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What motivates evidence based practice?

Doctor greating patientIt is assumed that doctors will always provide evidence based advice. Evidence based advice will be offered when three factors are aligned- Motivation, Ability and Trigger (BJ Fogg). Looking at the picture, assuming whatever is required is relatively easy to do and there is no problem with the doctors ability, what factors will impact on motivation to provide evidence based advice?

Doctor’s experience of an adverse event- complaint or bad outcome in relation to similar problems.
An overwhelming majority of respondents (91.0%) reported believing that physicians order more tests and procedures than needed to protect themselves from malpractice suits. These views were consistent across a range of physician characteristics, most notably across specialty groups, where 91.2% of generalists, 88.6% of medical specialists, 92.5% of surgeons, and 93.8% of other specialists agreed with the statement (P = .35). No significant differences were seen by geographic location, type of practice, or professional society affiliation. Bishop et al.
Doctor’s experience or training.

Widely used Continuing Medical Education (CME) delivery methods such as conferences have little direct impact on improving professional practice. More effective methods such as systematic practice-based interventions and outreach visits are seldom used by CME providers. Davis et al

The perception that the patient is ‘demanding’ a specific treatment, even if the indications are absent or equivocal.
A total of 4845 discrete items were mentioned as being capable of influencing Family Physicians’ (FPs’) decisions about referral for consultation. Aggregation of related items resulted in a list of 35 nonmedical factors, of which 11 were identified by at least half the respondents and 14 by less than half but more than 10. These 25 factors fell into three categories: patient and family factors (e.g., patient’s wishes), FP and consultant factors (e.g., FP’s capabilities), and other influences (e.g., style of practice). On the basis of both frequency of identification and priority scores “patient’s wishes” emerged as the most important factor.Langley et al.
Payment structures.
The use of financial incentives to reward Primary Care Practitioners for improving the quality of primary healthcare services is growing. However, there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care. Scott et al
Doctors mood.
 82 doctors reported recent incidents where they considered that symptoms of stress had negatively affected their patient care. The qualitative accounts they gave were coded for the attribution (type of stress symptom) made, and the effect it had. Half of these effects concerned lowered standards of care; 40% were the expression of irritability or anger; 7% were serious mistakes which still avoided directly leading to death; and two resulted in patient death. The attributions given for these were largely to do with tiredness (57%) and the pressure of overwork (28%), followed by depression or anxiety (8%), and the effects of alcohol (5%). Firth-Cozens and Greenhalgh.
Time of day.
The researchers looked at the billing and electronic health record (EHR) data for patient visits to 23 different primary care practices over the course of 17 months. Then identified visit diagnoses using billing codes and, using EHRs, identified visit times, antibiotic prescriptions and chronic illnesses. They analyzed over 21-thousand Acute Respiratory Infections visits by adults, which occurred during two four-hour sessions, 8 a.m. to noon and 1 p.m. to 5 p.m. The researchers found that antibiotic prescribing increased throughout the morning and afternoon clinic sessions. Linder et al
Multiple problems presented at the same consultation.
In many health care systems, providers see patients during brief office visits and are overwhelmed by the number of health maintenance activities recommended by guidelines and quality monitoring agencies. When diabetic patients have multiple chronic conditions, screening, counseling, and treatment needs far exceed the time available for patient-provider visits. Piette and Kerr
Cultural factors.
Most clinicians lack the information to understand how culture influences the clinical encounter and the skills to effectively bridge potential differences. New strategies are required to expand medical training to adequately address culturally discordant encounters among the physicians, their patients, and the families, for all three may have different concepts regarding the nature of the disease, expectations about treatment, and modes of appropriate communication beyond language. Kagawa-Singer and Kassim-Lakha
Distractions in the consultation.
The presence of the computer has changed the beginning of the consultation. Where once only two actors needed to perform their roles, now three interact in differing ways. Information comes from many sources, and behaviour responds accordingly. Future studies of the consultation need to take into account the impact of the computer in shaping how the consultation flows and the information needs of all participants. Pearce at al.
Influence of pharmaceutical companies
With rare exceptions, studies of exposure to information provided directly by pharmaceutical companies have found associations with higher prescribing frequency, higher costs, or lower prescribing quality or have not found significant associations. We did not find evidence of net improvements in prescribing, but the available literature does not exclude the possibility that prescribing may sometimes be improved. Spurling et al
All these could be summarised under three headings:
  • What the doctor believes
  • What the doctor hears (or fails to hear)
  • How the doctor feels

Many of these are difficult to influence and therefore innovations that have the greatest effect rarely focus on increasing motivation.

Picture by Vic

Primary care is not a panacea

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Barbara Starfield’s thoughts still resonate with many of us who work in primary care. Primary care serves to reduce costs in a health care system essentially by keeping people out of hospital.  However, recently there have been attempts to tinker with how the sector is configured in many countries where one would have assumed that no adjustment was necessary.

The demand for general practitioner services continues to rise. It may be tempting to assume that the drivers for this trend are the same as they have always been: infections, gluttony, sloth, ageing, substance abuse, accidents and genetics. And yet the literature records that practitioners know very little about their patients biography. So what does primary care actually do and what does this tell us about the way forward?

We know that seeing a general practitioner is not going to ‘cure’:

  • Divorce
  • Child abuse
  • Boredom
  • Debts
  • Loneliness
  • Poor parenting
  • illiteracy

Seeing a general practitioner for ten or fifteen minutes, even quite frequently, isn’t going to change these circumstances. Perhaps a perceived failure to improve outcomes for people living with these problems is the driver for reform of the sector in parts of the world. At best primary care might help people to cope, at worst it might add to problems through iatrogenesis. Then there is a possibility that our inability to cope has a biological basis and that attempts to deal with the symptoms alone may be misguided. After all such thinking led to at least one Nobel prize for medicine.

