Tag Archives: public health

Someone’s son or daughter

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There is increasing evidence that overweight and obesity exists in the context of families. There may be something about family dynamics that engenders or maintains the problem with excess weight gain.

  •  A 2004 study in the Journal of Pediatrics found that the biggest factor that predicted overweight in children was if the parents were also overweight.
  • Two-thirds of parents underestimate the BMIs of their children, especially when their children are overweight or obese.

Some data has even suggests trends according to relationship of the adults in the household:

  • Children raised by two co-habiting biological parents had the highest rates of obesity, at 31 percent.
  • But if those parents were married, the children had one of the lowest obesity risks, at 17 percent.
  • Children residing with an adult relative had a high (29 percent) likelihood of becoming obese.
  • But if that adult was their single father, they had a very low risk—just 15 percent.
  • The children of single mothers and those of co-habiting (not married) step-parents had similarly high rates of obesity, at 23 percent.

Furthermore:

Non-poor children living with married step-parents had a 67 percent higher risk of obesity compared to similar non-poor children raised by married biological parents.

The authors of the study couldn’t explain why children in married parent households had lower probabilities of obesity.

The final word is:

Information on children’s health and nutrition must reach not only mothers, but the other caregivers (relatives, fathers, step-parents) with whom mothers and children regularly interact. It is also important to ensure that caregivers are in agreement about issues of nutrition and physical activity for children. Augustine and Kimbro

Once again stressing that innovations to tackle obesity need to consider the context in which the person with the problem is presenting for help. That person is someone’s son or daughter. What else are they coping with? Could anything you have done reduce their status to someone who fails to appreciate the first law of thermodynamics? If so, are you going to make a bad situation worse?

Picture by Niccolo Caranti

Do you know if you stand in the way of your own success?

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Whose is the voice that helps you decide? Whose is the voice you listen to always? For you there is only ever one person in the room even though the room may be packed. In the end it is your own voice that will determine the outcome because without your input a team will only achieve partial victory or worse.

What is your self-talk?

This is dreadful. It’s a catastrophe. A disaster. We’ll never achieve this. It won’t work. It’s all too hard. We don’t have time. We can’t. We won’t. It’s always like this. What does he really want? We are going to fail.

Listen carefully to your prophecy. Because if you think you can or if you think you can’t- you will be right.

Catastrophe, Disaster, Never, won’t, can’t, don’t, always.

To dramatically improve the prospects for success revise this language. That doesn’t mean becoming a Pollyanna. Here’s an alternative dialogue

This is interesting. It’s a challenge. It’s a small hiccup. It’s an opportunity. What can we learn from this? How can I contribute? Can we make this better? Can we help this become a victory for everyone?

If you can’t change what you are saying to yourself at work then you have to ask three questions:

  • Why am I here?
  • Have I said this before?
  • Am I the problem?

If your self-talk is negative then the chances are that you are neither fulfilled nor satisfied with your role on this team. Your duty is to find out why and fix it or find an alternative place to be where your skills will bring you joy. Ultimately you are responsible for you. A free person’s happiness can never depend on the actions of others. If you don’t feel you fit where you work and decide to quit your colleagues may be disappointed. But they will also respect you for your insight.

Tomorrow you should indicate that you are on-board by voicing the alternative dialogue. Because sooner or later someone will over hear your negative self-talk (it’s not as private as you think) and you will find yourself removed from a seat at the table either figuratively or physically. In healthcare there is no room for those who are not fully committed to improving outcomes. The best place to begin to improve outcomes for patients is nurturing a can-do attitude. It costs nothing to make this change if required. Tony Teegarden offers a helpful short presentation on this issue.

Picture by Kevin O’Mara

What do you already know before you consult your patients?

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I tried this experiment today- given only a person’s name and address from a phone book what can you find out about them from the internet?

Location and state of home: Using Google street view I can see where the person I selected lives, or at least what her home looked like in May 2014. The house is a bungalow with a double garage, the garden is unkempt, and litter is strewn on an overgrown lawn. The fence with the neighbours is in a poor state of repair and has pieces of junk leaning against it. There are multiple old cars in the driveways or on the grassed areas of all the homes along the street; this suggests that there are many youngsters over the age of 18 living nearby.  The neighbour’s bin, which is on the kerbside, is full to overflowing, so it looks like the photo was taken on bin day. There are no children’s toys in the garden or on the lawn or anywhere in neighbouring yards. I can see a car on the driveway and Google has not blacked out the number plate. It is a new but cheap and small hatch back. At least one neighbouring home has a ‘for rent’ sign outside it. From Google earth I can see that none of the homes in the immediate neighbourhood have a swimming pool and that this home occupies most of the plot on which it has been constructed. From Google maps I can work out that she lives 10 minutes drive away from a doctors clinic, 11 minutes from the largest shopping centre, 7 minutes from the railway station (39 minute walk), 6 minutes from various fast food outlets and 15 minutes walk from the leisure centre. The house is not within a short stroll to any major amenities; there are no shops or cafes nearby. There are no bus stops on the street.

