Tag Archives: Symptoms

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 general practitioners are crucial to the economy

The odds of experiencing an event that will descend you briefly into your own private hell are significant.

These odds are much greater than the odds of getting something that requires heroic intervention:

Good news = You are more likely to catch a cold, sprain an ankle or have a runny nose than suffer anything more serious.

Bad news = What happens if you get one of the aforementioned ‘minor illnesses’.  I am living with fractured ribs this week. This is what happens:

  • You are told there is no treatment and no definite recovery period.
  • You can’t tie your own shoe laces, take off your socks or dry your back after a shower.
  • You can’t push open doors.
  • You can’t get out of, our turn over, in bed.
  • You dare not sneeze or pick anything off the ground.
  • You get persistent headaches because of paravertebral muscle strain.

The pain will get worse before it gets better. So at first you might go to the emergency department (ED) because your family will insist. At the ED you will be X-rayed. You will be prescribed analgesia and advised to take time off.  A day or two later in increasing pain you will toy with the idea of going back to hospital just in case they’ve missed something.  The codeine will cause constipation making things worse. Some doctors will advise you to take tramol others will advise against it. A specialist might recommend intercostal nerve blocks (anything looks like a nail when you are armed with a hammer). The cost of getting medical attention will mount. What you will need the most is symptom relief and a greater sense of control. Your only hope is a good GP.

In desperation you might consult YouTube for any useful hints on how to recover. This person has clearly never experienced rib fractures. I hope no medical student thinks this is how to approach the examination of anyone with this condition. On the other hand this person clearly has.

Health economists tell us that the increased costs in the healthcare system are due to unnecessary tests and treatments.

On average, a 50-year-old now is seeing doctors more often, having more tests and operations, and taking more prescription drugs, than a 50-year-old did ten years ago

You are at greater risk of ‘minor illness’ than any other illness. Yet we know that is when we are likely to request tests and treatments in the vain hope it will hasten the recovery. Good GPs  reduce this morbidity as well as the cost of caring for people when time is the only treatment.

This week we launched the Journal of Health Design. The scope of our journal is to support researchers who are developing innovations inspired by the patient experience of healthcare. This was also the week that the Royal Australian College of General Practitioners supported our team to conduct research that aims at supporting GPs in consultations with people with viral infections when antibiotics are not indicated.

Picture by Matt Pelletier

Continuity of care is a good thing right?

There’s a wonderful video that illustrates the point I’m making this week. You can see it here.

It is assumed that continuity of care is a good thing. That if you consult the same doctor every time then you will benefit with better health. We all have relatives who insist on seeing the same doctor every time. No one but Dr. X will do. Yet doctor X has all sorts of interesting approaches to their problems and despite knowing Aunt Mildred for years hasn’t twigged that her latest symptoms may be a manifestations of some family drama. She might suddenly be more bothered about her aching hip because Uncle John is making her miserable or making her carry the shopping on their visits to the supermarket.

So, is there strong evidence that people who consult the same doctor at every visit are:

  1. Less likely to be prescribed inappropriate drugs or have unnecessary tests?- Maybe.
  2. More likely to have symptoms of life limiting illness recognised early?- Not really.
  3. More likely to be counselled about poor lifestyle choices addressed?- Maybe.
  4. More likely to be screened for chronic illness? – Maybe
  5. More likely to be immunised?- Maybe.
  6. More likely to have better outcomes from chronic illness?- Maybe

The evidence is equivocal at best. Even the most ardent supporters of continuity conclude that there is ‘lots more research needed’.

So what does that tell us?

Perhaps it suggests that simply because people choose to see different doctors does not necessarily mean they are opting for, or receiving, inferior care.

When it comes to test ordering ‘walk-in’ patients are not necessarily after tests and there is some evidence that those doctors who order tests in the hope of ‘satisfying’ the patient are misguided.

There is lots of evidence that ‘continuity of care’ increases trust in a doctor. As per the example of Aunt Mildred. But there is no evidence that Aunt Mildred will be better off trusting her doctor because ‘trust’ ( which isn’t consistently defined) does not guarantee better outcomes. If Aunt Mildred attends here GP presenting with symptoms of bony metastases and is referred for urgent investigation because her GP recognises the clinical signs then she will have been well served regardless of whether she attends Dr. X, Dr. Y or someone at another practice. The point is one of them should spot the moonwalking bear.

Picture by torbakhopper

How to get your doctor to do what you want

I had no idea who he was other than a name in the appointment book and an address on some street I had never seen. What did he do for a living? Who was his partner? What was his home like? Where had be been before with this complaint? What was he told? What were his hopes and expectations?

