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Sharing information with patients

Worldwide the incidence and prevalence of chronic and complex health conditions (diabetes, heart disease, cancer, dementia) are rising. Therefore more conversations between doctors and patients will focus on the need for long term medication. Anyone who has been practicing medicine for two decades or longer has noticed a change in patient expectations. Here’s someone who suffered a myocardial infarction(heart attack) five years ago:

I just don’t want to take statins at this dose for ever. The cardiologist isn’t happy. My cholesterol is 3.6mmol/l and he thinks it should be less than 2. He has prescribed the maximum dose of a statin and insists that if it damages my liver there are drugs they can give me to counteract that. Are you prepared to guarantee that I won’t suffer another heart attack? And what is the risk that I will suffer side effects from these drugs? Why don’t you give me the numbers and let me decide? It’s my body!

On the one hand:

5 years of [name] statin would prevent about 70-100 people per 1000 from suffering at least one of major vascular events (and longer treatment should produce further benefit). The size of the 5-year benefit depends chiefly on such individuals’ overall risk of major vascular events, rather than on their blood lipid concentrations alone. Heart Protection Study Collaborative Group.

The Number Needed to Treat (NNT) with any statin to prevent one case of cardiovascular disease over 5 years was 37 (95% CI 27 to 64) for women and and  33 (24 to 57)  for men. Joanne Foody

On the other hand:

Treatment of 255 patients with statins for 4 years resulted in one extra case of diabetes. Sattar et al.

In women, the Number Needed to Harm (NNH) for an additional case of acute renal failure over 5 years was 434 (284 to 783), of moderate or severe myopathy was 259 (186 to 375), of moderate or severe liver dysfunction was 136 (109 to 175) and of cataract was 33 (28 to 38). Overall, the NNHs and NNTs for men were similar to those for women except for myopathy where the NNH was 91 (74 to 112). Joanne Foody

The world it not black and white, drug treatment may be beneficial but not risk free. The patient reporting to me was unhappy that his cardiologist had dismissed his concerns as trivial. Of every 100 people at high risk of cardiovascular disease treated with statins over five years 2-3 might benefit, 97 may not and 2-3 will suffer harm. At the time of prescribing it is not possible (yet) to identify who will experience adverse effects. All that can be said is that the bigger the dose, the longer the duration the greater the risk of harm. For my patient the impact of a second myocardial infarction may be catastrophic, the side effects of statins are mostly reversible. As an alternative to drugs he could have considered lifestyle modification. He may benefit although he may also be aware that there is only equivocal evidence for modest reduction in risk of a subsequent myocardial infarction. Incidentally effectively promoting lifestyle change brings into play a host of other considerations:

Support from family and friends, transport and other costs, and beliefs about the causes of illness and lifestyle change. Depression and anxiety also appear to influence uptake as well as completion. Murray et al 

As health professionals we are obliged to find ways to relay information in digestible format and support people whatever they choose. In most cases the choices also have a downside. Much of what we can achieve to improve health is predicated on our ability to communicate effectively. That is not possible if we do not address the perspective of the person who has sought our advice. After all it is they who must pay for the drugs or it is they who have to change their eating habits. Meanwhile the next patient I saw was a young man with moderate acne. He had been started on oral Minocycline by another GP. He opened with:

I don’t like the idea of taking these drugs for months.

How to make data more valuable

The 1st of July 2014 will be forever etched in my memory. On that date I woke up and peered across the bed to the window. Realising by the half light it was just past dawn I wondered why there was another body in the bed. It should have been at the gym. So I turned over and put my arm around her. I registered she was looking straight at me. She then uttered the words no man wants to hear who hasn’t planned for it. ‘Happy anniversary darling’. In the micro seconds it took my male brain to weigh up a response, her female intuition had already worked out my dilemma and laid the charge. ‘You’ve forgotten haven’t you?’  Guilty. I had forgotten. The rest of the day was spent demonstrating that 1. I loved her and 2. regretted forgetting our special (and easily remembered) date. It would have been so much easier to focus on one rather than both. A stitch in time and all that.

