Tag Archives: unmet need

Spend a few dollars to enhance the experience at your clinic

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Do you associate a smell with your doctor’s clinic? If you do it’s unlikely to be anything pleasant. I remember my GP’s waiting room when I was a child. He consulted, as did most doctors at that time, from his home and the patients waited in his converted garage. It was always cold and smelled-‘damp’. Not a nice place to be when you had a fever or anticipated an injection. The smell evoked the impression of being somewhere like the picture above which apparently is an abandoned hospital near Berlin. Research suggests this is not surprising:

Subjects then rated their memories as to how happy or unhappy the events recalled were at the time they occurred. Subjects in the pleasant odor condition produced a significantly greater percentage of happy memories than did subjects in the unpleasant odor condition. When subjects who did not find the odors at least moderately pleasant or unpleasant were removed from the analysis, more pronounced effects on memory were found. J of personality and social psychology

So the unpleasant memories of being ill and anticipating pain were reinforced by the musty smell of that waiting room.

We all know that smell can affect our feelings, whether it’s a loved one’s favourite perfume or the smell of a pastry in our favourite bakery. Humans are able to recall smells with an impressive 65% accuracy a year after smelling them, compared to just 50% of visuals after only three months, making it all the more important to use this additional sensory tool when trying to engage with customers. Engage Customer

Of all the things we consider about the experience we offer our patients smell is the least of them and yet potentially the most powerful. We carefully pick the colour scheme, the toys and magazines, may be even the floor coverings and the video entertainment but rarely if ever the smell. Perhaps it is because until relatively recently it was thought that humans had a poor sense of smell. However research has debunked that myth:

These results indicate that humans are not poor smellers (a condition technically called microsmats), but rather are relatively good, perhaps even excellent, smellers (macrosmats). This may come as a surprise to many people, though not to those who make their living by their noses, such as oenologists, perfumers, and food scientists. Anyone who has taken part in a wine tasting, or observed professional testing of food flavors or perfumes, knows that the human sense of smell has extraordinary capacities for discrimination. Gordon Shepherd, PLOS Biology

Here’s Engage Customer again:

Scent and sensory marketing have the potential to increase sales, boost brand loyalty, spur brand advocacy and create a strong lasting emotional connection with customers. Customer experience goes far beyond simply what meets the eye, or the ear, so try and create a lasting impression for your customers which appeals to all their senses.

Researchers shown consistently that scent has an important impact on satisfaction but also on the quality of the interactions between people in a public space. This has implications for the value of one of the ‘props’ in your practice i.e. the smell.

whats-it-aboutListen to Fred Lee  vice president at two major medical centers and a cast member at Walt Disney World in Orlando, Florida. He suggests in this TEDx talk that we should be focusing on ‘patient experience’ rather than ‘patient satisfaction’. More than 137,000 people have listened already.

We need to move away from the limitations of ‘patient satisfaction’ which is characterised by the cheesy phrase:

What else can I do for you today?

To patient experience which is all about engaging with the patient in all five senses. Some service providers are already on to this:

Airlines Infuse Planes With Smells To Calm You Down (And Make You Love Them). The Huffington post

Picture by Stefano Corso

Perspective is crucial when considering changes in healthcare policy

It was summer of 2010 in Australia. I had been working hard in the garden one Sunday afternoon. Feeling the need for a little mindless entertainment I suggested to our then 14 year old that we might rent a sci-fi movie. It was around 7pm and  getting dark. My son jumped into the car beside me and we took off toward the video shop. That’s when I noticed that the car headlights were far too dim. I turned on full beam- but it didn’t help. I ranted for a good five minutes about how difficult it was going to be to get a mechanic to look at the car so close to Christmas. I was also a bit put out that our teenager was showing no concern for my predicament. At this point he quietly reached across and took my sunglasses off my face.

There. Problem solved dad.

I learned something that day not least what it would cost me if that story was not be retold to his brothers.

I love the work of Deana McDonagh and Joyce Thomas, especially their thinking on empathic design. Deana and Joyce begin their sessions on empathic design by inviting participants to try on their designer glasses- the ones that demonstrate what it must feel like to have tunnel vision. They’ve written about it in the Australasian Medical Journal. I keep those glasses in my office to remind myself and visitors of the valuable insights they offer but also as a treasured momento of a fun workshop generously organised by a brilliant team.