I could take his pulse, his blood pressure and his temperature. I could listen to his heart sounds and palpate his abdomen. But his ideas, concerns and expectations were a mystery other than what he honestly shared with me.

We know little or nothing about the people who come to see doctors in many parts of the country. It is said that almost one in three Australians choose to see many GPs.

It would be foolish to assume people haven’t asked someone for advice before they present. A google search for ‘patient health advice sites’ yields 124 million results in 0.46 seconds. People are talking to each other even if they don’t always tell us what’s on their mind when they finally consult.

  1. Getting a sick certificate when you are not actually sick:

Usually if you say anything in regards to the gastro-intestinal area, they can’t really say no. It’s too hard to find out what the issue might be, plus it could just be something bad you ate the night before, so they usually just give you the certificate.

2. Hypothroid testing: what you need to know and ask for.

Please help!!! I feel like im going crazy! Im tired all the time. I’ve gained over 30 pounds in the last year. Dont get me wrong i have always been big but never gained weight this fast. I had my gallbladder out in March of this year due to a very large stone. My doctors and I contributed my symptoms to the gallstone but nothing changed after surgery. I feel like something is just off with my body. My GP did a blood panel and said everything came back normal. I feel sick all the time. Very fatigued with brain fog. What do I need to do to get this under control? I’m 34 years old and I feel like I’m falling apart. I need help and the doctors seem to think that it’s in my head because all my tests come back normal. What should i demand to be tested or done?

3. How to talk to Dutch Doctors so that they’ll listen

I don’t know how many times I went to the doctor with a sick child only to be told to go back home and give them Paracetamol. My husband, however, always gets medicine when he needs it. I’ve been wondering how he does it. Many times, I send him to the doc’s office with whichever child is sick at that time and he comes back home, waving the prescription for antibiotics at me. For a long time, I wondered, how does he do it? What am I doing wrong? So I asked him. The insights he gave me are just too precious to keep secret. Apparently, Dutch doctors require a special mode of communication…

4. Will my Doctor prescribe me Duromine??

Theoretically you have to have a Bmi of 30+ to be able to qualify(?) for a script in Australia. However many doctors don’t like it at all and won’t prescribe. Mine said it was evil and caused more problems than it solved. Refused.  I ended up going to a bulk billing clinic as figured if this doctor said no at least I wouldn’t be out of pocket.  Said my Bmi nudging 30 and weight making me sad and depressed. Losing confidence. Also that I had signed up at the gym with a series of personal training sessions to start me off. (True). And would like to use it to kickstart losing weight, a healthier lifestyle and better eating habits. (True) And that I had used Duromine in the past and not had any issues re blood pressure or heart etc. (not true). Initially this doctor said no, hates the stuff, banned in America, very bad drug etc etc. After some discussion he ended up writing me a script for 1 month.

5. How to convince your GP to refer you to a specialist?

You feel like you don’t have the right to make your GP listen. What they say goes. That is not the case, and sometimes you really have to push the issue or go elsewhere. You may have to be pushy, and you may have to be blunt and pretty much say “I don’t think you are taking me seriously and I think you are making excuses”. If the doctor you have still isn’t listening, then you have a right to a second opinion. Exercise this right. Go to another doctor if necessary.

It is more than likely that some people will present with ideas about what they think they need to get better. It could be a day off, or a blood test, drugs or a referral. For each of the examples above we need to consider how to facilitate the best in consultations. From what is said on such websites it appears that people come armed with arguments why their will should prevail even against expert advice.

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Why people will sack a plumber but won’t sue their doctor

Everyday somebody somewhere summons a plumber. The drain is blocked, the boiler isn’t working, there’s a leak under the sink. The problem is obvious the solution is technical and everyone knows when the job is done. If it’s not fixed asap the plumber is sacked.

That’s rarely what it’s like in medicine. Not everything is a blockage or a break. Not everything can be fixed by sitting quietly with a tool box and following the instructions in the manual.

Many of the commonest problems in healthcare don’t have an easy fix.

  1.  The pain of ‘tennis elbow’ can last for months despite treatment

Patients with tennis elbow can be reassured that most cases will improve in the long term when given information and ergonomic advice about their condition. Bassett et al.

2. Plantar warts don’t always respond to cryotherapy

Little evidence exists for the efficacy of cryotherapy and no consistent evidence for the efficacy of all the other treatments reviewed. Gibbs et al

3. Lung cancer is incurable in most cases

Lung cancer is the main cancer in the world today, whether considered in terms of numbers of cases (1.35 million) or deaths (1.18 million), because of the high case fatality (ratio of mortality to incidence, 0.87). Parkin et al. 

