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What is your approach when you know you can’t cure?

The upper respiratory tract infection or common cold is the commonest reason people  see a doctor. There is no ‘cure’. The symptoms last three to ten days and eventually resolve. Some symptoms take longer to resolve than others. Those with a cold have to bear with the discomfort for a few days or even weeks.

Placebo treatment has been reported to improve subjective and objective measures of disease in up to 30–40% of patients with a wide range of clinical conditions. A review of 8 clinical trials on the effects of antitussive medicines on cough associated with acute upper respiratory tract infection shows that 85% of the reduction in cough is related to treatment with placebo, and only 15% attributable to the active ingredient. R Eccles

Twenty-seven patients were randomized to placebo treatment and 27 to the no-treatment group (mean age 22.6 years). The median difference between post- and pretreatment CF was −3 in the no-treatment group and −18 in the placebo group (p = .0003). There was a significant increase in CST in the placebo group compared with no treatment (p = .027). Lee et al

However is it ethical to recommend treatment which is not proven to have any pharmacological effect?

OTC cough medicines do not appear more effective than placebo in relieving symptoms of acute cough. Even if statistically significant, effect sizes were small and of doubtful clinical relevance. The number of trials in each category was small, and the results of this systematic review have to be interpreted with caution. Based on the available evidence from a small number of studies, we cannot recommend OTC cough medicines as a first line treatment for children with acute cough. Schroder and Fahey

Experts are still pondering. Meantime what will you do today when you see that person with a cold who is still coughing a week later?
It has traditionally been assumed that deception is an indispensible component of successful placebo use. Therefore, placebos have been attacked because they are deceptive, and defended on the grounds that the deception is illusory or that the beneficent intentions of the physician justify the deception. However, a proper understanding of the placebo effect shows that deception need play no essential role in eliciting this powerful therapeutic modality; physicians can use nondeceptive means to promote a positive placebo response in their patients. Brody

Although the available evidence is incomplete and confusing at times there can be little doubt that the prevalence of placebo use outside of clinical trials is not negligible and that views and attitudes on placebos use differ considerably among individuals, both health care professionals and patients. Further research is needed to clarify these issues. Fassler et al

Picture by Sarah-Rose

What is your approach to the biggest health risk of our time?

Sixty to eighty percent of people are now overweight or obese. This is associated with considerable morbidity. Yet it is a very complex issue and the causes of the condition are many and varied.

…..the dramatic rise in the incidence of obesity in many countries appears to be due to the complex interaction of a variety of factors including genetic, physiologic, environmental, psychological, social, economic, and political. Wright and Aronne

The experience of overweight people with healthcare professionals is not universally good.

Seventy‐six individuals (aged 16–72) were interviewed. Most had struggled with their weight for most of their lives (n = 45). Almost all had experienced stigma and discrimination in childhood (n = 36), as adolescents (n = 41) or as adults (n = 72). About half stated that they had been humiliated by health professionals because of their weight. Thomas et al

Over my whole 40 year dieting history I found two doctors who have said ‘well, come back once a week or once a fortnight and I will weigh you’. I found that very helpful and useful, because you feel like somebody is on your side. (65 year old female)

 They have helped because they guided me and pointed things out and they were there for me. If I’ve got questions they are helpful. (28 year old female)

 Oh well, I have spoken to my doctor about it and he just says get more exercise. I did mention it to one other doctor and he said there is only one way to lose weight and that’s meal replacement drinks or tablets. So I never went back to him because I don’t agree with that. (49 year old male)

 My doctor keeps saying, you need to lose weight. And I say, yes, I know that and I want to and I try to watch what I am eating, but it is just getting harder and harder. (59 year old female)

If you are a healthcare professional it is very likely that you will see several people today who are overweight or obese. How will you raise the topic with them? How will you know they want to address the issue? What help will your offer? How do you know you have been helpful to others in these circumstances?

Picture by Paola Kizette Cimenti

How do you prepare for work?

I don’t know him personally but I don’t imagine that Michael Phelps dives into a pool when he isn’t ready to race. Similarly Usain Bolt might look like he jumped off the viewing stands and popped himself on the starting blocks but in truth his mind and his body are ready to make him the fastest man on dry land. However when we arrive at work we might still be thinking about the argument at home, the traffic jam or the news. We might arrive a bit disheveled, a bit breathless or a tad tired. We might not hear the first few things we are told or notice more than we can take in at a glance of our first customer client or patient. However to perform at our peak we might consider what might get us in the zone so that our performance is not in question.

Picture by Jörn Guy Süß

Are you catering to those who need you?

40 years ago people older than 65 years of age were a minority in the population. In the very near future they will be a significant minority and for some service providers they will be the majority. Healthcare is a good example. However the population may be ageing but it is also changing.

This aging population has many options from which to choose and they are looking for more than just a particular retailer, restaurant, product or service. They want their purchase to count: to satisfy mental, emotional and even spiritual needs as well. Older consumers: Redefining Health and Wellness as they age.

How has this been factored into your plans for how you will respond?

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Do your words strike a discordant chord?