Their work came to mind later when we were investigating the attitude to self-management of a condition that is progressive and for which there is no cure. Patients and doctors in an Asian setting were interviewed. We recorded poignant stories about the impact of this condition on people’s lives- resulting in social isolation, self loathing and a need to feel supported by a health practitioner:

Both patients and doctors were against the adoption of self-management strategies. This is contrary to recommendations for the management of COPD by many studies and guidelines. However, another study has similarly shown that self-management skills were not rated as important by patients. Furthermore, the psychosocial impact of their disease such as fear limited their ability to manage their own symptoms. A lack of knowledge may also contribute to their dependence on doctors and health care providers.

We concluded:

In reality, patients have to conduct self-management daily and it is not feasible for physicians to provide all of the management needs that patients have during their day-to-day lives. Therefore, self-management remains an aspect of overall COPD care. However, it should not be the only focus and future interventions should also examine ways to improve access to health care.

On reflection we noted something similar with patients in Australia. Those who had an established medical condition were much more likely to ‘trust’ their doctor than those who were not currently unwell or those from higher socioeconomic groups. Innovating requires the ability to see people as heterogenous having very different perceptions on the need to be in charge of their own health, perceptions that are liable to change with circumstances. I also wonder if policy makers consider what it must be like to implement their big ideas from this perspective:

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Will patients ever benefit from dubious surveys published in academic journals?

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The headline in the newspaper was provocative:

One in 10 parents do not trust GPs with their child’s healthcare: survey

Three questions arise:

  • Is it new?
  • Is it true?
  • So what?

It didn’t resonate. Children under the age of fifteen constitute at least one in ten encounters with General Practitioners (Family Physicians). That means there are at least 12 million consultations with children in Australia every year. The notion that parents don’t trust their GPs is questionable. Even in the study reported by the newspaper most parents (91%) had a regular GP and more than one in three children had visited a GP at least five times a year. The conclusions reported by the journalist were based on a study in which 666 parents were approached in a paediatric outpatient clinic to participate in a survey by a ‘trained research assistant’ and offered $10 for participating.  The context is important given that the conclusions as reported in the newspaper headlines were about people’s views on GPs.

100 parents in each of five specialties and 50 parents in each of the subspecialties was the ‘target number’- but we are given no justification for that number. The validity of the survey depends, in part, on the sample size which is governed by what was anticipated to be the likely response.

The questionnaire was ‘developed’ by the research team and pilot tested with 39 parents across both hospitals. We are not told how the questionnaire was developed and refined or how the validity and reliability of the responses were tested. Nor are we told why piloting ceased at 39. No scientific framework is cited. Without this information the interpretation of the findings is speculative.

It is reported that only half of the new patients seen in the paediatric speciality clinics were referred by a GP. The remainder were referred by other doctors. Therefore these participants were receiving their care from specialists and hospital doctors and it is reasonable to assume that their views were influenced by this experience.

If we are to read on notwithstanding the limitations evident early in the paper we note that only 45% of respondents were ‘completely confident’ that ‘a GP’ can provide general care to their child. From the way the question is posed we don’t know why the respondents were not ‘completely confident’. It could be because they think:

  • A GP doesn’t have access to the resources their child might need
  • Their child has had an illness that requires specialist to monitor their care
  • A GP doesn’t offer appointments when it suits them
  • A GP doesn’t do blood tests, X-rays, scans or prescribe the drugs they think their child needs
  • A GP isn’t qualified to look after their child
  • Someone they trust told them their child should see ‘specialists’ every time

Our understanding of this paper depends on which of these was meant by the respondent but the question was never posed in a meaningful way. The paper does not report the perspective of either the referring doctor or the specialist about the need for that specific referral. Without that information we can only draw conclusions based on our perspective on the issues. We certainly cannot conclude that GPs need more training in paediatrics unless we were looking for an excuse to come to that conclusion. Why publish a survey that cannot be interpreted meaningfully?  The concept explored is not new, the data can’t be safely interpreted and the only question is so what? Who benefitted from this ‘research’?

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Biomedicine falters when it ignores our messy lives

What this mum needed most was a good nights sleep. I proceeded to examine her smiling, curious, well fed, active infant. He reached up and grabbed my stethoscope than raised an eye brow and looked into my eyes and cracked a gummy smile the way babies do.