Later in the week I received what looked like a court summons with an official looking government stamp on the envelop. The letter inside read:

Dear (first name, last name),

Did you know that around 80 Australians die each week from bowel cancer? ..blah, blah , blah,…inviting people turning 50….blah, blah,.. faecal occult blood test kit with instructions…sent to you in the next few weeks…blah blah. If you are already being treated for bowel cancer contact….during business hours.

Yours sincerely,

Scanned signature

Chief Medical Officer.

Not ‘Happy birthday this is a big one mate!’ Not ‘We want you to stay healthy and happy’. No connection with me. Just a cold request to take a government funded test now that I have reached an age when my bowels are more likely to turn on me. Were they concerned about me or the statistics? This lack of connection may be part of the reason most people fail to participate in what is a life saving program.

Still later in the week my reception staff told me that a patient had left something for me in the staff room. Also being an Indian he anticipated my penchant for curries and had prepared a small feast as a thank you. Instant connection. I felt appreciated. I pulled out my pen and drafted him a note. The government invitation on the other hand, though it may save my life didn’t have the same impact. Sure I’ll take the test but only because I know it’s a good idea.

People who chose to share intimacies with us want to know that we really see them and that they matter. Medical practitioners and general practitioners in particular document all sorts of information about their patients; height, weight, gender, waist circumference, family history, alcohol and tobacco consumption, sexual orientation, menstrual history, temperature, blood pressure, pulse, heart sounds, medications, allergies, etc. How about their date of birth? Anniversaries of births, deaths and marriage? Why don’t we collect and use this information to make a connection? What I would have appreciated from my doctor in April this year was a hand written card that said something like:

Happy Birthday Moyez! Thank you for letting us be part of your life. We wish you health and happiness always. Don’t forget your wedding anniversary 01/07/2014! This year you can help keep yourself in good shape by taking the bowel cancer test, someone will write to you about that soon. To mark the very special occasion of your 50th birthday we have donated $20 to Medecins sans frontieres  Australia (http://www.msf.org.au/). Please stay in touch and call us if we can do anything to help you stay in good shape this year.

If a practice manager at an average Australian general practice searches their database for every 49 year old who visits the practice, I guess the list would contain a 100 souls at most. A 50th birthday card would cost the practice less than $25 including the donation. The goodwill that would generate would be priceless and make all of our lives better. As experts have noted:

GPs who initiate discussions about screening with underserved population segments in particular (e.g., those aged between 50 and 55, men, and people from a non-English speaking background) are in a unique position to decrease inequity in health outcomes and improve morbidity and mortality from bowel cancer. Carlene Wilson

 

Denying people the feeling that someone cares

The conversation I overheard in my practice many years ago went something like this:

Jean, I’m sorry there are no appointments available until Friday. Has he got a fever? Try him with some paracetamol today and I’ll book him in for Friday afternoon. There’s a lot of this flu like thing going around school. Ok, see you Friday.

A receptionist was triaging my patients! Medical qualifications = nil. She looked up with a pained expression, she was carrying more responsibility than I paid her for. And yet it has long been recognised that:

Little difference was observed between the symptoms reported by patients to the physicians as compared to those received by the receptionist staff. Physicians are more likely to use the telephone contact to treat the patient’s complaint with home care advice or a prescription. Receptionists are more likely to use the telephone contact for scheduling an office visit. Fischer and Smith.

What we also don’t acknowledge is that receptionists take calls from their friends, neighbours and relatives. The callers may be worried, unwell, confused, frustrated, angry, grieving, embarrassed, lonely, sad, suicidal, dying or just simply unable to cope. We place them in a front line role in a system that is often over subscribed, under staffed and the first port of call for anyone who thinks they need medical attention. Sometimes receptionists undertake tasks that should be the preserve of someone with other qualifications! We expect the receptionist to be polite, courteous, discrete, sensitive, thoughtful, obliging and intuitive. If she, and it’s usually a she, gets it wrong the practice faces complaint or litigation and a very bad press. Employers have recognised the challenge inherent in the role, but in many parts of the world those who under take this work have no formal qualifications or appropriate training. This issue has received research attention but there are challenges to developing innovations to help reception staff to prioritise patients.

