Tag Archives: physician

The welcome rise of alternative providers

Two weeks ago an 80-year-old waited without food or drink for 14 hours in a Dublin city emergency department having fallen in her local supermarket. She was black and blue from head to toe a response to the call of gravity when she was launched off a faulty escalator. She was ‘triaged’ and seated next to drunken revelers who also managed to injure themselves on that fateful evening. She was seen for all of 10 minutes by a medical student and then briefly by a doctor who recorded that her visual acuity couldn’t be assessed because she didn’t have her glasses. With that, she was sent home with her granddaughter and asked to return a couple of days later when she again waited another 9 hours for a five-minute consultation presumably so that the doctor could make sure she hadn’t really injured herself and wasn’t going to sue the hospital as well as the supermarket.  I know this person and read the discharge summary even though her daughter and I live on the other side of the world. As far as we know the provider believes we should be thankful because they are very busy and at least ‘someone’ saw her.

What’s it like to be your patient?

  1. How long do your patients wait?
  2. How are they greeted on arrival and how do they feel about waiting?
  3. What do they do while they wait?
  4. How long do they see you on average?
  5. What do they expect from the visit?
  6. Why do you order tests? What difference do these tests make to the outcome?
  7. Why do you prescribe those drugs? How many people take them as prescribed?
  8. Why do you ask them to return for a review appointment?
  9. Why do your refer them to someone else?
  10. What do they tell their family about your service?

No business would survive without a handle on this information. Arguably some sectors of the business of healthcare only survive because of a monopoly.

A newer take on the organizational environment is the “Red Queen” theory, which highlights the relative nature of progress. The theory is borrowed from ecology’s Red Queen hypothesis that successful adaptation in one species is tantamount to a worsening environment for others, which must adapt in turn to cope with the new conditions. The theory’s name is inspired by the character in Lewis Carroll’s Through the Looking Glass who seems to be running but is staying on the same spot. In a 1996 paper, William Barnett describes Red Queen competition among organizations as a process of mutual learning. A company is forced by direct competition to improve its performance, in turn increasing the pressure on its rivals, thus creating a virtuous circle of learning and competition. Stanford Business

Certainly, the 80-year-old had no option but to go to a state hospital emergency department because there was a very real possibility that she had fractured something coming off that escalator. The hospital manager might say in her defense that they have no option but to offer the service as described, but where is the data to demonstrate that it is the lack of options rather than a lack of interest or talent in managing one of the most important services the state is charged by taxpayers to provide? The monopoly may be around a little longer when it comes to life-saving treatments but what about primary care? If this 80-year-old can wait 14 hours to be seen by a medical student there may be real scope for the service to be provided by someone who is qualified, will see her much sooner and offer her a cup of tea while she waits for the X-rays to be reported. What about the scope to provide better than what you offer?

Picture by Toms Baugis

Cases too complex for a specialism other than general practice

It was a Friday evening. It’s almost always a Friday when this sort of case presents. She was in most ways unremarkable. She smiled readily, wasn’t evidently confused and worked in a senior administrative role. She came after work. This was the story:

I have a pain in my shoulder that becomes intense in my left arm pit. I can hardly bear to touch my arm pit. My hand becomes numb and cold. Today it’s so bad I’m finding it hard to turn the steering wheel.

I had 15 mins to sort this out, no scans, no blood tests, no discussion with a ‘team’ of young doctors working to pass their exams. She was describing symptoms that may have indicated a neurological emergency. And yet none of it made sense. She hadn’t fallen or been involved in any other trauma. There was no rash, no swelling. She swung her left arm over her head without any difficulty. I could not detect neurological signs, reflexes were normal. No Horner’s syndrome. No breast lesion. No obvious sensory loss. Twenty minutes later I could find nothing in her records or in her presentation that gave me any clue to the cause of these symptoms. And yet she was clearly worried. Regardless of the outcome I had to achieve one thing- this person like every other person who seeks help from a general practitioner needed to know that she had been taken seriously. Not for us the option of sending her back to whence she came with a note:

No organic pathology. Refer elsewhere.

A number of possibilities came to mind. Top of the list was ‘brachial plexus neuropathy‘ or Thoracic Outlet Syndrome. There were no objective signs at the time of presentation and I had never seen this before albeit that I had read about it sometime while at medical school. But then that’s primary care. We are the first port of call for anyone entering the healthcare system and often they present too early for anything to have manifested objectively. Not for us the text book presentation. About this diagnosis we know that:

Damage to the brachial plexus usually results from direct injury. Other common causes of damage to the brachial plexus include:

  • Birth trauma.
  • Injury from stretching.
  • Pressure from tumours.
  • Damage from radiation therapy.

