images, and metaphors that are sufficiently vivid to gain and retain attention, but which do not arouse undue emotion. It is important to be aware of affective responses.
  • Assume low numeracy of a general public audience and adopt a less-is-more approach by reducing the need for inferences, making clear and explicit comparisons, and providing optional additional detail.
    Interactivity and animations provide opportunities for adapting graphics to user needs and capabilities.
  • Acknowledge the limitations of the information conveyed in its quality and relevance. The visualization may communicate only a restricted part of a whole picture.
  • Avoid chart junk, such as three-dimensional bar charts, and obvious manipulation through misleading use of area to represent magnitude.
  • Most important, assess the needs of the audience, experiment, and test and iterate toward a final design.

The last offers a call to arms for innovators.

Picture by Alan

Am I going to be like this forever doctor?

There is an opportunity in nearly every medical interaction to make a substantial difference to the outcome by reassuring. What nearly every patient wants to know is:

How long will this horrible feeling last?

We can be reassuring in the various ways in which we conduct ourselves in healthcare. On the stage, with the props, in the persona we adopt, in the dialogue and in the action. All of it matters. Much of what appears on this blog speaks to these aspects of the consult.

People attend doctors for one main reason. They are worried. It doesn’t matter whether the cause is a minor self-limiting illness or a life-limiting cancer. Symptoms ultimately drive us to the medicine man. Here are the results of a study entitled ‘Why Patients Visit Their Doctors’:

We included a total of 142,377 patients, 75,512 (53%) of whom were female. Skin disorders (42.7%), osteoarthritis and joint disorders (33.6%), back problems (23.9%), disorders of lipid metabolism (22.4%), and upper respiratory tract disease (22.1%, excluding asthma) were the most prevalent disease groups in this population. Ten of the 15 most prevalent disease groups were more common in women in almost all age groups, whereas disorders of lipid metabolism, hypertension, and diabetes were more common in men. Additionally, the prevalence of 7 of the 10 most common groups increased with advancing age. Prevalence also varied across ethnic groups (whites, blacks, and Asians). St. Sauver et al

For each of these conditions it is possible to prepare a response that will reassure the person that things will improve.  It is interesting to read the lay commentary on the data:

What’s funny is that while skin disease is the most common reason for doctor visits in America, it’s usually the least detrimental to overall health……Pretty much everybody (and I mean everybody) has experienced a cold before. You know the symptoms; runny nose; coughing; sore throat; congestion. Due to the high volume of people who get colds every year (most people get multiple colds per year), it’s no surprise that some of those people will see the doctor about it. Therichest

And the implications of this commentary is that the response to patient is a ‘set-play’. Doctors and healthcare organisations can prepare to host a visit from most people who present for help. If you are a doctor what is your interaction like with someone with acne or eczema? How do you respond when this is the reason for attendance is a cold? What do you do? What do you say? Is that reassuring? How do you know? For most if not all these problems much of the treatment includes prescribing ‘tincture of time’ essentially that means reassuring the patient that they will not suffer forever.

There is evidence that such an attitude reduces the impact of the illness:

Clinician empathy, as perceived by patients with the common cold, significantly predicts subsequent duration and severity of illness and is associated with immune system changes. Rakel et al

Picture by Christophe Laurent

Your words are potent medicine


A principle of medical ethics is beneficence:

A moral obligation to act for the benefit of others. Not all acts of beneficence are obligatory, but a principle of beneficence asserts an obligation to help others further their interests. Obligations to confer benefits, to prevent and remove harms, and to weigh and balance the possible goods against the costs and possible harms of an action are central to bioethics. Med Dictionary

In saying that the business of medicine is not so different from many other forms of commerce where someone might offer a solution to what appears to be a problem. What we have learned from studying human interactions is that what is said, how and when it is said has a crucial impact on what the person with the problem decides to do. In medical research the hopes of improving outcomes sometimes seem to focus on labs manned by people in white coats funded by a research grant. What is often overlooked is that it may be possible to change outcomes in healthcare (for better or for worse) by working on the dialogue in the consulting room. What in previous posts I have dubbed the ‘script’ in the ritual that is the consultation.

