The future of healthcareLearn More

What is the role of doctors in health promotion?

Our health is a cause for concern.

  • Over 1 in 5 Australians aged 18+ (22%) reported having Cardiovascular disease in 2011.
  • In 2009, the risk of being diagnosed with cancer before their 85th birthday was 1 in 2 for males and 1 in 3 for females.
  • 1 in 10 Australians aged 18+ (10%) had biomedical signs of chronic kidney disease in 2011–12, with the majority of these showing early signs of the disease.
  • 1 in 19 Australians (5.4%) had diabetes in 2011–12 (self–reported and measured data). This is includes approximately 1% of the population who did not self-report they had diabetes, which may indicate they were unaware they had the condition.
  • In 2007, 1 in 5 Australians aged 16–85 (20%) experienced a mental disorder in the previous 12 months.
    In 2013–14, 1 in 7 children aged 4–17 (14%) were assessed as having mental health disorders in the previous 12 months .
  • Over 1 in 4 Australians (28%) reported having arthritis and other musculoskeletal conditions in 2011–12. The most prevalent conditions were back problems, osteoarthritis, osteoporosis and rheumatoid arthritis.
  • 3 in 10 Australians aged 25–44 had untreated tooth decay in 2004–06.
  • 1 in 10 Australians (10%) reported having asthma in 2011–12. This rate is significantly lower than the rate of 11.6% in 2001.
    1 in 42 Australians (2.4%) reported having COPD in 2011–12. The development of COPD occurs over many years and mainly affects middle aged and older people.

It seems:

  • We eat too much. Almost 2 in 3 Australian adults (63%) are overweight or obese. 1 in 4 Australian children (25%) are overweight or obese.
  • We don’t take enough exercise. Based on estimates that between 60 and 70 per cent of the Australian population is sedentary, or has low levels of physical activity, it has been suggested that increasing participation in physical activity by 10 per cent would lead to opportunity cost savings of $258 million, with 37 per cent of savings arising in the health sector.
  • We drink too much alcohol and have been drinking more every year.
  • We don’t eat enough vegetables. In 2007–08, just over half of all children aged 5–7 years (57%) and a third of children aged 8–11 years (32%) ate the recommended amount of fruit and vegetables but only 5% of people aged 12–18 years and 6% of people 19 years and over did so.
  • Too few of us avail of cancer screening tests.
  • We drive too fast. Speeding is a factor in about one third of road fatalities in Australia. Additionally, more than 4100 people are injured in speed-related incidents each year.

Someone must be to blame for all this- if only they would do their job and tell us to eat and drink less, exercise more and slow down.  But wait there are industries profiting from our bad choices. We are influenced by more than our doctor. We have known this for decades. It is known as the Bronfenbrenner’s Ecological Model:

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At the core of Bronfenbrenner’s ecological model is the child’s biological and psychological makeup, based on individual and genetic developmental history. This makeup continues to be affected and modified by the child’s immediate physical and social environment (microsystem) as well as interactions among the systems within the environment (mesosystems). Other broader social, political and economic conditions (exosystem) influence the structure and availability of microsystems and the manner in which they affect the child. Finally, social, political, and economic conditions are themselves influenced by the general beliefs and attitudes (macrosystems) shared by members of the society. Wikipedia

Most Australians (13 Million) spend over 18 hours a day online. One in every five minutes (3.6 hours) a day is spent on social media. On the other hand time spent with general practitioners (GPs) is declining:

The proportion of GPs providing ‘Level C’ consultations (longer than 20 minutes) is substantial (96%) and constant; however, the number of long consultations provided per GP decreased by 21% between 2006 and 2010. The proportion of GPs providing Level D consultations (longer than 40 minutes) decreased from 72% in 2006 to 62% in 2009, while the number of Level D consultations provided per GP decreased by 26%. AHHA

Secondly the number of problems presented to doctors in increasing. In one survey of the 8707 patients sampled from 290 GPs, approximately half (47.4%, 95% CI: 45.2–49.6) had two or more chronic conditions.