But he never cries doctor and today he hasn’t settled at all.

She was tired, she was a first time mum. She couldn’t see what I could see a content baby with a viral upper respiratory tract infection.

My sister says he could have a seizure when his temperature goes up. Both her boys have fits.

She needed me to tell her her baby was well, that he wasn’t going to have febrile convulsions and that one day soon, preferably today,  he would stop being wakeful at night. I mused that the child’s grandparents might have been helpful, but they lived in another city on the other side of the country. I had ten minutes to convince this mum that an immediate visit to the emergency department, ‘just in case’  was not warranted. She needed me to be calm and reassuring. She needed me to be confident. Anything else would reinforce the nightmare of visits to an emergency department every time the child had a fever.

The literature presents an interesting perspective on the issues:

  1. Acute illness in infants: a general practice study– Of the 126 consultations reviewed, 106 (84per cent) included at least one major symptom. None of the illnesses resulted in hospital admission or had a fatal outcome. It was concluded that this classification of symptoms into ‘major’ and ‘minor’ categories is not sufficiently discriminating to use in general practice. More specific definitions are required. No significant relationship was found between the reported presence of major symptoms at a consultation and maternal age, number of siblings, social class, unemployment, single parent family or proximity of maternal grandmother. Wilson et al.
  2. Non-urgent Use of a Pediatric Emergency Department: A Preliminary Qualitative Study– These visits ( to hospital) appear to be driven more by consequences of system design and structure than by family members’ decision making. Mistrust of primary care services was not a strong family decision-making factor; the study’s setting may have limited its ability to capture such data. Recommended system changes to lower barriers to primary care include expanded office hours, subsidized staffing for offices in medically underserved areas, and lowering barriers to sick care. Chin et al 
  3. New mother groups as a social network intervention: consumer and maternal and child health nurse perspective– The groups ran for approximately eight sessions and provided infant- focussed parent education and social contact. Women who joined the groups were followed up 18 months to two years later to determine the degree to which these groups continued to meet on their own accord and the extent to which they had become self-sustaining social networks. The study found a very high level of continuation, suggesting that providing such programs may be an important vehicle for enhancing social support during the transition to parenthood and thus a useful primary prevention strategy. Scott et al

I seems it is not possible to provide guidance based on a list of symptoms- ‘if this’ then reassure, ‘if that’ then refer. This makes it even more difficult for new parents to be ‘taught’ to seek care ‘appropriately’ and proximity of grandmothers makes no difference. Essentially the advice that if you are concerned then seek help is reasonable. Secondly when parents end up taking their infant to hospital there isn’t unequivocal evidence that it’s because they don’t trust their family doctor but rather it’s because they didn’t have access to one when needed.  Finally it may be possible to offer new mums more support at a time when access to extended families is reduced and becoming the exception rather than the rule.

Every day colleagues will be consulted about a child as a cry for help. We need an approach that crafts a solution in the context of these consultations rather than a mechanistic biomedical approach that ignores the messiness of our lives.  Family practice provides that approach and effectively reduces the cost of healthcare to our economy.

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Profiting from vanity- they may be targeting someone you love.

Where I live you’d be forgiven for thinking that you will be reported for child abuse if your teenager has less than perfectly straight teeth. Kids are growing up believing they need to be physically perfect.  So when the first crop of zits appears there is a hasty and often expensive trip to the chemist. Treating acne is a $3 billion industry in the United States alone.

..but i just feel so ugly when i see pretty girls with perfect skin around me.. it just makes me feel terribly disgusting, honestly. like i’m less of a person. it’s not fair. at my age there’s so much pressure to look beautiful constantly. even though i know most people don’t care how good you look a lot of them are secretly judging inside… everyone does it, even me..Nyla

Those in the age group 15-24 account for 7.6%  of consultations in general practice. Significant or life limiting pathology is unlikely in this age group but for many these meetings with their doctor will set the tone for a life long relationship with their main healthcare provider. For young people acne and eczema are the reason for almost one in three consultations with a GP. Sadly it has been reported that some teenagers get a very poor deal when they pluck up the courage to see a doctor:

It’s not that he doesn’t listen … sometimes he doesn’t fully comprehend that he’s talking in a way you can’t understand … it would help if they talked to teenagers. ( As reported by Jacobson et al in the BJGP)

This could be a missed opportunity to forge a relationship with the patient. If you are a doctor it may be worthwhile rehearsing a lucid explanation of common problems presented to you, including and especially acne. There is a bewildering array of opinions on this problem. Indeed the conclusion of research on this topic was that the majority of young people are getting information from non physician sources and there may be a need to evaluate the resources they are using to make sure they are receiving appropriate, helpful information. That includes parents who would rather their teenager would learn to live with her spots and expect you to endorse that view.