Beneficence dictates that we act to present the autonomous individual with options in a way that leads them to act in their best interests. That may include having the operation, taking the pills, accepting the referral or the test. But also steering away from  those options if they are not in their best interests. The art of communication received a boost in Robert Cialdini’s book Pre-Suasion. Cialdini catalogues the research on the subtle ways in which we are triggered to make choices from the options on offer. It is hard to summarise this extraordinary book but there are at least four essential lessons:

  1. There are ‘Privileged Moments’.  ‘Influence practitioners’ should target such moments before the interaction to greatly increase their effectiveness. It is possible to speculate what these might be for patients: pregnancy, diagnosis of a significant illness, receipt of worrying test results, significant birthday etc.
  2. During verbal exchanges leading questions try to get you to respond with certain answers and influence your later decisions. For example: “Given the recent cases of death from influenza, how dangerous do you perceive the threat of flu to be?” The way the question is posed is loaded with pre-suasion. By reminding you of these deaths the questioner draws attention to the recency of the topic, and thus the patient will evaluate the danger as high and be primed to accept the offer of vaccination.
  3. Whatever grabs our attention, we think is relevant. As Cialdini says:

All mental activity is composed of patterns of associations; and influence attempts , including pre-suasive ones , will be successful only to the extent that the associations they trigger are favourable to change.

In other words in any situation, people are dramatically more likely to pay attention to and be influenced by stimuli that fit the goal they have for that situation. In medicine being presented with information that suggests that someone might be ‘at risk’ of an illness might lead them to act to reduce the risk. However also in this context the heightened anxiety due to fear messages against for example smoking causes people to be delusional in order to dampen the anxiety effect. We also know that the public has a very poor understanding of numbers. In a study of laypersons published in Health Expectations it was concluded that:

Most participants thought of risk not as a neutral statistical concept, but as signifying danger and emotional threat, and viewed cancer risk in terms of concrete risk factors rather than mathematical probabilities. Participants had difficulty acknowledging uncertainty implicit to the concept of risk, and judging the numerical significance of individualized risk estimates. Han et al

Cialdini offers another insight:

The communicator who can fasten an audience’s focus onto the favourable elements of an argument raises the chance that the argument will go unchallenged by opposing points of view, which get locked out of the attentional environment as a consequence.

It isn’t just the facts but how the facts are presented. There are ways in which to engage if not by pass the logic. The three ‘commanders’ of attention that are highly effective are: the sexual, the threatening and the different. When an issue is presented in the context of these considerations their impact is boosted significantly.

    4. Our word choices matter a lot more than we think, because words get us to do things. The main function of language is not merely to  express or describe, but to influence. Something it does by channeling recipients to sectors of reality preloaded with a set of mental association favorable to the communicators view. Doctors may want to illuminate connections to negative associations and increase connections to positive associations. People also prefer things, people, products, and companies that have an association with themselves. This again emphasizes the vital importance of knowing what matters to the person whom you may wish to influence.

Finally and in medicine very significantly Cialdini draws our attention to the following:

Those that use the pre-suasive approach must decide what to present immediately before their message. But they must also have to make an even earlier decision: whether, on ethical grounds, to employ such an approach.

Every day patients consult doctors. Words are use. These words are designed to influence choices. In medicine the options presented may not take into account factors that the patient may not have disclosed and therefore the choice on offer may not be in their best interests. Nor do those choices take account of the practitioner’s own limitations in evaluating the choices offered. Therefore the first and most important aspect of communicating persuasively is to listen. As Cialdini suggests first determine identifiable points in time when an individual is particularly receptive to a communicator’s message.