Junk food is cheap and readily available. It is advertised to children. Fresh fruit and vegetables are less available, more expensive and of poorer quality in rural and remote Australia. These areas are also among our most economically disadvantaged and residents generally have less disposable income to spend on expensive, healthier food options. According to one report a multinational fast food company paid $500 million in taxes to the Australian government and might be due to pay more.

A 2017 poll  found that most Australians (78 per cent) believe Australia has a drinking problem, 74 per cent believe our drinking habits will worsen over the next five to ten years, and a growing majority (81 per cent) think more should be done to reduce alcohol harm. A price increase of 10%  on alcohol has been shown to reduce consumption by an average of 5%. Similarly for every 10% increase in price, consumption of tobacco reduces by about 4%. Finally a significant proportion of people are unhappy at work and this has been associated with snacking and weight gain.

So it seems that we are choices are triggered by far more than a doctor informing us that we are making bad choices. Doctors can make a huge difference to the individual who seeks advice in a teachable moment and can be triggered to make better choices. This requires more time with the patient and a greater focus on the needs of that individual patient rather than the distraction of a public health agenda.  At a public health level doctors’ impact is miniscule because of the much more powerful and ubiquitous drivers of poor choices that are fueled by those who profit from our dubious behaviour. A summary:

Image attribution

The chasm between patient experience and clinical practice

Can you guess what this abstract relates to without clicking on the link:

ABC is advisable if the patient does not show sustained improvement after a year of active treatment by other indicated means. The operation often represents the turning point in effective treatment. After the first year of ineffective treatment valuable time is being lost, with danger of fixation and deterioration. Then it is safer to operate than to wait. Calif Med. 1958 Jun; 88(6): 429–434.

That operation was last carried out in the 1960s. 40-50,000 were performed in the USA alone. This is what was reported about one person post op:

The reason for Dully’s lobotomy? His stepmother, Lou, said Dully was defiant, daydreamed and even objected to going to bed. If this sounds like a typical 12-year-old boy, that’s because he was.

What is being described below in 2011?

Remission of diabetes mellitus occurs in approximately 80 percent of patients after XYZ. Other obesity-related comorbidities are greatly reduced, and health-related quality of life improves. Complications and adverse effects are lowest with laparoscopic surgery, and vary by procedure and presurgical risk. Am Fam Physician. 2011 Oct 1;84(7):805-814.

In the same abstract the authors, Schroeder et al say:

The family physician is well positioned to care for obese patients by discussing surgery as an option for long-term weight loss…. Patient selection, pre surgical risk reduction, and postsurgical medical management, with nutrition and exercise support, are valuable roles for the family physician.

What do we know about this surgery?

According to the Schroeder:

Complications and adverse effects are lowest with laparoscopic surgery, and vary by procedure and presurgical risk…. Overall, these procedures have a mortality risk of less than 0.5 percent.

Here are some videos of what we are talking about. So what’s the patient experience?

Immediately post op:

Days 7-10: Now, at this stage, I shall only eat 4-6 Tablespoons of food each “meal” and I should have 5-6 meals a day. I can add mashed potatoes, custard, and pudding, but I must be VERY careful to keep it really low sugar and really low fat. Otherwise, my tiny pouch will rebel and make me regret it. Big Fat Blog

After a couple of years:

I had a lap-band. Then I had it removed after 2 years. The restrictions on drinking meant that exercise was difficult. And while I’ve felt emotionally broken for years, those two years were the only time I’ve felt physically broken. The experience was miserable. Big Fat Blog

Years later:

….almost 12 years later, there are still foods I have trouble eating. It still takes me 30 to 45 minutes to eat a meal, even if it’s just a sandwich and some chips. I have to stay away from anything that has a lot of sugar or a lot of grease in it (explosive diarrhea is not something you want to deal with in a public space, take it from me, been there done that). Big Fat Blog

Here are reflections from another blogger:

  • A few months after my surgery I started to have significant hair loss.
  •  It is important to take your vitamins.
  • There have been times that I have forgotten and do drink after I have eaten and when I do this I become quite uncomfortable and this is the occasions I may feel the need to vomit.
  • My taste buds have changed.
  • After I eat most of my meals or have a drink I get a little burppy. Not sure if it’s because I have eaten my meal too quickly (which I do), but it’s a side effect that hasn’t gone away.
  • This is really hard, everybody knows I have had the surgery but what they don’t understand is how little I can eat. I have to remember to ask for a small plate of food and I feel awful when I can’t eat all they gave me.
  • I hit a dark place about 2 weeks in, as I could only drink soups, watered down gatorade, sorbet etc. I really struggled with people eating around me being that I couldn’t eat.
  • I have tuckshop arms, which only recently have started to bother me like this morning when I saw them wobbling when I was drying my hair. It also does get me down a little when I lift my arm up and I notice people noticing my arms. I have an apron fold on my stomach from my pregnancy with the twins. When I have lost all my weight I would like to get the excess skin on my stomach removed. I will only do this when I have lost all my weight though. The organised housewife 

Experience of referral:

A few years later I moved and had to find a new primary care physician. She suggested Weight Loss Surgery… I asked her if she was familiar with WLS research regarding success (lack thereof), mortality rate, etc. After she answered, no, I asked her how she could recommend such a surgery when she was ignorant of its effects. She had no answer. Big Fat blog

So back to the literature (note the dates):

Undergoing laparoscopic sleeve gastrectomy induced efficient weight loss and a major improvement in obesity-related comorbidities, with mostly no correlation to percentage of excess weight loss. There was a significant weight regain and a decrease in remission rates of diabetes and, to a lesser extent, other comorbidities over time. JAMA Surg 2015

And

Not all bariatric patients, however, experience mental health gains from weight loss surgery, which is likely attributable to patients’ reactions to common undesired physical outcomes postsurgery: lack of weight loss, weight regain, and undesirable skin changes. Patients’ expectations that bariatric surgery will undoubtedly change their life may also set them up for psychological failure if expectations are not met. Journal of Obesity 2013

Finally we might reflect on the lobotomy as per Gregory Myers:

  1. The surgeon who introduced the world to the lobotomy was awarded the Nobel prize
  2. Some thought it was better than the alternative
  3. There was poor patient follow up
  4. It had significant adverse effects
  5. There was inadequate patient information and consent
  6. It destroyed people’s lives
  7. It was often a rushed procedure
  8. The indications for this invasive surgery were not limited to severe illness
  9. It was replaced by drug treatment

Is history repeating itself? It may by relevant that the global bariatric surgery market size was valued to be over USD 1,300 million in 2014.

Picture by rossodilbolgheri

Placebos catering to the desperate and now delivered to your door

2294965204_5d6b5ee39c_zShe was delighted with the ‘results’. She showed me that her blouse was loosely fitting. “A couple of weeks ago this was tight” she insisted. I guessed her BMI was still at least 30 but ‘Tiny deal‘ had sent her the answer to her prayers. An appetite suppressant that you wear on your toes!

They hurt your feet. It’s like walking with corns on your toes but you can eat whatever you like. You just don’t feel hungry. It only cost five bucks and that includes postage.

She recounted a life long struggle with her weight.

It started when I was a little girl. My step mother didn’t like me so I was bashed regularly and given lots of ‘bad’ foods to eat. Later I was teased at school because I was plump. People think I’m lazy because I’m fat. I have been tested for sleep apnea, diabetes and high blood pressure. The doctors have given up, they can’t fix it….I didn’t want that for my little boy. We don’t feed him junk and he isn’t overweight.

Now she was also ‘detoxing’ with insoles that turn black overnight. What do they do I asked?

Dunno, the information leaflets are all in Chinese.

Don’t you worry about any of this I asked? How does it work? What’s it actually doing?

Nope all I know is that I feel really clean in the morning and that’s proof enough for me.

What would you like me to do for you today? I wondered out loud.

Nothing doc…except that I need a certificate for work. The detox requires you to drink lots of lemon juice and it’s giving me diarrhoea so I can’t work.