Where contamination of the study population is an early complication, no current gold standard exists to define safe triaging, contextual differences between practices lead to inter-practice variation, and proxy outcomes (improvement in receptionist response to written scenarios of varying urgency) are used. Hall et al
Can we really guide someone who isn’t a doctor, or have any medical qualification, to make appropriate decisions based on a telephone conversation about potential medical emergencies?  There was a recent report of a disastrous failure to appropriately sign post the parents of a very sick child which involved ‘suitably qualified’ people working to nationally accredited algorithms. The issue at heart is that there is a greater demand for access to medical practitioners than supply. In response to demand policy makers have promoted ways to limit or control access to that expertise. The temptation is to innovate for alternatives that don’t involve the doctor. Those who advocate for this approach may be failing to recognise that people in distress aren’t simply disordered machinery in need of a technical fix. They can’t be rescheduled like a car service. That doesn’t mean they need to see the doctor straight away but they do need to feel they have had that experience sooner rather later. People are hard wired to feel better after contact with a doctor- it’s fundamental to how medicine works. That was what we decided back then so we relieved our reception staff from having to determine who was ‘not urgent for today’ when our schedules were full- instead we, the doctors, spoke to the patient by telephone and if we were not absolutely sure we had enough information we saw the patient and we still reduced our workload by 40%. Innovating to ration access to the healer is a bad idea if only because we are deny people the feeling that someone cares. The cost of that loss of connection is a failure to fulfill our purpose in people’s lives.

 

Removing the triggers to unhealthy choices

Much of the work in medicine is persuading people to give things up; tobacco, fizzy drinks, junk food, alcohol. Health professional also need people to do things- take medication, have surgery, keep appointments, exercise and so on. An entire industry profits on persuading people to make such choices and on helping doctors to sell more effectively. BJ Fogg has distilled such business into a simple equation.

My Behavior Model shows that three elements must converge at the same moment for a behavior to occur: Motivation, Ability, and Trigger. When a behavior does not occur, at least one of those three elements is missing. (Behaviour= Trigger+ ( Motivation+ Ability)

Our health and well being depends on how effectively doctors can do this. Notwithstanding that medicine hasn’t always got it right. Not that long ago doctors were trying to persuade people to take up smoking. Perhaps something like this could happen again, but I digress. The point is that health professionals are in the business of selling health messages, services and treatment. Last week I raised concerns about how some elements of this industry has taken to offering data as the key cue to action. Data elicitation and display has become a very profitable business. This week I explore this issue with reference to obesity.

It is often assumed that people make decisions about food and eating in rational conscious ways. However, if this were so, the obesity epidemic would not be happening. People overconsume in response to environmental cues and they lack insight into the extent to which their food choices and eating behaviors are being manipulated by sophisticated advertising and marketing techniques. They also have a limited capacity to sort through the increasingly overwhelming mountains of information and claims about food choices and, as a result, too often choose default option foods high in fat and sugar that, when consumed routinely, lead to chronic diseases. Deborah A. Cohen

So the challenge is trying to persuade people to eat less or at least less often. I offer four pieces of empirical advice to any of my patients who wants to lose weight some of which has come from the extensive review by Cutler, Glaeser and Shapiro:

1. Don’t put anything in your mouth while standing up other than a tooth brush-based on the observation that people consume a lot of calories while preparing food or snacking on the move.

2. Don’t eat other than at a dinning table- people often eat at their desks or worse, in front of the TV.

3. Don’t go shopping when you are hungry- it tempts you to bring things home that will sabotage your efforts to reduce consumption.

4. Don’t eat between meals…Duhhh!

Foggs Behavior Wizard suggests that to persuade people to decrease a behaviour:

  1. Remove the trigger that leads to the undesirable behaviour
  2. Reduce ability to perform the behaviour (make it harder to do)
  3. Replace motivation for doing the behaviour with de-motivators:  pain, fear, or social rejection

So the trigger that leads to the undesirable behaviour is the feeling that you are ‘hungry’. What Fogg recommends is:

When you design for persuasion, you don’t start by manipulation for motivation. That’s what you do last.

