Tag Archives: primary care

Dog walking may assist weight control

Height and weight were measured for 281 children aged 5–6 years and 864 children aged 10–12 years. One parent reported their own and their partner’s height and weight (n=1,108), dog ownership, usual frequency their child walks a dog, and usual frequency of walking the dog as a family. Logistic regression analyses were adjusted for sex (children only), physical activity, education, neighbourhood SES, parental weight status (children only) and clustering by school.

Dog ownership ranged from 45–57% in the two age groups. Nearly one in four 5–6 year-olds and 37% of 10–12 year-olds walked a dog at least once/week. Weekly dog walking as a family was reported by 24–28% of respondents. The odds of being overweight or obese were lower among younger children who owned a dog (OR=0.5, 95% CI 0.3–0.8) and higher among mothers whose family walked the dog together (OR=1.3, 95% CI 1.0–1.7). Health Promotion Journal of Australia

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Triggering better health outcomes

The first piece of data we collect in healthcare is: date of birth. Could it be used to trigger better habits?

50th birthday bashes have overtaken 21st celebrations as 50 now considered the “peak” age to throw a party, sales figures for cards and party paraphernalia show.

Sales of 50th birthday cards have for the first time eclipsed the number of 21st birthday cards sold, according to data from Clintons, the UK’s biggest cards retailer.

With 50th birthdays now leading on the birthday league table and accounting for 16 per cent of all card sales, 21st birthday cards now make up 14.1 per cent of all cards sold. Katie Morley. The Telegraph Oct 2017

I explore the possibilities.

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Why don’t people take medical advice?

Significant proportions of people walk out of doctors’ clinics and disregard or fail to act on the opinion offered. The data reported in the literature does not make for encouraging reading. This behaviour has been observed in almost every clinical scenario and every speciality:

Paediatrics

Medication compliance in pediatric patients ranges from 11% to 93%. At least one third of all patients fail to complete relatively short-term treatment regimens.

Psychiatry

Of the 137 patients included in the study, 32% did not show up for their first appointment.

Hypertension

Similarly, although men receiving health education learned a lot about hypertension, they were not more likely to take their medicine.

Diabetes

We conclude that compliance with the once-daily regimen was best, but that compliance with a twice-daily regimen was very similar, and both were superior to dosing three times a day.

Primary care

Seven hundred and two patients (14.5%) did not redeem 1072 (5.2%) prescriptions during the study period, amounting to 11.5% of men and 16.3% of women.

Sexual health

Eighty percent of 223 patients enrolled completed the study by returning their bottles. The rate of strict compliance with prescription instruction was 25%. The rate of noncompliance was 24%. Fifty-one percent used some intermediate amount of medication. There was no statistical difference in compliance by gender, presence or absence of symptoms, or site of enrollment.

Physiotherapy

Ultimately, this study suggests that health professionals need to understand reasons for non-compliance if they are to provide supportive care and trialists should include qualitative research within trials whenever levels of compliance may have an impact on the effectiveness of the intervention.

The fact that this happens is important because it is a costly waste of resources. There are many explanations for this phenomenon but they are all summarised in the findings of one study:

Studies have shown, however, that between one third and one half of all patients are non-compliant, but different authors cite different reasons for this high level of non-compliance. In this paper, the concept of compliance is questioned. It is shown to be largely irrelevant to patients who carry out a ‘cost-benefit’ analysis of each treatment, weighing up the cost/risks of each treatment against the benefits as they perceive them. Their perceptions and the personal and social circumstances within which they live are shown to be crucial to their decision-making. Thus an apparently irrational act of non-compliance (from the doctor’s point of view) may be a very rational action when seen from the patient’s point of view. The solution to the waste of resources inherent in non-compliance lies not in attempting to increase patient compliance per se, but in the development of more open, co-operative doctor-patient relationships. Donovan and Blake

What practitioners can do without waiting for policy change is to review their communication style. As Bungay Stanier has suggested it can’t be assumed that the first thing the person mentions is what is uppermost in their mind. Bungay Stanier’s suggested questions will reduce the rush to action. A rush that fails to identify the issue that the patient may feel is a greater priority than hypertension or diabetes.

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The infographic bandwagon rolling in to your clinic

In the wake of her book launch I had the honour to interview Dr. Halee Fischer-Wright President and CEO of MGMA. In her book: ‘Back to  balance:The art, science and business of medicine’ the author asserts:

We have lost our focus on strengthening the one thing that has always produced healthier patients, happier doctors, and better results: namely, strong relationships between patients and physicians, informed by smart science and enabled by good business.