Brachial plexus neuropathy may also be associated with:

  • Birth defects.
  • Exposure to toxins.
  • Inflammatory conditions.
  • Immune system issues.

There are also numerous cases in which no direct cause can be identified.

We also know that:

Signs and symptoms of thoracic outlet syndrome vary from patient to patient due to the location of nerve and/or vessel involvement. Symptoms range from mild pain and sensory changes to limb threatening complications in severe cases. Physiopedia

Diagnosis is difficult, tests and examination can be normalprognosis is variable. By the time a diagnosis was made weeks later and she presented to a specialist everything was obvious. But on that Friday evening with a surgery full of patients I was on my own. My patient trusted that I would not let her walk out of there only to lose a limb. Assuming a benign cause she would be back and need more. This was the start of a longterm relationship and how I managed this episode would set the tone for the duration.

While improvement may begin in one to two months, complete functional recovery may not be achieved for up to three years or longer in some cases. Tsairis et al

Picture by Mahree Modesto

Why healthcare outcomes are resistant to policy change

13799802965_b07db37bf2_zAfter every match, the cricket coach gives feedback about how the match was won or lost. Whenever the team wins it’s usually because of high scoring batting, or a great performance by the bowlers. However, when they lose there’s almost always one reason—poor fielding, dropped catches, easily conceded single runs and inaccurate throws.

In medicine surgeons are the batsmen, in most games they are seldom in play for very long. When the surgeon gets involved the crowd holds its breath for something magical to happen and when it does they celebrate with ‘Mexican wave’. Physicians are akin to bowlers, trying different deliveries, aiming to make it difficult to concede runs, patiently waiting for an unforced error. Occasionally screaming at the umpire for a decision in their favour. In the limelight an over at a time.

General practitioners are the fielders, rarely flamboyant and hard to tell apart. Constantly moving across the field, often to simply return the ball back into play. Standing for hours in the hot sun, occasionally chasing a ball to the boundary. Always trying to limit the damage. No matter how good the batting or the bowling is, if those in the field are not fully engaged, or solving problems creatively, if they are not intuitive, or working for the common good, without waiting for instruction after every ball is delivered then the game is lost.

As a primary care practitioner I am aware that most of the patients I see won’t have life-threatening pathology, but occasionally I’ll get a chance to make a game-changing difference, and on other days, my patients feel safer knowing that I am there. I don’t need to make any fancy moves, most of the time what I do is simply ensure that I nip things in the bud.

In medicine, most people consult a general practitioner and not a surgeon. That’s where innovation has the scope to make a difference to most people. Without reference to the practitioners who work at the coalface no amount of policy change is likely to make a difference to outcomes. That’s because fielders can’t do their job with one hand tied behind their back or by ignoring the evidence of their own eyes, or by focusing other than on the ball. According to the experts good fielders:

  1. Don’t move. When the captain puts them somewhere they stay there until they are moved again.
  2.  Show confidence. Looking confident in the field can save many runs.
  3.  Will throw at the stumps whenever there is a chance.
  4. Back up.
  5. Want to get every ball.
  6. Are close enough. If they are on the boundary their job is to save fours so they stay as deep as possible without giving away two runs if they can.
  7. Know themselves. If they have a setback in the field, they are aware of how they will react to it.

These simple rules tell us that it is imperative to work with the fielders if the team is to win the match. Failing to do so, like failing to work with the doctors most likely to come into contact with patients leads to frustration. The emotion that most funders experience perhaps because they do not understand the business of doctoring. We need to reframe problems in healthcare as a failure to engage with front line staff.

Picture by Lawrence OP

How improving the experience of hospital death can help redesign healthcare

 

The residents always approached my father as if he was a person and there weren’t any divisions between them. They didn’t come in and say, “I’m Doctor so and so.” There wasn’t any kind of separation or aloofness. They would sit right on his bed, hold his hand, talk about their families, his family, golf, and sports. From Steinhauser et al.

The chances are when the times comes you will die in hospital. It may be sudden or it may be expected and either you will die a good death or the experience for you and those who are left to grieve will make a bad situation worse. Charles Garfield put it like this:

A good death is no oxymoron. It’s within everyone’s realm of possibility. We need only realize its potential and prepare ourselves to meet it mindfully, with compassion and courage

John Costello concluded his research on patient experiences of death as follows:

The findings also challenge practitioners to focus attention on death as a process, and to prioritize patients’ needs above those of the organization. Moreover, there is the need for guidelines to be developed enabling patients to have a role in shaping events at the end of their lives. John Costello

Therefore, the needs of the ‘organisation’ may impact adversely on the experience of death. These might include the need to adhere to routines such as ward rounds, meal and medication time on open wards which may make it difficult to cater to the needs of the family when the patient dies.