Therefore targeting motivation through calorie counting or calorie expenditure isn’t going to work. There are too many hours left in the day after you’ve consumed the few calories you need to lose weight and you have to do an unrealistic amount of exercise to be able to consume more. The real  problem is that people misinterpret four emotions associated with the urge to eat:

  1. Hunger
  2. Thirst
  3. Boredom
  4. Unhappiness

Therefore the trigger is often unrelated to the need for food and more to do with something else that hasn’t been acknowledged. To remove the trigger it must first be recognised as false. Therefore you might substitute or associate with another established trigger – namely answering a mobile phone or checking for email or facebook updates. By associating the urge to eat with checking an app on their mobile phone the person can work out if what they really want is food or something else. To reduce the ability to perform the behaviour (eat that popcorn, cake or choclate bar) the person needs to remove themselves from the place (physical or psychological) where the behaviour takes place- in front of the TV, at their desk at work or on the concourse at the station. This means either finding a new hobby, making a habit of only eating at a dinning table or carrying a bottle of water to and from work. Finally replacing the motivation for doing the behaviour with de-motivators could be part of the proposed solution by offering a diary of the poor choices that have tempted the individual between meals. I look forward to sharing a solution soon. Wearable not required.

 

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.

 

Semiotics and the placebo

It has long been acknowledged that the ‘doctor’ can have a therapeutic effect without ever ordering a test, prescribing a medicine or performing surgery. Indeed the earliest thinkers about the the role of the doctor talked about the ‘drug-doctor‘. But what are the constituent parts of this most powerful of placebos and what impact does this have on our attempts to improve outcomes?

The placebo pill, the saline injection, and the invasive procedure or device that works by virtue of a placebo effect are each signs, or sets of signs, that convey information to patients or research subjects. Additionally, the placebo intervention, like a standard treatment, is delivered within and surrounded by a context, which includes a host of other signs that convey information with the potential for producing therapeutic (and also counter-therapeutic or nocebo) responses. These include the clinician’s white coat, diagnostic instruments, the appearance of the doctor’s office or hospital room, the words communicated by the physician, the physician’s disposition in listening and responding to the patient, gestures, and touch. The patient does not come to the clinical encounter as a blank slate but with a history of experiences and memories evoked by prior responses to signs related to the milieu of therapy, some of which may influence the way in which the patient processes the information from signs emanating from the present clinical encounter. Franklin G. Miller and Luana Colloca

More recently evidence has emerged that hints at more specific ways in which these elements might be improved. When I was training our mentors recommending that we should never be casually dressed when consulting patients. This was based on their impressions of patient expectations. Later in my career my wife who was a staff nurse at our local hospital was amused that the patients I had admitted overnight were  impressed that their doctor was wearing a neck tie even at 2am. I’m not sure whether that was by design or accident.

Rehman and colleagues conducted a study of patient preferences about how they preferred their doctor to dress. Within a North American context it was clear that patients preferred their doctor to wear a white coat, whether the doctor worked in a hospital setting or not. According to the respondents to the survey doctors in white coats were more likely to be knowledgable, competent, caring compassionate, responsible and authoritative. It was evident from this study as well as a study from the UK that older patients in particular prefer their doctor to wear a white coat. There are differences in attitude based on geography and culture. However it is important to consider the importance of this question if only because patients who trust their doctors are more likely to take advice. It is argued how much of a difference attire makes to patient trust but the consensus appears to be that business wear and formal clothing generally inspire more confidence than tee shirts and shorts.

A second issue has recently become relevant. Research has documented negative stigma by health providers toward overweight and obese patients, but it is unknown whether physicians themselves are vulnerable to weight bias from patients. Puhl and colleagues surveyed 358 adults. Respondents were less trusting of physicians who were overweight or obese, were less inclined to follow medical advice, and were more likely to change providers if the physician was perceived to be overweight.  Normal-weight physicians elicited significantly more favorable reactions. These weight biases remained present regardless of participants’ own body weight. A more recent study from Johns Hopkins University School of Medicine suggests that although patients might trust their doctor regardless of his or her weight, those seeing obese primary care physicians, as compared to normal BMI physicians, were significantly more likely to report feeling judged because of their weight.

Therefore attending to how we come across to patients might be an important place to start improving the chances that they will trust us. This is based on intuition and a little bit of evidence, it doesn’t require a grant or a change in government policy. If you think it needs work- start today.