Picture by Andreas Bloch

For a medical test to be of value the patient needs to see a doctor

Among the commonest tests ordered by doctors is a full blood count. The test presents signs of iron deficiency anaemia. The prevalence of that condition is reported as follows:

In Australia in 2011–12, around 760,000 people aged 18 years and over (4.5%) were at risk of anaemia, with women more likely to be at risk than men (6.4% compared with 2.5%). The risk of anaemia was highest among older Australians, with rates rapidly increasing after the age of 65 years. People aged 75 years and older were more likely to be at risk of anaemia than all other Australians, with 16.0% in the at risk range compared with 3.6% of Australians aged less than 75 years. Australian Health Survey

With regard to this blood test (AACC):

  • Haemoglobin (Hb)—may be normal early in the disease but will decrease as anaemia worsens
  • Red blood cell indices—early on, the RBCs may be a normal size and colour (normocytic, normochromic) but as the anaemia progresses, the RBCs become smaller (microcytic) and paler (hypochromic) than normal.
    • Average size of RBCs (mean corpuscular volume, MCV)—decreased
    • Average amount of haemoglobin in RBCs (mean corpuscular haemoglobin, MCH)—decreased
    • Haemoglobin concentration (mean corpuscular haemoglobin concentration, MCHC)—decreased
    • Increased variation in the size of RBCs (red cell distribution width, RDW)
    • A guide to interpreting the test is here

Therefore among the pathognomonic features of established iron deficiency anaemia (IDA) is a low Mean Corpuscular Volume (MCV). The sensitivity and specificity of a low MCV for a diagnosis of iron deficiency anaemia are quoted as  42% and 93%. Assuming a prevalence of 3.6% in the under 75 year old age group this means that if 100 adults in Australia had a full blood count then 3-4 will have iron deficiency anaemia. Screening these people for IDA with this test 8.3% of people will be told they have an abnormal test i.e. 8 people. Of these only 1-2 will be a true positive for IDA. On the other hand 6-7 may be misled into thinking they might have iron deficiency. 91 will be told they have a normal test in this case 2 may be incorrectly reassured. Of course there are other significant conditions which present with a microcytosis ( low MCV) although ‘treatment’ is not necessary in many such cases and also screening for IDA involves other and more sensitive tests.

If the prevalence of the condition was 20%, then even the modest sensitivity and specificity of this test would identify more people at risk of IDA even though it will also miss people with the condition.

  • Number of people with positive test: 14, correctly identified: 8
  • Number of people with negative result: 86, incorrectly reassured: 11

In practice the sensitivity and specificity of tests may be assumed closer to 90% in each case. Given these figures the numbers of people from 100 people test and correctly identified, incorrectly reassured or told they are ill depends on the prevalence. The prevalence of most pathology in the community is low often well below 1%. The figures are presented in the infographic below.

Prevalence 0.005% ( 5 per 1000 people, e.g. hypothyroidism )  2% ( e.g. diabetes)  20% (e.g. common and plantar warts).

From these figures it can be seen that testing is more fruitful in circumstances in which the prevalence is high. The prevalence is higher in those who have signs and symptoms of a condition. One could argue therefore that the ‘prevalence’ is much higher in those who choose to consult a doctor as opposed to the ‘prevalence’ in the community.  For iron deficiency anaemia these circumstances are well known. Which means an effective consultation in which the patient is heard and examined is crucial to interpreting test results. As can be seen from the calculations there is a substantial risk of labelling people as ill, or requiring yet more tests given the modest prevalence of most conditions in the community and where there might be an indiscriminate use of tests.

It is hard to disagree with Campbell and colleagues who considered this issue and noted that:

1) Diagnosis is based on a combination of tests and clinical examination and there is little research based on the sensitivity and specificity of the combination of different examinations as opposed to a one-off test, which is why GPs are unlikely to know the values.

2) It is unclear what is meant by the prevalence of asthma or diabetes for these GPs. It is not the proportion of people in the population with the disease, but rather the proportion of people who come to consult who have the disease (perhaps with similar age and clinical history). This proportion is likely to be quite high and so the issue of overestimating the positive predictive value is less important.

3) The prevalence of the disease will also depend on the severity of the disease being tested for and so this also muddles the calculations.