So here’s some advice from Health Mango on the use of magnets to treat obesity:

Metabolism of the body is directly related to the thyroid glands. If this gland which is located at the base of the throat is stimulated with the North Pole, the basal metabolic rate goes up and the food is burnt in larger quantity and that too faster.For this purpose a fat person should keep the North pole of a medium, powered (1500 to 200 Gauss) magnet at the base of the throat for about 15 minutes. This action should be repeated 2 or 3 times in a day right after meals. Simultaneously one should drink the water treated with the North Pole of the magnet 3 or 4 times a day. Each time the intake of water should be about half a cup. Try this with some doctor’s advice and it will surely be beneficial.

What would ‘some doctor’s advice’ add? The notions described are entirely alien. The doctor’s advice would be….! this is nonsense. To which my patient’s retort might be:

This blouse is definitely looser, it’s only costing me $5 so what harm?

I did a literature search and found a review published in Acupuncture in Medicine a sister to the BMJ. The paper was entitled: Magnets applied to acupuncture points as therapy. The authors concluded:

Based on this literature review we believe further investigation of acu-magnet therapy is warranted particularly for the management of diabetes and insomnia. The overall poor quality of the controlled trials precludes any evidence based treatment recommendations at this time (2008).

None of this had prevented some enterprising person from selling magnets making extraordinary claims directly to the public. But wait, there is science involved. The placebo response in studies with binge eating disorders is estimated to be a whopping 32.6%. Furthermore the literature says:

Short-term intervention with a placebo, however, appears of little value with respect to the long-term management of these binge eating problems. Even among individuals with fewer complications related to obesity and comorbid psychopathology, Binge Eating Disorder may be a refractory condition.

So I guess we might be forgiven for thinking, as she hobbles over to the door clutching her certificate

See you next time

Picture by Indiamos

The way you practice medicine is about to change

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Healthcare reform is inevitable. We are not doing enough to meet the growing need for healthcare in our communities. A failure to act now could bankrupt our economies or reduce our capacity to maintain a productive, taxpaying workforce. Outcomes in healthcare have many drivers and are not limited to incentives to meet arbitrary targets. Attempts to reform healthcare have not been universally successful with many adverse consequences of misguided policies such as introducing ‘pay for performance’ especially in general practice. There is a limited supply of doctors in some parts of many countries with a relative oversupply elsewhere. There is much scope to improve access to doctors by deploying the Internet without forcing doctors to locate to those areas. There is much to do to reduce medical errors and to curb the cost of treatment. These ten very short videos are the case for the prosecution:

The population is getting older.

The prevalence of chronic disease is rising.

There are not enough doctors where they are needed.

There is scope to radically improve access to medical practitioners.

There is sometimes a failure to communicate with patients.

The cost of treatment is rising above the rate of inflation.

We conduct unnecessary investigations.

There are expensive medical errors.

There is limited flow of information across provider interfaces.

Plans to reform healthcare have not been universally successful.

Picture by Hendel Thistletop

Quantified self – the downside

The manufacturers of wearable health tech devices are set to make millions if not billions. Wearables are relatively cheap adjuncts to existing technology. But what difference will they make to the health and well being of the average user?  We have been offered a preview of what these devices can do- monitor your heart rate, blood pressure and blood glucose. Keep track of your respiratory rate, calorie expenditure and sleep patterns. Detect cardiac arrythmias and abnormal brain electrical activity. It sounds good, but so what? If you experience a significant drop or severe rise in blood pressure you are going to notice even before you check the readings- you will feel very unwell. Similarly low blood sugar and dysfunction of the respiratory or cardiac system. Do we really need our smartphone to tell us we aren’t taking enough exercise and eating too much? Or that it’s time to see a doctor urgently? I agree with Jay Parkinson:

The exclusive-to-human part of our brain evolved so we can be creative and manipulate the world around us so we can invent things like the iPhone. And now, the creators of the iPhone want to give us the tools we need to badly do what evolution solved for us hundreds of millions of years ago.