From Realestate.com.au I can see that this home sold for over $300,000 in 2011 and that it occupies 500 square meters of land. The estate agent described it thus:

A good sized home with 4 bedrooms, 3 separate living areas, a huge kitchen meals area complete with bench space, 5 hotplates and dishwasher as well as wall oven. Ducted heating, reverse cycle air con, 2 bathrooms (ensuite to master) and a 2 car carport as well as a large driveway complete this house. Catching a train to work? Well, you are only 5 minute drive to the town CBD and station. Schools and buses are nearby and petrol station around the corner for your fuel, milk and bread will give you convenience plus.

I can see inside the house and note that there is Jacuzzi in the back yard. The real estate site tells me that families with adult children occupy one in five properties in this area and that one in ten people living here are retirees. According to domain.com.au sixty nine percent of home locally are owner-occupiers and the average age of people here is 40-59. If this person has a mortgage they are likely to be paying just under $600 per month or if renting $350 per week. Manufacturing is the largest employer in the area. As this person is female, she may be a widow or a divorcee.

Facebook: I also note on Facebook that there is someone by the name of this person from this town. I couldn’t be sure if this is the same person. It is unlikely as the person on Facebook looks quite young and the vintage of the name is more likely to be of a person in their 40s. Google didn’t have any information on this person and this suggests she doesn’t hold a senior position in employment locally and hasn’t been in the news for any reason.

Would any of this information help in a consultation with this person as a patient?

What I already know leads me to suppose that this person is working, probably locally and has a modest income. She probably lives with other adults, possibly her children and moved into the home in 2011 when the property was sold. Given the poor state of the garden it is likely the home is rented.  In addition from her medical records I will know her age, her occupation, her current medications and any significant past medical history. That’s even before I set eyes on her.

The information above will be of limited value if she presents with a minor self-limiting illness, except that she may be very keen to get a medical certificate because she will not want to risk losing her job. She probably has a modest income and may be at risk of work related stress. She may also find it difficult to attend the clinic during office hours unless she works close to the clinic. This is unlikely. If in middle age she has a chronic illness and she requires to attend the clinic regularly or she needs to go to a gym four times a week then her address is going to be a significant risk factor. Secondly the cost of medications and the availability of quality food may be a challenge to an individual living in this location. Matters would be worse if she can’t drive for any reason. Some research our team has just completed suggests that people who are at increased risk from the adverse consequences of diabetes, and possibly other chronic conditions, tend to live in close proximity to one another. Therefore if my computer was to alert me, in addition, that this address is in such a hot spot area, then the information I have freely gathered from the internet and from my own clinic records before I see her may offer useful insights into my patient’s circumstances. It may be that we would have to work hard to find someway to help her cope with the rigors of a demanding medical problem should it exist. Of course all of this is speculation, the best thing I can do is to ascertain the whole truth by giving her my undivided attention when she attends. Nonetheless if I didn’t have to spend a lot of time playing detective I would be much better placed to understand her needs.

Picture by Duncan Hull

How to deliver good ideas quickly and cheaply in healthcare

12643873903_7860231974_zBad news-the words ‘good’, ‘quick’ and ‘cheap’ are incompatible. There are no short cuts in this business. To be a successful innovator you have to be intimately familiar with the healthcare business, you have to evaluate your innovations within the very strict rules that govern how to test ideas in health and you have to enlist and fund the support of a team that can negotiate the hurdles along the way.

It takes years to develop something that might make a difference in clinical practice. First and foremost you have to know something about the business you hope to improve. Those who are more likely to become frustrated have a very limited understanding of the paradigm which operates in healthcare. In particular those who develop well meaning ideas to improve ‘prevention’ in primary care. There is a growing focus on this from the misguided view that we could all be healthy if only our family doctor would tell us to notwithstanding the many other factors that are operating to keep us fat, drunk and smoking.