For those who want a ‘cure’ the opportunity for to profit from their distress makes them vulnerable to the most unscrupulous practices. $3 billion USD represents a substantial market for lotions, potions and diets that don’t work.

Substantial numbers of those surveyed had ideas about cause, treatment, and prognosis that might adversely affect therapy. Rasmussen and Smith

The truth is acne is a manageable condition, it’s just a matter of finding a treatment that works for an individual. For most people, it may take few attempts at find something that works. For some, over-the-counter topical creams are fine, for others, oral antibiotics or hormonal treatments work better, and yet others only respond to drugs prescribed by a dermatologist, with multiple courses required in relatively rare circumstances. The goal of having clear (or at least totally acceptable) skin is not unreasonable. This is a teachable moment in the interaction with young people.

Picture by Caitlin Regan

How can medicine compete against the new normal?

Joanna was exactly the person we are being urged to help. In her forties, overweight verging on obese. Hypertensive, asymptomatic but well on her way to chronic diseases. We discussed her diet.

I like salt. So my food tends to be salty. Also most people in my house are my size. I thought about reducing my portions but I like meat, lots of meat. I’m a member of a gym but I rarely go there.

We talked about her risk of heart disease and encouraged her to banish the salt cellar from the table, perhaps think again about reducing the portion size and making time to go to the gym. She looked at me pityingly her eyes said

Well that ain’t gonna happen

This was not a teachable moment. She was not ready to make an investment in changing her habits. She could not see that she was at risk. She was ‘normal’ as far as she could see. So she was not going to change her diet to deal with a problem that she did not perceive as real.

There are many things that are regarded as ‘normal’.

It is now normal:

  1. To have to wear extra large clothes.
  2. To be offered larger portion sizes when we dine out
  3. For more than one in three Australians aged 14 years and over to consume alcohol on a weekly basis
  4. For friends or acquaintances to be the most likely sources of alcohol for 12–17 year olds (45.4%), with parents being the second most likely source (29.3%)
  5. For more than one in three Australians aged 14 years and over to have used cannabis one or more times in their life
  6. For more one in ten people to drink and drive
  7. For one in three people to lose their virginity before the age of 16 ( i.e. before the age of consent) and also to have multiple partners
  8. For 66 percent of all men and 41 percent of women to view pornography at least once a month, and that an estimated 50 percent of internet traffic is sex-related.
  9. For most people who join a gym to never use it

These and many other trends dictate what is ‘normal’ to the average person. It’s OK to eat and drink far too much because everyone else does. It’s OK to be promiscuous, watch pornography and take risks because that’s what people see happening all around them.

Against these trends the challenge is to seek opportunities when ‘normal’ is seen as risky and hopefully before that risk has manifested as pathology.

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How improving the experience of hospital death can help redesign healthcare

 

The residents always approached my father as if he was a person and there weren’t any divisions between them. They didn’t come in and say, “I’m Doctor so and so.” There wasn’t any kind of separation or aloofness. They would sit right on his bed, hold his hand, talk about their families, his family, golf, and sports. From Steinhauser et al.

The chances are when the times comes you will die in hospital. It may be sudden or it may be expected and either you will die a good death or the experience for you and those who are left to grieve will make a bad situation worse. Charles Garfield put it like this:

A good death is no oxymoron. It’s within everyone’s realm of possibility. We need only realize its potential and prepare ourselves to meet it mindfully, with compassion and courage

John Costello concluded his research on patient experiences of death as follows:

The findings also challenge practitioners to focus attention on death as a process, and to prioritize patients’ needs above those of the organization. Moreover, there is the need for guidelines to be developed enabling patients to have a role in shaping events at the end of their lives. John Costello

Therefore, the needs of the ‘organisation’ may impact adversely on the experience of death. These might include the need to adhere to routines such as ward rounds, meal and medication time on open wards which may make it difficult to cater to the needs of the family when the patient dies.