Here’s the problem with this technology in practice:

About 10 percent are “quantified selfers” with an affinity for this kind of feedback; just by looking at the numbers, they are motivated to be more active. An additional 20 percent to 30 percent need some encouragement in addition to tracker data to effectively change their behavior. Kamal Jethwani

Therefore the vast majority of people who buy a wearable device right now will not benefit from that purchase. Those who do, might be amenable to other interventions. Unfortunately much of the data is meaningless or has no impact on long term decisions about health and well being. Sure, a trend in high blood pressure over a few weeks might indicate a need for treatment but a single high reading might be an anomaly or simply confirm that you are excited. Worrying about every little bleep on the chart is not going to add to your quality of life but will detract from it. For a sustained and beneficial change in life style people need more than data. They need motivation and help to workout the benefits of making different choices. They need the undivided attention of a practitioner who understands their needs and assists with a bespoke plan.

Information that we need right now, which our built in human senses may not already have alerted us to is another issue; microscopic haematuria (blood in the urine) proteinuria (protein in the urine), faecal occult bleeding (blood in the faeces), raised intraoccular pressure (high pressure in the eye ball) and changes in moles, breast or testicles will prompt doctors to investigate for sinister causes. Investigations that might lead to the early diagnosis of some costly and treatable or life limiting condition. Acquiring this information doesn’t require you to wear a device continually for a year. The business case for manufacturing devices to do that isn’t as compelling because of a limited market. Enthusiasts for wearables argue that:

Studies are beginning that examine the data from wearables, which is much more granular data about human activity than scientists have been able to access previously. This will answer questions like: how much of an increase in activity, of what type (moderate or cardio-challenging) leads to what degree of health benefit? Todd Hixon

What we may also discover is that there are probably side effects associated with wearable devices. Psychological harm may be associated with prolonged and heightened anxiety and obsession with self. What we won’t discover (and this is a guess) is that there is a short cut to losing weight that doesn’t require any significant effort. We might also discover that there are limited indications for wearable devices and that the market for them is much smaller than we envisage. Parallels exist with some parts of the pharmaceutical industry which has begun to promote ‘illnesses’ that would benefit from it’s offerings. So called disease mongering. We may well find ourselves being circumspect about wearables in the way that we have misgivings about drugs:

…drugs approved for devastating illness, such as clinical depression, are indicated for milder conditions, such as shyness, which is now dubbed ‘social phobia’. Howard Wolinsky

Data is no more the answer to all problems than are drugs. The indications for collecting data have parallels with the indications for prescribing drugs and how and why that data is collected merits thought. Those who promote the use of wearables need to question a trend which isn’t without a downside.

The case for shared care

People are uncomfortable, if not alarmed, when the behaviour of someone they live with suddenly becomes ‘deviant’, ‘offensive’ or embarrassing; Grandfather becomes disinhibited, son becomes violent, wife starts shoplifting, daughter steals money from home. The unfamiliar moves us out of our comfort zone and we start to question the future, often catastrophising. Many chronic medical conditions result in behavioural changes. People hope that there is something that can be done to remedy the situation quickly so one of the first steps is to seek medical advice. It may be that the person has one of a host of acute or chronic conditions including life limiting pathology; Depression,  psychosis, dementia, substance abuse or cancer. The reaction to the behaviour may also result from misinterpretation or the complainant may be the one with the problem or feel stigmatised by the experience. Once an explanation is found it is often the case that medicine could make things worse- prescriptions, hospitalisation and tests may be harmful. There is also a risk of medicalising the problem as noted by Dworkin.

In the past, medical science cared for the mentally ill, while everyday unhappiness was left to the religious spiritual or other cultural guides. Now, medical science is moving beyond its traditional border to help people who are bored, sad or experiencing low self esteem- in other words people who are suffering from nothing more than life.