As our team reported last week there is little or no redundant capacity or ‘spare time’ in the short primary care consultations to devote to delivering effective health promotion advice. In fact the attempt may harm the patient because that would take time away from a focus on the symptomatic patient’s ideas, concerns and expectations. It is possible, on some occasions that the patient is specifically seeking advice on how to lose weight, stop smoking or reduce their alcohol consumption but that is unusual. Therefore innovations that are aimed at increasing the effort on health promotion or worse still policy that redirects the doctor’s efforts in that direction may distract from the core business of communicating effectively and devoting time to the patient’s agenda rather than a public health agenda. As was reported by Richard Wender:

Practitioners and patients face three types of obstacles: provider-specific obstacles; patient-specific obstacles; and health care delivery system obstacles. Provider-specific obstacles include lack of time, distraction by other health issues, lack of expertise, lack of positive feedback, and disagreement with recommendations.

Secondly ideas that are likely to work have to be tested and shown to be promising but sadly lack of data rarely discourages people from thinking they can become rich and or famous from their latest brain wave. Testing innovations in healthcare is a painstaking and often frustrating business. Several things can and do go wrong: it is difficult to find a suitable place to test ideas; it can be challenging to get approval to test ideas on ‘real’ people; it can be difficult to source consenting subjects to test ideas in the relevant clinical settings; it requires skill to collect and interpret the data and it can take a long time to get data published following review by an independent set of experts in a reputable forum. Research in primary care in particular is not for the faint-hearted.

Finally what you need most is a team, led by a determined champion who have worked out how to negotiate the many obstacles towards a clear outcome. Such teams are rare and must be funded. Therefore it is not possible to deliver successful ideas for healthcare quickly and those who attempt it will do more harm than good.

Picture by Neil Moralee

The most effective way to improve health outcomes

6842253071_a9b35831c0_zThere is no doubt that the demand for healthcare is rising in parallel with an aging demography and the increasing  prevalence of chronic conditions. Most healthcare is delivered in primary care. Only a relatively small proportion of people need specialist services or hospitalisation. Attempts to improve outcomes in healthcare are firmly focused on prevention and reducing the physical, social, economic and psychological impact of chronic illness. In most countries innovators are working with general practitioners to maintain the health and well being of our precious taxpaying workforce. In the following series of short videos there are some indications where and how to support GPs to take the next big step forward in improving the health of humanity.

Improve access to GP services.

Give GPs more quality time with their patients.

Show GPs where they can target their efforts in their local community.

Make patient data more accessible to GPs.

Provide GPs with better tools to communicate health messages.

Make guidelines easy to implement.

Write better discharge summaries to GPs.

Develop ways for other health professionals to share information with GPs.

Facilitate communication from GPs.

Encourage GPs to use their insights to improve healthcare outcomes.

Picture by UW Health

First we have to agree that there is a problem

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

It was also underlined in a research paper which concluded:

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

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

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

Picture by Will Temple

What do you want from your doctor?

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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

Twenty minutes every three months

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I recently said goodbye to my patients when I moved to another job. One of my general practitioner friends also said goodbye to his patients, albeit it temporarily. He has been visiting Australia this week. I am pleased to recount his story.  For him the light bulb moment came when he noticed that people were concerned that he ‘might never return’. He wondered if he could deploy this connection to encourage his patients to be more active and or stop smoking.

Two months before Dr Klein left ( for one year), he wrote to his patients, challenging them to set 1 health-related goal to work on while he was away. He suggested they consider a lifestyle change, such as losing weight or quitting smoking.

Two of his colleagues offered to support the patients in their efforts to achieve any goals they set in Dr. Klein’s absence.

About 1 in 8 adult patients (48 out of 350) set goals, including losing weight, exercising so many times per week, and quitting smoking; some set more than 1 goal.

The ‘intervention’ took only a few minutes to initiate and 20 minutes of staff time every 3 months. This was essentially a reminder letter every 3 months. The results were impressive.

Among the participants, 18 (38%) did not achieve their goals; another 15 (31%) could not be reached, so their results were unknown. The remaining 15 patients (31%) succeeded, 8 completely and 7 partially reaching their goals, and some meeting more than 1 goal. The successes included 3 patients who quit smoking, 7 who increased physical activity levels, 7 who lost weight, 1 who reported decreased shoulder pain after exercising more often, and 1 who made an overall lifestyle change.

It sounds as if the reminder letters were triggers to keep working towards the goal. This ‘lean innovation’ did not require a research grant or a large team to complete. No drugs were prescribed, no tests were required. It was rewarding and demonstrated the value of the social capital in the doctor patient relationship. A relationship that defines the role of the medical practitioner even in 2015. The same relationship that creates tangible results. Medicine is a people business. We do well to remember that at a time when there is an obsession with quantified self.  You can read more about Doug Klein’s experience here.

Picture by Kellan.

What factors trigger an urgent and appropriate medical consultation?