We might however equally reasonably expect doctors to have an understanding of the issue if only because the practice of medicine involves the most crucial of ‘tests’ the history and the examination and this issue highlights the importance of that activity. Tests that are not appropriately interpreted can be harmful if only because they become a source of anxiety.

Picture by Aplonid

Small changes big impact in healthcare

According to the Royal College of General Practitioners, UK:

The consultation is at the heart of general practice… As a general practitioner, if you lack a clear understanding of what the consultation is, and how the successful consultation is achieved, you will fail your patients. RCGP

The impact of the consultation varies because of the different perspectives between doctors and their patients:

…. in the consultation the patient is most commonly construed as a purely “biomedical” entity—that is, a person with disconnected bodily symptoms, wanting a label for what is wrong and a prescription to put it right. Even under this guise the patient still sometimes fails to report their full biomedical agenda. Not all symptoms were reported and not all desires for a prescription were voiced. Barry et al BMJ

Much of what transpires in the consult is a ritual. Over the course of a professional lifetime most doctors will greet the patient in the same way, say the same sort of thing, prescribe similar drugs and order the same sorts of tests.  This occurs for a variety of reasons perhaps because a doctor learns to present herself and behave in a specific way but also because the doctor’s training and experience has a significant impact on their clinical practice. There is ample evidence that how doctors interact with their patients is crucial to the outcome of the consultation and ultimately to outcomes in healthcare:

An increasing body of work over the last 20 years has demonstrated the relationship between doctors’ non-verbal communication (in the form of eye-contact, head nods and gestures, position and tone of voice) with the following outcomes: patient satisfaction, patient understanding, physician detection of emotional distress, and physician malpractice claim history. Although more work needs to be done, there is now significant evidence that doctors need to pay considerable attention to their own non-verbal behavior. Silverman BJGP 2010

With this in mind, if you are a doctor you may want to consider seven components of your interaction with patients that warrant occasional re-evaluation:

Image attribution

What is the role of doctors in health promotion?

Our health is a cause for concern.

  • Over 1 in 5 Australians aged 18+ (22%) reported having Cardiovascular disease in 2011.
  • In 2009, the risk of being diagnosed with cancer before their 85th birthday was 1 in 2 for males and 1 in 3 for females.
  • 1 in 10 Australians aged 18+ (10%) had biomedical signs of chronic kidney disease in 2011–12, with the majority of these showing early signs of the disease.
  • 1 in 19 Australians (5.4%) had diabetes in 2011–12 (self–reported and measured data). This is includes approximately 1% of the population who did not self-report they had diabetes, which may indicate they were unaware they had the condition.
  • In 2007, 1 in 5 Australians aged 16–85 (20%) experienced a mental disorder in the previous 12 months.
    In 2013–14, 1 in 7 children aged 4–17 (14%) were assessed as having mental health disorders in the previous 12 months .
  • Over 1 in 4 Australians (28%) reported having arthritis and other musculoskeletal conditions in 2011–12. The most prevalent conditions were back problems, osteoarthritis, osteoporosis and rheumatoid arthritis.
  • 3 in 10 Australians aged 25–44 had untreated tooth decay in 2004–06.
  • 1 in 10 Australians (10%) reported having asthma in 2011–12. This rate is significantly lower than the rate of 11.6% in 2001.
    1 in 42 Australians (2.4%) reported having COPD in 2011–12. The development of COPD occurs over many years and mainly affects middle aged and older people.

It seems:

  • We eat too much. Almost 2 in 3 Australian adults (63%) are overweight or obese. 1 in 4 Australian children (25%) are overweight or obese.
  • We don’t take enough exercise. Based on estimates that between 60 and 70 per cent of the Australian population is sedentary, or has low levels of physical activity, it has been suggested that increasing participation in physical activity by 10 per cent would lead to opportunity cost savings of $258 million, with 37 per cent of savings arising in the health sector.
  • We drink too much alcohol and have been drinking more every year.
  • We don’t eat enough vegetables. In 2007–08, just over half of all children aged 5–7 years (57%) and a third of children aged 8–11 years (32%) ate the recommended amount of fruit and vegetables but only 5% of people aged 12–18 years and 6% of people 19 years and over did so.
  • Too few of us avail of cancer screening tests.
  • We drive too fast. Speeding is a factor in about one third of road fatalities in Australia. Additionally, more than 4100 people are injured in speed-related incidents each year.