A good place to start with innovation is to consider what, how and when things go wrong. Costello’s interviews with nurses identified several determinants of a bad death:

  • Sudden, unexpected or traumatic deaths especially soon after admission
  • Death other than on the ward
  • Family not aware of impending death or family conflict a major feature
  • Lack of dignity or respect
  • Diagnosis uncertain

Therefore, the key features are the circumstances surrounding the death. The consequences are far from trivial:

Dying patients with unresolved physical and psychological problems, such as pain, nausea, vomiting or spiritual distress, and who were unresponsive to treatment or nursing care, were invariably regarded as experiencing bad death. John Costello

This begs the question why not prepare for death in every hospital admission especially where death is a less than distant possibility. The majority of hospital deaths occur in those over 75 years of age. How is the team prepared if there is a death on the ward expected or otherwise, whether it’s convenient to the routines or not?

Achieving seven goals appear to mark a ‘good’ death:

  1. The patient should be physically, psycho-socially, and spiritually pain-free
  2. Recognize and resolve interpersonal conflicts.
  3. Satisfy any remaining wishes that are consistent with their present condition.
  4. Review their life to find meaning.
  5. Hand over control to a trusted person, someone committed to helping them have the kind of death they desire.
  6. Be protected from needless procedures that serve to only dehumanize and demean without much or any benefit.
  7. Decide how social and how alert they want to be.

Many of these goals are in the purview of the doctor and her prescription pad, others require all those involved to help prepare for an event that will impact on everyone associated with the patient. Healthcare is now a team effort and nowhere more than at the end of life.

When physical symptoms are properly palliated, patients and families may have the opportunity to address the critical psychosocial and spiritual issues they face at the end of life. Steinhauser et al

The point is if we prepare every hospitalised patient who may conceivably deteriorate and die as if we were preparing them and our units for that experience we will treat all patients with greater dignity. That’s the foundation of good outcomes for healthcare staff and the dying.

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Health is not a commodity

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I read through the questions on the dentist’s new patient form.

What is important about your smile?

Having something to smile about! I wrote.

Then showed the answer to my teenage son. He was called in next. He avoided eye contact with his grinning father. Soon afterwards a young woman entered the now almost empty waiting room. She leaned over the counter on tiptoe and whispered to the receptionist.

How much is it for a check up, scale and polish?

$150 if you are not insured. Said the receptionist.

Oh, right

The girl looked deflated.

I’ll leave it for now.

She turned on her heels and disappeared through the door. My son returned to the waiting room, followed by the dentist.

He’s got impacted wisdom teeth. If they don’t come out now it will be a bigger job in year or two. My receptionist will give you the details.

‘The details’ were a bill for $1500 to have them removed. Our son didn’t choose to have troublesome wisdom teeth. According to Colgate:

An impacted tooth can be painless. You may not even realize it’s there. However, when an impacted wisdom tooth tries to come in, the flap of gum on top of it can become infected and swollen. This can hurt. You might even feel pain in nearby teeth, or in the ear on that side of your face.

An impacted tooth can lead to an infection called pericoronitis. If untreated, this infection can spread to the throat or into the neck. Severe infections require a hospital stay and surgery.

Impacted teeth also can get cavities. An impacted tooth can push on the neighboring molar. This can lead to tooth movement, decay or gum disease. It also can change the way your teeth come together. Rarely, impacted teeth can cause cysts or other growths in the jaw.

I thought about the girl who’d walked out of the clinic. She wasn’t ‘insured’. She couldn’t afford the $150 it would cost to check if her wisdom teeth were impacted, or if she needs fillings or had gum disease. The cost to society of her inability to pay for her healthcare will mount exponentially if she needs hospital care. At some point in time ‘society’ deemed it acceptable for those who can’t pay for dental care or orthotics to suffer or to take risks with their future. And yet if someone were in the street howling in pain somebody would be moved to do something to help. Well, we’d like to think so.