Most upper respiratory tract infections are caused by viruses. However saying that to a parent with a sick child doesn’t always help:

Parent 2: They think they make you feel better saying it’s a virus…but they make you feel worse

Parent 7: When they say it’s a virus, I mean what kind of virus? Just where does it come from? Parent 1: You’re none the wiser how they got it, what you can do, how long it will go on…

Parent 5: You feel you’re no further forward…you just have to accept it if they don’t explain further, I would like to know…

Parent 2: It’s an unknown thing to a doctor, they can’t pinpoint it, they don’t know really…

Parent 1: I feel a bit annoyed really because you think they’ve studied for years to learn that and I haven’t studied at all, you feel dissatisfied as if you wanted to hear something more…you just wish that everything was clean cut

Parent 4: At least if you really knew what it was then it’s easier to cope with (Group 3) Joe Kai BMJ 1996

What do you say in these circumstances?

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Does your performance at work depend on coffee?

Does the time of day determine how you respond at work? Are you tired by mid afternoon? Are you slow to get going in the morning? How does that impact on the decisions you make at that time?

Decision fatigue is the concept that as we make more decisions during the day, they become less and less good quality… I know that I would much rather be one of my first five patient contacts of the day than my last five. Rachel Ali

Remedies for decision fatigue might include time-dependent decision support, modified schedules, shorter sessions, mandatory breaks, or snacks. Further studies could clarify the sources of the problem and test corresponding solutions. Linder et al

Does this resonate with you? What are you doing about it?

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What do you share about yourself that’s a safe topic?

Health warning:

As a doctor, the reality is you are never off duty and their status in the public eye demands a high standard of conduct at all times. Dr Naeem Nazem 

At some point someone will ask you where you went on holiday or why you have a model airplane on your shelf. You can choose to be very ‘private’ or have something you might find increases the connection with that person without befriending them on Facebook.

Physicians aged 40 to 59 years report that they most enjoy running or jogging (36%), bicycling (35%) and camping or hiking (24%). About 50% of physicians older than 60 years reported walking to stay healthy.  Other interests include golf, aerobics and cardio, skiing, tennis and fishing. Other leisure activities reported include reading, with many physicians describing themselves as avid readers; regular reading was reported by more than half of physicians under 40 years, 58% of those aged 40 to 59 years and more than 64% of those aged 60 years and older. Endocrinology advisor

The trick is not raising topics that should be off limits but it makes you more human if your client, customer or patient knows you are an avid reader, you play golf or sing in the choir. You can prompt the chat by having a prop for something that you are happy to share. My doctor has a picture of a civet cat in his room. I’d love to know why,  he tells me everyone asks him about the cat.

Picture by  Daniel Colovini  

What are you selling?

Whatever your role in life you are ‘selling’. That might be obvious because you work in a shop or own a factory but less obvious if you work in a clinic, office or a hospital. According to Dan Pink white-collar workers now spend an enormous portion of their time persuading, influencing, and moving others. He would argue that everyone is in sales.

So if that’s how you choose to frame your role in healthcare what are you selling? What do you spend your time persuading people to do? How effective is your sales technique? How do your product works? How do you know it is in anyone’s best interests to buy what you sell?

Dan Pink says it well:

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What was the journey like?

Do you know what your customer, client or patient’s journey to your office, clinic or shop was like? How did they get there? How long did it take? Who travelled with them? What did it cost? If they drove where did they park? Did you take any of that into account in your dealings with them today? Does it matter?

If you’re lying on a table waiting for radiation, you can’t just jump up and plug your meter,” she wrote to the city. “As someone who has gone through and survived cancer, I can’t tell you the anxiety experienced at finding a parking ticket on my vehicle. Nancy Piling

That patient’s experience was impacted by factors that had nothing to do with the professional care she was receiving. But…..

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What would happen if you didn’t show up at work today?

What would happen if you didn’t show up to work unexpectedly today? Would the show go on? Who would provide continuity for the what you have been working on? Is there a contingency plan for that possibility?

Data from the Office for National Statistics (ONS) for 2016 recorded an absence rate across all workers in the health sector of 3.5%. This compares with an average rate of 2.9% across the public sector and 1.7% in the private sector. In its analysis of these data, the ONS says, “It is possible that the exposure of health workers to infections and diseases contributes to their higher sickness absence rate.” BMJ May 2018

….any policy that mandates strict back-to-work rules must also ensure adequate staffing and coverage of health care personnel to limit feelings of personal responsibility that encourage presenteeism. Despite the best efforts of education and mandatory exclusion rules, health care providers will likely continue to come to work if they feel that their absence would burden their colleagues or affect delivery of patient care. Policies that maximize efficiency at work can therefore be detrimental to public health. Furthermore, a policy that ensures adequate coverage may be cost-effective for health care institutions by mitigating the negative financial impact associated with large nosocomial outbreaks. Widera et al

Meanwhile what do you do to ensure someone at work knows where to find that crucial document? Who knows what you are working on? Who is  on standby if something unexpected happens? What is the risk to the team if you can’t be there tomorrow?

Picture by  Ben Seidelman