A good place to start with innovation is to consider what, how and when things go wrong. Costello’s interviews with nurses identified several determinants of a bad death:

  • Sudden, unexpected or traumatic deaths especially soon after admission
  • Death other than on the ward
  • Family not aware of impending death or family conflict a major feature
  • Lack of dignity or respect
  • Diagnosis uncertain

Therefore, the key features are the circumstances surrounding the death. The consequences are far from trivial:

Dying patients with unresolved physical and psychological problems, such as pain, nausea, vomiting or spiritual distress, and who were unresponsive to treatment or nursing care, were invariably regarded as experiencing bad death. John Costello

This begs the question why not prepare for death in every hospital admission especially where death is a less than distant possibility. The majority of hospital deaths occur in those over 75 years of age. How is the team prepared if there is a death on the ward expected or otherwise, whether it’s convenient to the routines or not?

Achieving seven goals appear to mark a ‘good’ death:

  1. The patient should be physically, psycho-socially, and spiritually pain-free
  2. Recognize and resolve interpersonal conflicts.
  3. Satisfy any remaining wishes that are consistent with their present condition.
  4. Review their life to find meaning.
  5. Hand over control to a trusted person, someone committed to helping them have the kind of death they desire.
  6. Be protected from needless procedures that serve to only dehumanize and demean without much or any benefit.
  7. Decide how social and how alert they want to be.

Many of these goals are in the purview of the doctor and her prescription pad, others require all those involved to help prepare for an event that will impact on everyone associated with the patient. Healthcare is now a team effort and nowhere more than at the end of life.

When physical symptoms are properly palliated, patients and families may have the opportunity to address the critical psychosocial and spiritual issues they face at the end of life. Steinhauser et al

The point is if we prepare every hospitalised patient who may conceivably deteriorate and die as if we were preparing them and our units for that experience we will treat all patients with greater dignity. That’s the foundation of good outcomes for healthcare staff and the dying.

Picture by Alyssa L. Miller

What do you want from your doctor?

2247431698_f68ed874ed_z

Finding a good doctor is like finding a good lover: there are lots of anecdotes but no data Richard Smith

Our family has moved to an new city and we are looking for a family doctor. What would you look for if you knew a little about evidence based medicine? Would you want your doctor to have read the latest medical journals and could quote research evidence for every decision they make? New premises? New furniture? Free wifi? Short waiting times? A coffee machine? Text messaging? Internet booking? A PhD?

How do you choose a new dentist? A new hairdresser? Do you just walk in to the nearest premises and hope for the best? Do you ask your neighbours for a recommendation? Do you google the names you see in the phone book? The chances are you spend more time choosing a restaurant then you do choosing your doctor. And yet there is far more at stake other than a good meal or a hair cut.

For us in selecting a doctor nothing matters as much as the doctor’s interest in our family. Our new doctor may not have read this week’s medical journal but he or she will be curious about our family because they will want to understand the context of any symptoms . That isn’t simply limited to our medical history, allergies or genetic predisposition. It also means the fact that we have moved interstate, we have new jobs, renting for the first time in years and experiencing a number of other life events. They will take into account any support we might be receiving from friends or family and our satisfaction or otherwise with our decision to relocate.

If you feel the same way then you might agree that doctors, especially family physicians aka general practitioners, provide a relationship and not just a service. This is what we seek when we consult a doctor:

Their willingness to make eye contact, to listen actively, to pick up verbal and non-verbal cues, to be respectful  and unwavering in the opinion that our perspective on our bodies and its functioning is what matters the most. To our new doctor we will be free to make choices. They will see their role as adviser and advocate rather than enforcer of what’s best for us as determined by somebody else. The best doctors understand that they may not have all the information on which we make decisions but faithfully realise that we also want what they want i.e. what’s in our best interests.

I love this quote from Anatole Broyard:

What do I want in a doctor? I would say that I want one who is a close reader of illness and a good critic of medicine…I see no reason or need for my doctor to love me, nor would I expect him to suffer with me. I wouldn’t demand a lot of my doctor’s time, I just wish he would brood on my situation for perhaps five minutes, that he would give me his whole mind just once, be bonded with me for a brief space, survey my soul as well as my flesh, to get at my illness, for each man is ill in his own way.

We will choose our next doctor based on how we feel not what we think. Is that a good thing? It’s not logical, but it’s the only basis on which humans make the most important decisions in life.

Picture by frances1972

My first day as a doctor

912907071_1770dfe5a8_z

I’ll never forget my first day as a doctor. I donned my freshly laundered white coat, swung my new stethoscope around my neck, clipped the newly acquired Parker pen into my shirt pocket, stuffed a copy of the drug formulary into my coat pocket and made my way to the gynaecology ward of the large Dublin hospital where decades ago on the 1st of August I was to be the new medical intern.