4. Anti hypertensives aren’t guaranteed to prevent stroke

Our analysis indicated that the absolute benefits of antihypertensive therapy depended on BP as well as the presence or absence of additional cardiovascular disease risk factors and the presence or absence of preexisting clinical cardiovascular disease or target organ damage. Ogden et al

5. Mild depression can be hard to treat

The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. Fournier et al 

6. There is no cure for the common cold ( You don’t need a link for this)

These and most other problems in healthcare cannot be ‘fixed’. They can be diagnosed and they can be ‘managed’ but they can’t be fixed in the way that faulty plumbing can be fixed. Therefore that queue of people in the waiting room is saying something more than ‘I’m here to be fixed.’ Patients are saying:

  1. I am in pain
  2. I am anxious
  3. I am unhappy
  4. I am bored
  5. I am angry
  6. I am confused
  7. I am lonely
  8. I don’t like my job
  9. I can’t pay my bills
  10. I need tablets or surgery

The job of the doctor is to work out which and then to fix what can be fixed and help the patient to live with the rest until their perspective or their circumstances change.

  1. Most people won’t take their tablets as prescribed.

    Because non-compliance remains a major health care problem, high quality research studies are needed to assess these aspects and systematic reviews are required to investigate compliance-enhancing inteventions. Let us hope that the need will be met by 2031. Vermeire et al 

  2. Most people won’t benefit substantially from health promotion advice.

Exercise-referral schemes have a small effect on increasing physical activity in sedentary people. The key challenge, if future exercise-referral schemes are to be commissioned by the NHS, is to increase uptake and improve adherence by addressing the barriers described in these studies. Williams et al

3. Most people get better in spite of treatment and not because of it.

Disease mongering can include turning ordinary ailments into medical problems, seeing mild symptoms as serious, treating personal problems as medical, seeing risks as diseases, and framing prevalence estimates to maximise potential markets. Moynihan et al

But then most people will be deeply grateful to their family doctor because they don’t have to respond a certain way to be treated with respect and they don’t expect a ‘cure’ and won’t ask for their money back when things don’t work out. The doctor’s role is to be there, to encourage, to educate, to accept and to walk with their patient through all the challenges that life has to offer.

Picture by Vicki

Address the patient’s greatest fears ASAP

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I think my son has meningitis.

I glanced at the boy who was now walking across the room to look more closely at a poster on antenatal care.

I don’t think so was my first thought, followed by thank you for telling me exactly what you are worried about. It’s not always that easy. Often the ‘hidden agenda’ remains just that- hidden. The longer it remains unchallenged the greater its hold. Then it’s much less easily to address head on. Sometimes you get a sense of it from the smell of fear as it comes into the room. Occasionally it’s hidden in a request for curious tests:

Could you check my vitamin levels?

My favorite is those who come for ‘check ups’ and are seemingly asymptomatic. I recommend the paper by Sabina Hunziker and colleagues. They studied 66 cases of people who explicitly requested a ‘check up’. All consults were video recorded and analysed for information about spontaneously mentioned symptoms and reasons for the clinic consultation (“open agendas”) and for clues to hidden patient agendas using the Roter interaction analysis system (RIAS).In RIAS, a cue denotes an element in patient-provider communications that is not explicitly expressed verbally. It includes vague indications of emotions such as anxiety or embarrassment that patients might find difficult to express openly and that prevent the patient from being completely forthcoming about his or her reasons for requesting a consultation. All 66 patients initially declared to be asymptomatic but this was ultimately the case in only 7 out of 66 patients.

Back to the boy with ‘meningitis’. He had a fever and aches and pains. However according to Dr. Google, who mum consulted just before rushing to the surgery, if the child had ‘cold hands’ one of the possibilities is that the child has meningitis.

I examined the child thoroughly and found that he had a mild pyrexia and signs of an upper respiratory tract infection. He was awake, alert and clearly interested in his surroundings. He was persuaded to smile and had no signs of septicemia. As this is a common fear in anxious parents I am prepared with standard advice that might be helpful and outline the way meningitis presents. Something I have encountered in practice.

There are many other fears that are presented in an urgent consult. In 99.99% of cases, they are unfounded. However the opportunity to allay the patient’s fears is also an opportunity to forge a bond that may be of enormous assistance when those fears prove to be well-founded. It may be worth considering how you will respond to patient fears of the many monsters that appear in the dead of night; cancer, heart attack, Kawasaki’s disease and meningitis in particular. Bearing in mind these monsters do occasionally present in the most atypical fashion.