In a separate blog post Larry Alton, business consultant addressing the business community says:

In 2017, you’ll find it difficult – if not impossible – to be successful without strategizing around customer communications. Customers have become conditioned to expect interaction and service. Provide both and you’ll be delighted with the results.

Most people will interact only with primary care when they need healthcare. The average consultation in primary care is less than 15 minutes. Therefore efficient communication is a priority. Larry Alton goes on to advise:

Communication is at the heart of engaging and delighting customers. The problem is that, even with all of the new advancements in communication technology, very few businesses are taking this all-important responsibility seriously. This results in poor relationships and a bad brand image.

His four key action points are:

  1. Hire empathetic employees
  2. Leverage the right communication mediums
  3. Use analogies to explain technical concepts
  4. Become a good listener

One area that seems to receive scant attention in medical practice is explaining technical concepts. And yet technical concepts are integral to medical practice:

  1. What pathology brought me here today?
  2. Why has my physiology responded in this way?
  3. What is the prognosis?
  4. Why do need this therapy?
  5. What are the risks?

Ours is a technologically proficient but emotionally deficient and inconsistent medical system that is best at treating acute, not chronic, problems: for every instance of expert treatment, skilled surgery, or innovative problem-solving, there are countless cases of substandard care, overlooked diagnoses, bureaucratic bungling, and even outright antagonism between doctor and patient. For a system that invokes “patient-centered care” as a mantra, modern medicine is startlingly inattentive—at times actively indifferent—to patients’ needs. Meghan O’Rourke

When explaining complex ideas there is a checklist:

  1. Does the patient want all the information?
  2. What are the implications of the prognosis?
  3. How can you explain with reference to something they are already know?
  4. What details can you leave out that would only serve to distract from an understanding?
  5. How can the patient assimilate this information actively?

Adapted from a post by Thorin Klosowski

Perhaps the neatest medium to communicate some aspects of a complex idea is the infographic. According to experts:

In the past 5 years, the term “infographic” has seen an impeccable rise in trend.In fact, the popularity of infographics is expected to see an increase of almost 5% by next year, meaning that anyone who isn’t yet riding the infographic bandwagon is bound to fall behind. The Daily Egg

Here are the data:

The Journal of Health Design has recently introduced the Infographic as a submission type. Communicating using this medium could reduce the time required to assimilate the information needed to make a decision.

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Is your motto reflected in every interaction?

Every interaction with patients should reflect the motto of the healthcare organization serving their needs.

Motto: A sentence, phrase, or word expressing the spirit or purpose of a person, organization, city, etc., and often inscribed on a badge, banner, etc. Dictionary

I like the motto of the Royal College of General Practitioners, UK:

Cum Scientia Caritas

Compassion with knowledge. So here are a list of unacceptable explanations when someone interacts with a service provider and things deviate from whatever noble aim is adorned above the front door:

  1. I’m not paid to do that
  2. I don’t have the resources
  3. That’s not how things are done
  4. Where’s the evidence?
  5. It’s not my fault
  6. It’s not in the protocol
  7. Too idealistic
  8. It’s not me it’s them
  9. I didn’t know
  10. We didn’t negotiate that in the contract
  11. People expect too much
  12. We never promised that
  13. We might do that in the future
  14. We would never get through the day if we did that for everyone
  15. I don’t care
  16. I only work here
  17. Too busy
  18. Maybe next time
  19. What about me?
  20. It doesn’t matter

Every interaction should reflect what we say and what we believe the patient /customer/ colleague is entitled to from our service or our staff. The response when deviations are reported should also reflect the motto. Choose your motto with care.

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More can be done to help people who consult doctors

In general practice patients generally present with undifferentiated conditions. People come for help with a cough and not ‘pneumonia’, back pain and not ‘metastatic prostatic cancer’, fatigue and ‘not diabetes’. In a study published in 2015 it was reported that a diagnosis is not established in 36% of patients with health problems. According to the research team half of the symptoms were expected to resolve or persist as ‘medically unexplained’. In their summary the team concludes that:

The study highlights the need for a professional and scientific approach to symptoms as a phenomenon in its own right. Rosendal et al

We also know that the commonest symptoms relate to the musculoskeletal system, respiratory system and the digestive tract. As long ago as 1984 Gordon Waddell and colleagues made a similar point in the BMJ :

The amount of treatment received by 380 patients with backache was found to have been influenced more by their distress and illness behaviour than by the actual physical disease. Patients showing a large amount of inappropriate illness behaviour had received significantly more treatment (p <0 001).