She greeted me with a warm smile as she stood at her desk in the ward office. ‘Sister Eileen Doorly’ it said on her name badge. She must have been in her mid 50s and had the bearing of someone to be respected.

Good morning, doctor.

This was the first time anyone like her had called me doctor and my heart missed a beat.

Me: Good morning, Sister. What can I do for you this morning?

Her: Well, you might want to prescribe an anti emetic for the patients post op doctor.

I hesitated. I knew what the drug was but wasn’t sure about a number of other important details. I hesitated. She watched me closely. Smiling kindly. The formulary was within grasp but I left it in my pocket and chose to ask.

What does the professor like to use post op sister?

Her smile broadened.

That would be stemetil doctor

I unclipped the pen and stood with the nib poised over the first drug kardex.

Me: S..t…..

Her: e..m..e..t..i..l.

Me: Thank you. And what dose does he like to use?

Her: 12.5 mgs i.m. twice a day. 6am and 6pm. The rest, is on your name badge, doctor.

She had a twinkle in her eye. She was teasing me but somehow I could sense that she didn’t mean to be rude. Eileen Doorly spent the following three months teaching me everything I needed to know to get through the most demanding year of my career. She did it willingly, she did it with the deepest respect and she did it with discretion. I am forever grateful to her. I never saw her after that year and because I moved overseas for my specialist training I didn’t have the opportunity to thank her. She also taught me that sometimes it pays to let those who work with you teach you things, to show your vulnerable side and to trust them. I published my first academic paper while working on that ward. It set me up to get a place as one of six to be offered a prestigious training job against stiff competition.

Eileen Doorly inspired that work because in that first week on the ward she explained that my job as an intern was not only to provide basic medical care but to support the catholic Irish women who would be told in the course of their admission that they would be unable to bear children. That experience was critical to my decision to choose to specialise in general practice. In the course of my career I have met a number of people like Eileen Doorly, men and women, older, wiser and more experienced. Always willing to teach, always with the patients best interests at heart. Medicine requires team work, it is a demanding profession in which errors can cost lives. Men and women like Eileen Doorly ensure that patients are not harmed despite the many inexperienced doctors who must participate in healthcare to learn the art.

Picture by Jez

A test has most value when the prevalence is high

4647883696_c564082a24_zA perennial problem in primary care is whether to schedule laboratory tests. This is an issue that is often very perplexing early in clinical careers because there is often a lot of pressure or perceived pressure not to miss the rarest of rare conditions. The secret, if there is one, is to know the prevalence of the condition before testing for it. Supposing a condition has a prevalence of 20% (1 in 5) in a population, this would be considered very high. What if the recommended test detects 95% of cases (sensitivity) and identifies 80% of people who did not have the condition (specificity). If the test were applied to 200 people:

  • 70 would be identified as positive and of these 38 would be ‘true positives’. Therefore 32 people would be told they might be sick when they were not (positive predictive value = 54.29%).
  • On the other hand 130 would be told they were not sick when two of them were ‘false negatives’.

If the same test were applied to the same population but the prevalence was 2% (1 in 50), in other words pathology is unlikely, then:

  • 43 people would be identified as abnormal and of these 39 people would NOT have the condition (positive predictive value = 9.3%).
  • On the other hand 157 would be reported well, which was everyone with a negative test.

The impact of a test is not only on those who are found to have pathology but also on those who are told they might have pathology and need more, often invasive tests, for a very unlikely condition. Prostate cancer testing has been studied in this respect.

In primary care tests for life limiting illness in particular can be calibrated with a high sensitivity (more true positives), so that pathology is not missed and a modest specificity (more false positives) which means that more people might be subjected to further investigations because their symptoms need explanation and they may need more investigations. However a false positive result has a significant impact on the patient’s life. The numbers above illustrate the impact of prevalence on the proportion of people without pathology who would be subject to further tests. The higher the prevalence, the more worthwhile the test and the better the positive predictive value of a test. You can play with these numbers using this on line calculator.

A question to ask whenever requesting a test is how common is this condition in people like the person to be tested?  If it isn’t very common what harm could be caused by multiple tests to ‘prove’ this person doesn’t have this condition? In the business of healthcare no patient, client or customer should be subjected to tests without the practitioner having a firm grasp on how the test will help to manage the case. By corollary there is no short cut to taking a detailed history and examining the patient in order to make a diagnosis. Tests can never compensate for poor practice, nor should they be used to try to impress a patient that ‘everything is being done’, often what is being done is iatrogenic harm.

Picture by National Library of Medicine.

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.