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There are circumstances in which it is critical for a patient to consult a doctor sooner rather than later. Imagine someone with symptoms of a stroke or a myocardial infarction ( heart attack), or with a breast lump.

In these circumstances timely intervention may be life saving. These circumstances are often the subject of public health campaigns and perhaps one of the most popular attempts to improve health care outcomes or reduce costs. Predictably such attempts are not universally successful. That may be because the issues are rarely considered from the patients’ perspective, because a solution is imposed from what seems to help ‘some people’, possibly those who might have consulted a doctor anyway.

Our help seeking behaviours are subject to the same three factors that Fogg speaks of in his behaviour model. Motivation is contingent on the person’s understanding of his or her risk to adverse outcomes. Ability is the person’s perception of access to treatment that may be life saving and finally, and crucially, triggers are factors that compel the person to make the effort to consult a doctor when they have the most to gain.

Therefore there are four possible scenarios:

High motivation and high ability to access health care.

This is ideal. In these circumstances a ‘signal’ trigger will suffice. Think ‘red traffic light’ .  Therefore someone who is bleeding or  experiences crushing central chest pain or develops sudden onset weakness on one side of their body, will quickly act to do what is necessary. Alternatively they might do the needful, as in the picture, when they are prompted by a relative or friend. Unfortunately it cannot be assumed, as it often is, that everyone is in this boat.

A health promotion campaign might be considered successful if five percent of the target audience make long–term changes in overt health behaviour. Rogers and Storey

There are three other less ‘easily’ remedied situations.

High motivation but poor access.

For these people ‘red lights’ will do nothing but cause frustration. What is needed is well publicised improved access to skilled care providers. For many people in specific areas of many countries access to health care is poor and it is reflected in inequity of outcomes for what is, anywhere else in the country, a preventable cause of morbidity and premature mortality. There is real scope to innovate here, perhaps the most promising avenue is online  or telephone access to care providers or innovations that better integrate care providers at the point of presenting symptoms especially within primary care.

Low motivation and easy access.

On the face of it this might be easily fixed simply by ‘educating’ people. However the empirical evidence is that such campaigns have limited ( as opposed to ‘no’)  effectiveness. Often the causes of low motivation are  many and varied. What speaks to one community or individual may not resonate with others and the scope for frustration or patchy results are very high. If this were not the case our jails would not have quite so many inhabitants. Law breaking like poor health is a complex issue and no solution including the death penalty will promote the most desirable behaviour. People don’t always respond to dire warnings. One strategy is to make the alternative action ( i.e. non consulting) less desirable than consulting. However such solutions fly in the face of patient autonomy.

 Low motivation and poor access.

Bad news. These individuals are unlikely to respond to anything. Changing attitudes is unlikely to follow ‘educational’ campaigns unless and until the issue of access to health care is sorted out. There are many individuals who have poor access to health care. The reasons for this are far too diverse for any strategy to be universally successful. If there were a simple way to do both then any of the triggers in the other of these four quadrants  might suffice. Fortunately only a minority of people are in this category but there are enough here to ensure that the idea of universally good outcomes for everybody is a utopian dream. Innovation, however well meaning, is set to fail some individuals most of the time.

Picture by amy_kearns

Primary care is not a panacea

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Barbara Starfield’s thoughts still resonate with many of us who work in primary care. Primary care serves to reduce costs in a health care system essentially by keeping people out of hospital.  However, recently there have been attempts to tinker with how the sector is configured in many countries where one would have assumed that no adjustment was necessary.

The demand for general practitioner services continues to rise. It may be tempting to assume that the drivers for this trend are the same as they have always been: infections, gluttony, sloth, ageing, substance abuse, accidents and genetics. And yet the literature records that practitioners know very little about their patients biography. So what does primary care actually do and what does this tell us about the way forward?

We know that seeing a general practitioner is not going to ‘cure’:

  • Divorce
  • Child abuse
  • Boredom
  • Debts
  • Loneliness
  • Poor parenting
  • illiteracy

Seeing a general practitioner for ten or fifteen minutes, even quite frequently, isn’t going to change these circumstances. Perhaps a perceived failure to improve outcomes for people living with these problems is the driver for reform of the sector in parts of the world. At best primary care might help people to cope, at worst it might add to problems through iatrogenesis. Then there is a possibility that our inability to cope has a biological basis and that attempts to deal with the symptoms alone may be misguided. After all such thinking led to at least one Nobel prize for medicine.

If primary care needs to be reformed than the first issue is to recognise the limitations. For those who live in relative poverty, those with multimorbidity, those with competing priorities in complex lives more of the same primary care cannot be the only response to degenerative and chronic conditions.

Picture by Mike Smail