Innovating for a specific patient at a specific time

In a previous post I mentioned that a focus on prevention is recommended during the meeting between doctor and patient. I have also expressed the view that when this is promoted by rewarding doctors for health promotion it may interrupt the business at hand namely focusing on what has brought the patient to see the doctor in the first place. There are those who believe that prevention focused on one individual at a time is much less effective then population based strategies. For example making ‘unhealthy’ foods more expensive than healthier options or raising tax on tobacco and banning advertising. However it is a fact that most people will visit a primary care practitioner, be it a doctor or an allied health practitioner at least once a year. It is therefore possible that primary care practitioners could make a significant contribution to prevention given that most acute and chronic illness may be directly or indirectly attributed to over eating, substance abuse and or lack of exercise. A major caveat that should be borne in mind as was outlined by Polly Ryan  :

Health care professionals believe that these behaviours can be eradicated by teaching patients about the consequences. …However as multiple groups of at-risk persons are monitored , it becomes clear that a large percentage of these persons continue to engage in risky behaviours. By itself, an understanding of the need to quit smoking, lose weight, exercise , take appropriate medications, and reduce saturated fats and salt does not change behaviour for the most part.

Some individuals who attend a health care practitioner will already have developed a chronic condition and the evidence from a cross sectional survey is that such people are more likely to respond to advice:

members at highest risk of adverse health outcomes have the greatest readiness to change behavioral risk factors

Readiness to change is recognised as a limiting factor in the response to brief interventions  for health promotion.

Doherty and colleagues concluded:

The relationships between readiness to change various behaviours suggest that there are synergies in counselling strategies and methods of identifying patients who might be especially responsive.

In this context a study by Lloyd-Jones and colleagues is relevant:

Higher BMI at 50 years of age was associated with increased lifetime risk for CVD and with reduced median survival (by 3 to 4 years).

The team made a recommendation:

Given the high lifetime risks and lower survival in those with intermediate or high risk factor burden at 50 years of age, these data may be useful in communicating risks and supporting intensive preventive therapy.

Therefore efforts to promote healthier life style choices, something that could and should be done at all ages may be particularly effective at age 50. Not merely because the relevant data exists but because the individual is more open to acting on the advice, either because they have already developed the early features of a chronic illness and or because they are further along with readiness to change. An innovative approach that takes account of what’s going on in the patients life was also reported by Burke and colleagues working with couples who had just moved in together:

We first evaluated the program in couples beginning to live together, a group chosen because of the risk of weight gain and decreased physical activity after marriage, readiness to change behaviour at that time in the life course and the opportunity to use partner’s support in achieving behaviour change. In an initial short-term study with 39 couples, intake of fat and take-away foods decreased and consumption of fruit, vegetables and reduced fat foods increased…. Weight loss and a decrease in waist circumference were maintained in the program group up to 16 months after entering the study.

Health promotion is an important aspect of primary care however it needs to be targeted at individuals most likely to respond using innovations that engage the patient emotionally as well as intellectually. Health promotion however is a secondary goal in the consultation- the primary goal is to respond to the agenda outlined by the patient. Whatever tools are used to promote healthy lifestyles will need to be brief and effective if they are not to become a distraction.

‘Dear Patient’, You Matter To Us.

Research reveals that a US civilian is expected to spend 72.35 years in the community, 59.5 days in short-stay hospitals, and 2.28 years in nursing homes throughout his or her lifetime. The probability of receiving care from a primary care physician is 100%.  It is conceivable that an individual may never need specialist services but it is inconceivable that an individual will never need to attend a primary care practitioner.

It is therefore a priority to ensure that the impact of contact with primary care practitioners is optimised. Two recent studies meet the criteria for lean innovations- low cost, agile, intuitive and creative solutions to common problems. The first of these was published in the British Journal of General Practice . The authors set out to increase the attendance rate for adolescents to general practitioners. Simply writing to young people as they reached the age of 16, assuring them of their privacy was enough to boost attendance rates. The results were remarkable. The authors, Aarseth et al conclude:

The proportion of adolescents in contact with a GP increased from 59% in the control group to 69% in the intervention group (P<0.001). For the males, the increase was from 54% to 72% (P<0.001). An information letter about health problems and health rights (such as the protection of the adolescent’s privacy) seems to enhance the accessibility and utilisation of GPs, as measured by contact rate, particularly for males.