Someone must be to blame for all this- if only they would do their job and tell us to eat and drink less, exercise more and slow down.  But wait there are industries profiting from our bad choices. We are influenced by more than our doctor. We have known this for decades. It is known as the Bronfenbrenner’s Ecological Model:

Hchokr

At the core of Bronfenbrenner’s ecological model is the child’s biological and psychological makeup, based on individual and genetic developmental history. This makeup continues to be affected and modified by the child’s immediate physical and social environment (microsystem) as well as interactions among the systems within the environment (mesosystems). Other broader social, political and economic conditions (exosystem) influence the structure and availability of microsystems and the manner in which they affect the child. Finally, social, political, and economic conditions are themselves influenced by the general beliefs and attitudes (macrosystems) shared by members of the society. Wikipedia

Most Australians (13 Million) spend over 18 hours a day online. One in every five minutes (3.6 hours) a day is spent on social media. On the other hand time spent with general practitioners (GPs) is declining:

The proportion of GPs providing ‘Level C’ consultations (longer than 20 minutes) is substantial (96%) and constant; however, the number of long consultations provided per GP decreased by 21% between 2006 and 2010. The proportion of GPs providing Level D consultations (longer than 40 minutes) decreased from 72% in 2006 to 62% in 2009, while the number of Level D consultations provided per GP decreased by 26%. AHHA

Secondly the number of problems presented to doctors in increasing. In one survey of the 8707 patients sampled from 290 GPs, approximately half (47.4%, 95% CI: 45.2–49.6) had two or more chronic conditions.

Junk food is cheap and readily available. It is advertised to children. Fresh fruit and vegetables are less available, more expensive and of poorer quality in rural and remote Australia. These areas are also among our most economically disadvantaged and residents generally have less disposable income to spend on expensive, healthier food options. According to one report a multinational fast food company paid $500 million in taxes to the Australian government and might be due to pay more.

A 2017 poll  found that most Australians (78 per cent) believe Australia has a drinking problem, 74 per cent believe our drinking habits will worsen over the next five to ten years, and a growing majority (81 per cent) think more should be done to reduce alcohol harm. A price increase of 10%  on alcohol has been shown to reduce consumption by an average of 5%. Similarly for every 10% increase in price, consumption of tobacco reduces by about 4%. Finally a significant proportion of people are unhappy at work and this has been associated with snacking and weight gain.

So it seems that we are choices are triggered by far more than a doctor informing us that we are making bad choices. Doctors can make a huge difference to the individual who seeks advice in a teachable moment and can be triggered to make better choices. This requires more time with the patient and a greater focus on the needs of that individual patient rather than the distraction of a public health agenda.  At a public health level doctors’ impact is miniscule because of the much more powerful and ubiquitous drivers of poor choices that are fueled by those who profit from our dubious behaviour. A summary:

Image attribution

Why our jobs are making us fat

We spend most of our time at work.

  • Expressed as terms of a percentage of your life, this 39.2 hours a week spent working is equivalent to:
  • 14% of your total times over the course of a 76 year period (based on the average projected life expectancy of 76 for people born in the year 2000 according to the ONS’s National Life Tables for the United Kingdom.)
  • 23.3% of your total time during the course of a 50 year working-life period
  • 21% of your total waking hours over a 76 year lifespan, assuming 8 hours of sleep a night.
  • 35% of your total waking hours over a 50 year working-life period assuming 8 hours of sleep a night
  • 50% of your total waking hours during any given working day. ReviseSociology

This is a significant chunk of our lives. Yet we note that many people are disengaged at work.