They concluded:

We know that a standard medical history and examination provide a wealth of information not only about the disease from which the patient is suffering but also about how that particular person is reacting to and coping with his or her illness. What is necessary now is to devote as much time and effort to the study and understanding of illness behaviour as we do at present to the investigation of physical disease. Only thus can we put the art of medicine on to a sound scientific basis.

Decades later these words are prophetic and we find that the thrust of research is on the diagnosis and treatment of specific pathology rather than on how to help people to cope with persistent back pain, acute cough or ill defined abdominal pain. This continues to be a bone of contention between doctors and patients as was illustrated in a classic paper by Joe Kai writing about the management of illness in preschool children in general practice:

Parents expressed a need for more information about children’s illness. Advice about the management of common symptoms was insufficient. They sought explanation and detail that was specific and practical to help them make decisions about the likely cause of an illness, how to assess severity, and when to seek professional advice. They wanted to know of any implications of the illness or its treatment and the potential for prevention in the future. Most thought that being more informed would reduce rather than increase their anxiety.

In a literature review published in 2002 in the BJGP Hay and Wilson charted the progress of children under 4 who develop an acute cough:

At one week, 75% of children may have improved but 50% may be still coughing and/or have a nasal discharge. At two weeks up to 24% of children may be no better. Within two weeks of presentation, 12% of children may experience one or more complication, such as rash, painful ears, diarrhoea, vomiting, or progression to bronchitis/pneumonia.

The authors conclude that:

Illness duration may be longer and complications higher than many parents and clinicians expect. This may help to set more realistic expectations of the illness and help parents to decide when and if to reconsult.

By implication, as well as knowing when and how to investigate symptoms, it would help patients if doctors also routinely communicated the natural history of the commonest symptoms including and especially:

  • Acute cough
  • Acute low back pain
  • Rash
  • Depression
  • Sprain /strain

For example it has been demonstrated that the experience of individual doctors on this issue is unreliable. Writing on acute low back pain researchers from New Zealand suggests that 91% of patients stop consulting their doctor at 3 months after the pain starts and long before their symptoms have resolved. Also that only 1:5 patients are free of pain or disability one year after an acute episode of low back pain.

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Are you addressing the right problem or the one you think you can fix?


The act of consulting a doctor has been shown to be highly ritualized.

Ritual has long been thought to play an important role in the healing processes used by ancient and non-Western healers. In this paper, I suggest that practitioners of Western medicine also interact with patients in a highly ritualized manner. Medical rituals, like religious rituals, serve to alter the meaning of an experience by naming and circumscribing unknown elements of that experience and by enabling patients’ belief in a treatment and their expectancy of healing from that treatment. John Welch. Journal of religion and health

There are five elements to this ritual:

  1. The stage- office, clinic room, cubicle.
  2. The props- what can be seen and or felt.
  3. The actors- doctor, patient and sometimes nurse or therapist.
  4. The script- what is said.
  5. The action- what is done.

All have an impact on the outcome. The doctor’s ‘script’ is of particular importance as it is what the patient hears. The literature offers evidence of the impact of what is said and how it is said on outcomes for patients:

 The quality of communication both in the history-taking segment of the visit and during discussion of the management plan was found to influence patient health outcomes. The outcomes affected were, in descending order of frequency, emotional health, symptom resolution, function, physiologic measures (i.e., blood pressure and blood sugar level) and pain control. M.A Stewart CMAJ

One conclusion of the literature review published in CMAJ was that the process of sharing information includes a discussion about what the patient understands to be the problem and their options with regard to treatment:

These four studies taken together debunk the myth that the only alternative to the physician’s total control of power in the therapeutic relationship is his or her total abdication of power. They indicate that patients do not benefit from the physician’s abdication of power but, rather, from engagement in a process that leads to an agreed management plan.