Nonetheless people seek help from doctors and there is great scope to assist by sharing care with others who may be able to help with a problem for which there is no pill and people have to revise their ideas, concerns and expectations. It may be that doctors are reluctant to engage people in these circumstances because they do not perceive that they have the resources or expertise to assist with what they consider outside their sphere of influence. Nonetheless people will continue to expect assistance. Epidemiology records that the rates of chronic and complex conditions are set to rise almost exponentially as the population ages and suffers the pathological consequences of poor life style choices. At the same time the cost of healthcare is increasing to the extent that services may be rationed. Already in Australia, even with a relatively healthy economy, the government is proposing cuts to healthcare expenditure. Meanwhile the number of people living with a family member who has a condition where behavioural changes are possible, if not likely, will increase. For instance the prevalence of dementia in Australia will increase from 332,00 to just under a million by 2050. The proportion of people with behavioural changes in the context of  this diagnosis is the majority of patients with an average duration of about 8 months during the illness. Such behaviours may have a profound impact on the emotional well being of the caregiver. It is  acknowledged that some caregivers do not easily adapt to the stresses of caregiving and are at risk in terms of their ability to continue in their role. A failure to maintain this unpaid caring role would have a significant impact on the cost of caring for the patient who may have to be institutionalised sooner rather than later. The conclusion of a study from Sweden was that:

Informal care, measured as hours spent caring, was about 8.5 times greater than formal services (299 and 35 h per month, respectively). Approximately 50% of the total informal care consisted of time spent on surveillance (day and night).

Therefore innovations that allow the medical practitioner to quickly incorporate assistance from organisations that specialise in supporting caregivers will enhance the prospects of sustaining an effective health service for all. The services of organsiations such as Alzheimers’ Australia may be underutilised because of a failure to respond to calls of help from stressed carers. Similar observations can be made about other chronic illnesses including substance abuse, cancer and palliative care where changes in behaviour may be common and medication has a limited role.

 

Seven trends influencing lean medical innovation

Innovators recognise that the their circle of influence is contingent on an awareness of their customers’ world view. Seven trends now impact on whether people are likely to welcome innovation into their lives.

Mobile communication

For many people mobile phones have replaced their wrist watch, camera and PDA. Phones are now used not only to keep in touch but also to access information with two taps. This is achieved on a ubiquitous device that is getting cheaper and more portable. An allied trend is for tablet computers that are little bigger than a phone to obviate the need for a laptop.

Testophilia

People now demand validity for professional advice that until recently was accepted as gospel because an authority figure proffered it as the truth. This means that you no longer trust me simply because I am a doctor. What’s more people want the results of medical tests in a format that makes sense to them regardless of their ability to digest complex information .

Quantified self

There is an increasing desire to measure and record whatever can be measured as if that in itself will be enough to influence our behaviour. Everything from blood pressure to how much we sleep. Quite what people are doing with all this information is a matter of debate but people are seeking ways to access this information.

Information overload

Because of the almost unlimited source of information at their fingertips people are actively filtering data. A quick Google search for ‘best diet’ revealed 625 million results with page upon page of conflicting and confusing advice. On the one hand you could opt for intermittent dieting or you could take the advice to ditch the diet altogether. As I hold the view that it has to be proved scientifically before it can be deemed true I more or less ignored (i.e. didn’t read) anything that didn’t appear to conform to my own worldview for valid and reliable advice.

Dr. Google.

Concerned people want relief from the outpouring of adrenalin with its unpleasant physical effects. In a Googlised world iving with uncertainty is regarded as unnecessary. This means as a clinician you have to assume people will have done some homework before they speak with you. Either what you say will resonate with their ‘ informed opinion’ or your advice will be rejected unless you are able to say or do something that changes how they feel about their problem and or the treatment.

Commercialisation

The cost of staying healthy increases every year . In Australia the cost of attending a doctor have fast outstripped the rate of inflation. As we age and need more maintenance we will either spend a greater proportion of our income on medicines or look for cheaper alternatives. There is now a compelling business case for marketing cheaper and more effective ways to deal with health problems that until recently required doctors’ appointments.

Want it now

Anyone living with a teenager knows that they no longer accept the wait for Christmas. If you want it, there must be a quick, cheap and immediate way to get it, preferably delivered to your door with a money back guarantee. Therefore speed of delivery is necessary, but not sufficient for success. Innovations that do what they say on the tin, at a reasonable price and come with excellent after sales service are almost guaranteed a bright future.

Lean medicine is about working in a world that has an insatiable appetite for quick, convenient, cheap solutions. The seven trends outlined here have a significant impact on the diffusion of innovation in healthcare. How have they impacted on the success of your ideas?