Earlier that day my credit card had taken a $400 hit to cover said teenager’s orthotics. He has flat feet and the bill was on top of our insurance cover. Without the orthotics he can’t play sport. We can afford to pay. There are many who can’t. As a result they have fewer choices. This happened on the same day that a company informed me that unless I ordered $750 in academic regalia for the up coming graduation ceremony that they wouldn’t hire the one they had for me to use next week. I exercised the choice not to be held to ransom by mercenary commercial interests. I’ll find another way. That’s not an option in orthotics or dentistry. And yet the dentist seems like a nice enough person. He lives in the leafy suburbs, his wife has a good job and they are better off then most. He and his compadre the podiatrist are in the ‘business of medicine’. It is every bit as commercial as the gown hire business. When he went to dental school I think it’s a safe bet to assume he didn’t say his desire to do dentistry was so that he could make money by offering his skills only to those who can pay to be healthy. The rest, well the rest are someone else’s problem.

What is important about your smile?

Picture by Parveen Chopra

We have to be part of the solution because we are part of the problem

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She blinked at me expectantly. Her companion sat in the corner of the room, arms folded staring at the floor. She glanced at him side ways and then said in a loud whisper

We are here about that business last week. You know.

I didn’t know. So I frantically searched through the notes. The man in question had been seen here several times recently for various dressings. Nothing to say how he had been injured or the nature of the wound. At that point she lost it.

I don’t like talking about it in front of him! Because of his you know……well I told the doctor everything a couple of weeks ago. We need a report for the police and a referral for counselling.

I was mystified. The cryptic notes mentioned an injury to the arm and the application of various dressings but nothing about a bashing. She would have to see ‘the other doctor’ for the report. He was on holiday and not expected back for 10 days. Neither of us was satisfied. The next patient didn’t help matters. She had been pushed to the ground at the railway station and injured her wrist. She had been to the Emergency Department a couple of days ago and had been sent to the practice for an X-ray report. I assumed that someone had seen the X-rays and that she hadn’t been discharged with a bony injury. But there was no note from the Emergency doctor, hand written or otherwise and I now had to spend the next 20 minutes listening to musak while the ward clerk searched for a copy of the report and faxed it to me. In any other industry this waste of time would be tweeted as an example of bad service.

Meanwhile we are spending millions of dollars in search of electronic records that will somehow transform continuity of care. The assumption is that given such a record a doctor will document the circumstances in which she has come to reviewing a patient repeatedly or that the emergency department will reliably record why a patient was fit to be discharged. All of this is possible now if only doctors will plan for when the patient turns up when they are on a day off or choose to go to another provider. Hours can be saved each day, millions of dollars can be redeployed to make a system that already serves us well even better.

Assuming the technical challenge of a personal electronic record can be overcome the question is whether such a record will deliver its promise given that not all who work in healthcare are committed to treating the patient as they would wish to be treated themselves. There is no doubt that the free flow of information will help improve healthcare provision however the most valuable data that helps us serve people (history and examination) have to be documented by a human rather than a machine. Innovation should start with a change in the mindset of those who work in an industry. Are you confident that no one you served today would have to have their problems reassessed if you didn’t show up for work tomorrow? If so then we will be on the way to better outcomes overnight.

It’s also hoped the new system will reduce the high rate of medical errors (18%) that occur from inadequate patient information, reduce unnecessary hospital admissions, and save doctors from collecting a full medical history each time they see a new patient. The conversation

Picture by Ben Hussman

 

How you might stumble during a marathon medical career

299398986_994a9e9feb_zMedicine is an art. Sure there is science involved but in essence it is an art because science alone does not guarantee good outcomes in healthcare. If you fail to communicate with the patient, no amount of science is going to make a difference if the patient does not choose to act on your advice. That means the neither doctor nor patient can be removed from the outcomes equation. The needs and wants of the physician have as much of a bearing on the outcome as anything else in the mix. How we feel as health practitioners, how we are perceived, our biases and shortcomings are worthy of close attention and may be a great place to focus efforts to innovate in healthcare. Here are ten videos, reports or papers that identify the pitfalls.

Workloads can make it difficult for some doctors to perform optimally.

We may not be communicating effectively.

4 out of 5 doctors don’t get enough exercise.

Nearly 60 per cent of doctors may be overweight or obese.

Some doctors might lose empathy in the course of their training.

Burnout is a real risk in medicine.

While obesity may be increasing some doctors can harbour prejudice.

Dangerous drugs may be over prescribed .

The evidence doctors adopt in a specific case may be flawed.

Some doctors don’t explain risk well

Picture by Giulio Volo