Picture by Pimthida

 

Healthcare is not akin to internet shopping

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It’s encouraging when the patient asks you for your card after consulting about their warts. It suggests you have earned their trust and the next time they present you can expect to hear about something more worrying.

With regard to primary care there are those who believe there is money to be made by providing access to any doctor, anytime over the internet. However, the first commercial failure of this approach has just come to light. HealthSpot was featured in the New York Times, the BBC news and the HuffPost tech. According to posts on the internet:

HealthSpot Inc. told its largest pharmacy chain customer, Rite Aid Corp., that it would “cease operations” as of Dec. 31, and its telemedicine stations have shut down in Rite Aid pharmacies in northeast Ohio and the Dayton area.

And this after announcements in Mar 2015 that Internet provider Cox Communications was pouring money into HealthSpot, a telemedicine kiosk provider. At the time the Internet provider was reported to suggest that this could be:

As important to health care as ATMs have been to banking.

There was an expectation that doctors would virtually diagnose ailments such as allergies, bronchitis, the flu, earaches and ear infections, fevers, rashes, and sinus infections.

The model was nicely illustrated in this video.

But something appears to have gone drastically wrong and according to journalists attempts to reach the HealthSpot CEO have been unsuccessful. Commentators have been speculating that what may have contributed to the demise. An interesting comment was reported by Neil Versel

Jason Gorevic, CEO of telemedicine company Teladoc, expressed his belief that there are three critical elements to success in this industry segment: the technology platform, clinical capabilities and consumer engagement. “Consumer engagement is hard to do,”

And that may be the crucial point- the patient experience was not baked into the design of this innovation. The limitations of telemedicine in the context of primary care may be far greater than is being acknowledged by people who have very little insight into the business of doctoring.

Three years ago our research concluded:

Patients with minor self-limiting illnesses and those with medical emergencies are unlikely to be offered access to a GP by video. The process of establishing video consultations as routine practice will need to be endorsed by senior members of the profession and funding organizations. Video consultation techniques will also need to be taught in medical schools. Jiwa et al.

A minor illness provides an opportunity for the doctor to bank social capital, something that both will rely on when the symptoms presented at a future consultation suggest a life-threatening pathology.

Photo by C.C. Chapman

Are doctors OK with being fallible?

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Every doctor’s nightmare

  • Patient presents to doctor looking reasonably well one day.
  • Doctor fails to make the correct diagnosis of some dreadful disease.
  • Bad outcome the following day.

It starts in medical school. Student’s, especially those who are used to giving the right answer, may feel unworthy if they didn’t ask the right question, didn’t examine under the drapes or didn’t order the right test. How mentors handle receiving the ‘wrong’ answer will make a huge impact on whether the student will cope with mistakes in future.

In reality patients rarely present as described in textbooks. Biology is not a mathematical science. People may not be good witnesses to their own illness. There are four presentations that are troublesome in relation to people with significant pathology:

In these circumstances misdiagnoses are possible and, in theory, could result in legal action. Bad outcomes however are rare. So could a doctor survive a lifetime in clinical practice worrying about their fallibility?

How doctors handle a case of someone in each of these four scenarios will depend on the context. Their response might vary depending on:

  • What they know about this person before they presented
  • Who was expressing concern
  • What they say that doesn’t fit with what appears to be wrong
  • How the patient describes what’s happening to them and not just what they say

But more than that it depends on how they practice:

  • Are they able to review the patient soon afterwards?
  • Is there anyone else who can corroborate the patient’s story?
  • If they take shortcuts on the way to making a diagnosis (too little time listening, no examination or too many distractions) .

The consequences of the bad outcome will also vary. They are most likely if the patient or their family don’t believe the doctor cares.

Four things might help:

  1. If the description of the symptoms doesn’t fit with what the doctor can confirm on physical examination, the doctor should think again before dismissing it as benign.
  2. Doctors must have excellent communication skills to practice medicine even if their patients are going to be a sleep most of the time they have contact with them.
  3. Doctors should anticipate being wrong at some point in their career and have a strategy for how to handle that scenario.
  4. Clinicians must be aware of the circumstances in which they are more likely to get it wrong and have contingencies in place.

The other lesson that is seldom taught is the harm that is done because of an injudicious use of tests in search of the needle in the haystack. But that’s another story.

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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.

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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