This issue assumes great significance when it comes to difficult consultations in which it is perceived that the patient is seeking an option that is not in their best interests. Greenhalgh and Gill wrote the following commentary in the BMJ in 1997:

Two thirds of consultations with general practitioners end with the issuing of a prescription. The decision to prescribe is influenced by many factors, to do with the doctor, the patient, the doctor-patient interaction, and the wider social context, including the effects of advertising and the financial incentives and disincentives for all parties. Hardline advocates of rational drug use do not look kindly on variations in prescribing patterns that cannot be explained by purely clinical factors. The prescriber who allows the “Friday night penicillin” phenomenon to sway his or her clinical judgment tends to do so surreptitiously and with a guilty conscience.

The team go on to conclude that:

The act of issuing a prescription is the culmination of a complex chain of decisions. It is open to biomedical, historical, psychosocial and commercial influences, no aspect of which can be singled out as the ”cause” of non-rational prescribing. The search should continue for methods to measure the interplay of these disparate factors on the decision to prescribe.

Michael Bungay Stanier offers an approach to business coaching by focusing on what a person perceives to be their challenge, what they want and how that choice might be impacting on their other options. A similar approach can be taken in medicine. Two decades after Trish Greenhalgh’s editorial in the BMJ there are still many circumstances in which doctors find it challenging to negotiate options these include but are not limited to:

In this context our team surveyed nearly 9000 patients who had been prescribed antibiotics for Upper Respiratory Tract Infections during the latest flu season. We surveyed patients using a validated tool on the third day and the seventh day after a prescription was issued. We look forward to presenting the results at the forthcoming GP17 conference. We will be offering information on the following questions:

  1. What is the profile of patients who were offered a prescription?
  2. What was the symptom profile at these time points and how does this compare with data on patients who have been offered no treatment in other studies?
  3. What are the characteristics of the respondents to the survey?
  4. What proportion of respondents completed the course of treatment?
  5. What proportion of respondents also took regular symptomatic measures?
  6. What is the profile of patients with relatively severe symptoms at each time point?
  7. Are longer consultations or type of antibiotic predictive of compliance with treatment?
  8. Within the limitations of a study that offers only the patient perspective what might help people with Upper Respiratory Tract Infections?

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The encounter could end well if you give it a chance

There is a moment in any consultation when someone could take an unhelpful perspective. That perspective could severely undermine the subsequent exchanges between those concerned.

In social categorization, we place people into categories. People also reflexively distinguish members of in-groups (groups of which the subject is a member) from members of out-groups. Furthermore, people tend to evaluate out-groups more negatively than in-groups. In this way, social categories easily lend themselves to stereotypes in general and to negative stereotypes in particular. Cohen

The problem with such categorization is that we then rate aspects as positive and negative disregarding evidence to the contrary. In a series of classic studies researchers recruited a group of 12 year old boys to attend a summer camp. The boys were divided into two teams which were then pitted against each other in competitive games. Following these games, the boys very clearly displayed in-group chauvinism. They consistently rated their own team’s performance as superior to the other team’s. Furthermore 90% of the boys identified their best friends from within their own group even though, prior to group assignment, many had best friends in the other group. M&C Sherif

Healthcare professionals can also be prone to social categorisation:

It is equally important to recognize that physicians and other health care workers are not mere empty vessels into which new cultural knowledge and attitudes need to be poured. They are already participants in 2 cultures: that of the mainstream society, in which some degree of bias is always a component, and the culture of medicine itself, which has its own values, assumptions and understandings of what should be done and how it should be done. Reducing racially or culturally based inequity in medical care is a moral imperative. As is the case for most tasks of this nature, the first steps, at both the individual and societal levels, are honest self-examination and the acknowledgement of need. Geiger

The patient opened the consultation saying ‘I don’t sleep well’. He wore a raggy teeshirt, torn jeans and old trainers. A baseball cap was perched atop an untidy mop of greasy hair. He was overweight verging on obese and had two days of growth on an unshaven face. He worked in a warehouse. Thirty seconds into the encounter I caught myself thinking ‘he wants a prescription for a hypnotic’ but stopped myself launching into a prepared speech on the addictive dangers of hypnotics. It turned out that he had worked to lose 15kgs, studied and practiced sleep hygiene and was keen to explore any option other than drugs. He was far from interested in a script for Temazepam. It turned out that he was keen to hear if I approved of his low carb diet and wondered if yoga and meditation might help. The next seventeen minutes were a mutually satisfying consultation which ended with a handshake. A sure sign that it had gone well.

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’ BJGP

Therefore there is a point in the consultation when the healthcare professional needs to scan their impressions for evidence of  stereotyping.

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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:

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