The second study, also involved writing to patients and was published as part of a PhD thesis.

The project ’10 Small Steps’ encompasses the development and evaluation of a general practice based RCT designed to improve ten lifestyle behaviours known to be associated with chronic diseases. The low-intensity intervention involved providing computer-tailored feedback, based on a health behaviour summary score, to more than 4500 adult patients recruited through 21 general practitioners in Brisbane, Australia. Participants were followed-up at 3 and 12 months. The intervention was effective in improving the health behaviour score. These findings demonstrate the potential for a low-intensity intervention to improve the adoption and maintenance of health behaviours in a primary care population and for general practice as a conduit for the primary prevention of non-communicable diseases.

These studies exemplify the scope for significant health gains through low cost interventions developed, administered and evaluated in primary care.

Innovating locally

The foreign-looking chap in the baseball cap, the one wearing a pair of torn jeans and a singlet, the one on the mobile phone, sporting a dragon tatoo on this forearm might be a famous musician and the only son of a bedridden widow. But you’ve decided he is  probably a drug addict and treat him with suspicion and hostility. On the other hand the smartly dressed, attractive white woman carrying the brief case might be a drug dealer and you greet her with a welcoming smile. I was born of an ethnicity that wherever I have lived or worked people I meet for the first time assume things about me that are false, even laughable. Before I open my mouth, my students are invited to guess the nationality on my passport, the city where I was born and my first language. They mostly get it wrong. Therefore I do people the courtesy of not making assumptions. Often in medicine the doctor is the only person who will treat some people with respect in a day when they have to contend with lots of challenging behaviours, whether because of their appearance, their accent, their culture, the clothes they wear, their disability or their needs.

I should not have been surprised by research that suggests that doctors know very little about their patients. And least surprising was the finding:

Physicians were poorer judges of patients’ beliefs when patients were African-American (desire for partnership) (p=0.013), Hispanic (meaning) (p=0.075), or of a different race (sense of control) (p=0.024).

Street and Haidet

Could a doctor pick out a patient’s partner, whom they have never met from a police line up? Would they know what car that person drove? Would they have any idea what their patient had for breakfast? Where that person is planning to go on holiday ? What they wanted to be when they grew up? In many cases it doesn’t matter but as innovators we feel we are able to develop interventions that will make it more likely that those very people will comply with our prescriptions, give up smoking, eat more vegetables, wear a condom and monitor their chronic condition. Not all at once of course!

Technology now allows us to take a bird’s eye view of our practices. We record key parameters for people who attend our clinics- for example blood pressure, cholesterol and glycosylated haemoglobin and can link that to geographical data- demonstrating where our poorly controlled diabetics live. We might like to guess before we are presented with the data- I bet we would be way off the mark.

Then we can see if there is public transport to bring those people to the clinic. Where they buy their food. Whether there are open spaces and leisure centres within reach.  Could those people easily attend an optician or a podiatrist? Only then should we contemplate something locally that will make it more likely to improve outcomes. But only after we check our assumptions with the people for whom the innovation would be designed. This work has a local flavour- ineffective innovations are designed on a ‘one-size fits all’ model as if everyone lives in an affluent middle class neighbourhood and seek care at the convenience of the healthcare provider. To quote Idris Moottee:

The customer is King, Queen and Jack. Any innovation efforts will fail eventually if the end user is not driven to use your new product or service. Most consumers are intelligent and can contribute so much to the process. It is true that people can not always voice their needs and desires in a way that makes sense, but our job is find creative ways to understand their attitudes, values and behaviors and figure out how to include them in your innovation process.

Meanwhile my friend Alan Leeb noticed that people are wedded to their mobile phones and are likely to respond to an SMS from his practice. So now each time his nurse administers a vaccine, the practice sends them an SMS asking if they had any sort of adverse reaction. The practice is now able to monitor reactions to vaccines in real time, that means if there are severe reactions his practice will know within 24-48 hours, probably faster than any other agency. This information might just help to save lives in his practice but perhaps in yours too.