Gallup

This is a problem because being disengaged at work is also associated with other behaviours that are problematic. Faragher and colleagues reported in the BMJ:

A systematic review and meta-analysis of 485 studies with a combined sample size of 267 995 individuals was conducted, evaluating the research evidence linking self-report measures of job satisfaction to measures of physical and mental wellbeing. The overall correlation combined across all health measures was r = 0.312 (0.370 after Schmidt-Hunter adjustment). Job satisfaction was most strongly associated with mental/psychological problems; strongest relationships were found for burnout (corrected r = 0.478), self-esteem(r = 0.429), depression (r = 0.428), and anxiety(r = 0.420). The correlation with subjective physical illness was more modest (r = 0.287).

There is increasing evidence for an association between job dissatisfaction and the most significant health challenge we face in the next decade- namely obesity. A survey of nurses in Ohio concluded that:

..disordered eating differed significantly based on perceived job stress and perceived body satisfaction. Nurses with high levels of perceived job stress and low levels of body satisfaction had higher disordered eating involvement. King et al

A more recent paper in BMC obesity reported that obesity rates varied across industries and between races employed in different industries:

Obesity trends varied substantially overall as well as within and between race-gender groups across employment industries. These findings demonstrate the need for further investigation of racial and sociocultural disparities in the work-obesity relationship to employ strategies designed to address these disparities while improving health among all US workers. Jackson et al

Lui and colleagues suggest a possible explanation:

Study 1 sampled 125 participants from 5 Chinese information technology companies and showed that when participants experienced higher levels of job demands in the morning, they consumed more types of unhealthy food and fewer types of healthy food in the evening. In addition, sleep quality from the previous night buffered the effect of morning job demands on evening unhealthy food consumption. Study 2 used data from 110 customer service employees from a Chinese telecommunications company and further demonstrated a positive association between morning customer mistreatment and evening overeating behaviors, as well as the buffering effect of sleep quality. J Appl Psychol

Possibly a very useful question we can ask people seeking medical advice with weight management: ‘ What do you do for a living and how do you feel about it?’. It may be that they are eating their feelings. Review what people are eating at their desk or during breaks. Snacks have become the fourth meal of the day — accounting for 580 extra calories per day, most of which come from beverages — and may be a primary contributor to our expanding waistlines. Here’s why employees become disengaged at work. A summary:

Image attribution

A cough is not minor in any sense

 

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

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

On the other hand:

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

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

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

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

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

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

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

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

Picture by Rebecca Brown

Why when you are sick don’t you do what you can to help yourself?

At 68 Frank has been prescribed the usual mix of medications: three different drugs for blood pressure, a statin and two different pain killers. His problems, as he lists them are fatigue, snoring and back pain. From his doctor’s perspective, the problems are obesity, a dreadful diet, and sedentary lifestyle.

OK doc, but I think I need a referral for my snoring.

Two weeks ago he wanted a different pain killer and the week before that he wanted to be referred to a physiotherapist. The major challenge in helping people who are struggling with chronic disease is persuading them that they have the wherewithal to slow or possibly cease the march towards disability. It seems incredible that someone who cannot walk to the end of the street without stopping for breath several times cannot see any reason to stop eating junk food and sugary drinks while watching telly from 6 pm until two in the morning. Bad habits will drive choices even when people are aware of their growing disabilities. There may be many reasons for this but one that may be worth considering is boredom.

Our culture’s obsession with external sources of entertainment—TV, movies, the Internet, video games—may also play a role in increasing boredom. “I think there is something about our modern experience of sensory overload where there is not the chance and ability to figure out what your interests, what your passions are,” says John Eastwood, a clinical psychologist at York University in Toronto. Anna Gosline.

What is challenging is that some people who have already developed a life-limiting illness cannot be ‘educated’ to make different choices while they don’t admit even to themselves how and why they are contributing to their own demise. If healthcare is to actively promote well-being we need to find ways to help people identify when they are bored and not just focus on the consequences including atheromatous vascular disease. The role of doctors needs to include tackling harmful habits and not limited to therapeutics.

Picture by Craig Sunter