Share the post "Twenty minutes every three months"
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.
Share the post "A test has most value when the prevalence is high"
A 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.
Share the post "Research to solve rather than explore"
To make an appreciable contribution to health research must address real world problems. The recurring dozen themes at primary care research conferences have hardly changed in decades. Many projects are exploratory and despite a plethora of peer reviewed publications hardly ever result in tangible solutions:
- Audits of compliance with guidelines.
- What goes wrong in a particular topic at a particular location in general practice.
- Exploring the needs of minority groups of people who are poorly served by the health care system.
- Engaging doctors in getting people to eat less, drink less and exercise more.
- Getting doctors to do more of some things we want and less of other things they like.
- Working out what’s wrong with people who come to doctors more, or less, often than average.
- Defining the characteristics of people who need to come to doctors sooner.
- Measuring what doctors do and how to incentivise them, financially, to do more.
- Surveying or interviewing doctors about their patients or their work.
- Getting health care professionals in different disciplines to work together under the leadership of a general practitioner.
- Working out what doctors’ databases tell us about their patients or their performance.
- Tools to research all of the above.
Perhaps the time has come to swap these for an alternative set of dozen themes focused more fully on generating tangible solutions:
- How to empower patients with specific needs to get what they require from identified healthcare providers.
- How to share decision making within the context of the limited benefits and significant risks of medical treatment.
- How to facilitate access to what the patient really needs. When and where they need it.
- How to trigger lifestyle behaviour change rather than deliver a medicalised means to achieve it.
- Establishing what can be achieved when health practitioners focus on what they are good at rather than become distracted by issues that are beyond their interest, training or expertise.
- How to signpost some people to more appropriate sources of advice other than their doctor.
- How to increase access to appropriate advice and support for those who are motivated to seek it.
- Defining the limits of what can be achieved by doctors working on any and every social ill.
- Designing and testing ways to promote the specific behaviours in healthcare professionals that are associated with the best outcomes in very precise circumstances.
- Working out what exactly needs to be done and by whom and when to get the patient with a defined need that which helps in a particular way. Then finding a way to trigger that behaviour in the most specific way in a particular context.
- Looking more closely at what doctors and patients do rather than just what is recorded and finding specific ways to trigger whatever benefits the patient in specific circumstances.
- Tools to meet the specific needs of patients and support healthcare providers in deploying them consistently.
The current research agenda aims to support the status quo. The times call for a radical review . Primary care, where ninety percent of healthcare is delivered needs to provide leadership about its role in making a real difference to people’s lives. This means acting on the evidence for the limited effectiveness for what we do today to design and test solutions for tomorrow. The focus should move away from trying to mimic researchers in the specialist medical sector and own the space that is primary care. In primary care what matters is what the patient thinks and needs and not on what the sector seeks to provide to sustain itself or maintain external and outmoded notions of academic or clinical excellence.
Picture by Jiwa New York Public library.
Share the post "Convenient trumps promising"
The innovator dreams of conditions that are common and for which there are untested treatments. There are many conditions that present in primary care that might fit the bill. Conditions that improve in time regardless of what is done for them. Here are a few examples from a very long list:
- Common Cold
- Plantar Warts
- Molluscum contagiosum
- Ankle Sprain
Yet there are a number of apparently effective treatments for some of these that have been known for decades. However few have been tested formally in randomised clinical trials. Our team recently attempted to test a traditional remedy in an RCT. Without that evidence the treatment cannot be recommended, even though the ‘gold standard’ can hardly be said to be effective. Ethics committees require patients who are offered participation in a trial to give informed consent. That’s as it should be. There are documents to read, special appointments to make, then follow up for a number of weeks to determine if the treatment is working and then yet more form filling to assess the impact of the treatment. Our team is good at this sort of thing. We design documents that are easy to read and procedures that are simple to follow.
So Jean turns up with 12 year old Megan after school because has been told by the teacher that Megan can’t go swimming until she has had her warts treated, or Megan has been complaining that the warts are bothering her. Mum knows, or has heard from the woman next door that the doctor can ‘burn’ them off. Not that in many cases the treatment has to be repeated and that mostly it doesn’t work. And then she is told- ‘ Well there is this trial we are doing…….. blah, blah.’
Never mind that just burn them off doc.
Cryotherapy stings as Megan will discover. The trial treatment is virtually cost free and painless and if it doesn’t work then you still have the cryo option. However mum has been persuaded that cryo works and isn’t interested in anything else- especially something that involves form filling. The woman next door says it worked for her little Freddie. Doctor may not have time to debate the case for testing an alternative in a busy clinic- so the idea is jettisoned and Megan is ushered into the treatment room for cryotherapy.
Here lies a major challenge in testing treatments for which an immediate commercial return is not on the cards. Pharmaceutical companies may not want to put effort into testing something that is unlikely to generate profits and what’s worse is that practitioners may not be willing to invest time promoting research that the patient deems inconvenient. It cannot be assumed that the beneficiary of innovation will participate in a trial if the established treatment is moderately effective and at that point in time convenient.
Picture by Mirko Fontemaggi