If primary care needs to be reformed than the first issue is to recognise the limitations. For those who live in relative poverty, those with multimorbidity, those with competing priorities in complex lives more of the same primary care cannot be the only response to degenerative and chronic conditions.

Picture by Mike Smail

What’s needed to get doctors online?

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Anyone who doubts that doctors will consult patients on line hasn’t heard of the hugely successful Sherpaa. It’s happening already in the US and in some other parts of the world. Elsewhere doctors will soon consult via the internet. It is only a question of how the service will be configured.

In a previous post I offered a way to consider what motivates doctors, what determines their ability to do things and what might trigger that action. The key questions in relation to video consults is how doctors might respond when faced with the variety of clinical problems that could possibly present on line. Also what that might tell us about the implementation of such technology.  We set out to explore these questions recently. You can read our paper and watch videos of how patients might present on line here.

Motivation

A: Rewards for action

Funding restrictions were a major factor in deterring doctors from consulting on line. Unless governments subsidise the consultation it is unlikely to happen for people relying on government funded schemes. Where it is happening, private providers are stepping in to offer the service to paying customers.

T: Time

In a previous study we demonstrated that telephone consultations significantly reduced consultation time relative to face to face meetings. There is no reason to suppose that video consults would be any different.

R: Risk

This was perhaps the greatest factor moderating the motivation for video consults. Some scenarios were regarded as extremely high risk for adverse events and for litigation. Patients presenting with symptoms of an acute life threatening condition were considered the least suitable for a video consultation. Some scenarios were deemed too difficult to manage without a physical examination. Others were considered suitable if there was scope to see the patient in person in the near future. A literature search also raised concerns about potential breaches of patient confidentiality when consults are conducted via video technologies.

Ability

C: Cost

The issue of cost was not explored in our study. However this may be related to the lack of remuneration for video consults. No payment would result in a significant opportunity cost.

E: Effort

Some scenarios were considered too difficult to manage without a physical examination. Indeed the need for physical examination to establish a diagnosis was a common concern. Unexplained abdominal pain and upper respiratory tract infections were of particular concern. In other cases the scope to establish a rapport was considered insufficient, for example in the case of the patient with substance abuse:

…the use of an online consultation in this case inhibits developing rapport particularly with a patient whom I have only seen occasionally.

We also recorded a significant difference in attitudes to video consults based on the demographic profile of respondents to our study. Participants who had been practicing as GPs for longer, GPs in training, those who worked in remote practice, and those from larger group practices were most enthusiastic about video consultations.

Trigger

R: Recognising the suitable patient

Our data indicate that access to video consultations will need to focus on patients with on-going medical illness, where the purpose of the consultation is to offer support. Medical practitioners appear confident about their ability to conduct video consultations however in the context in which we explored this question it is not yet routine practice.

K:Knowing what is available

Doctors in our study were unequivocal in asserting that the video consult option was not available to them at this point in time. In a previous review we explored the possibility that internet speeds and access to the relevant hardware and software may be a rate limiting step in the adoption of video technologies.

Summary

Video consults will become routine practice in most countries when they are supported with the infra structure to make is easy for doctors to make the choice to offer the service to their patients. In many scenarios motivation and ability appear to be high.  The majority of doctors in our study would either conduct video consults or consider doing so. The service is most likely to be offered to patients who either will be seen in person in the near future or seeking support for an established condition.

Picture by Matthew Hall

Can healthcare providers be more supportive?

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Most people who get cancer survive. The treatment now available means they are likely to die, years later, of some cause other than cancer. That’s great news. Unfortunately in many cases the intervening years may be punctuated by symptoms or problems that are related to the treatment. So cancer like many other human ailments is a ‘chronic’ illness rather a problem that is ‘cured’. For cancer it is likely that one group of doctors will offer treatment (specialists) but another group of practitioners (generalists) will be called on if there are problems later. The experience of many people in these circumstances is that a lot more could be done to help after treatment. Our team recently conducted a series of studies to explore what happens, from the practitioners’ perspective, given that one might want to develop interventions to assist them do a better job. In one study we focused on prostate cancer, you can read the paper and watch a video of how men might present to their doctors here. As we deployed simulations, no patients were harmed in this study. I present the results with reference to a map offered in an earlier blog. The analysis below pertains to how doctors respond.

Motivation

A: Rewards for action

For the most part men in these circumstances are unlikely to present with symptoms that are only ever a feature of recurrence or treatment side effects. It was accepted in our research that many of the problems presented (sexual dysfunction,anxiety and depression) were common in general and therefore subject to the same remuneration as other primary care visits. There were some scenarios that were considered outside the generalist scope of practice including radiation proctitis. However in these circumstances it was also accepted that such patients needed generalist investigations before specialist referral. It was interesting that rural practitioners were more attuned to expert opinion.  We speculated that they have greater involvement in supporting men in these circumstances compared to colleagues with much easier access to major hospitals.

T: Timeliness

We did not explore the time taken by such consultations. However this is likely to be similar to many other such problems that are presenting outwith the context of a cancer diagnosis.

R: Risk

Some scenarios, for example one in which a man presented with a raised level of ‘tumour marker’, proved very problematic for some respondents who immediately, and unnecessarily, referred for specialist advice. The doctor’s fear of missing a recurrence rendered it more challenging for the person living with the diagnosis to receive the strong reassurance that was indicated.

Ability

C: Cost

Referral for treatment of problems related to treatment or recurrence may be problematic in these circumstances. For example we could not assume that every practitioner had easy access to a radiation oncologist. This may have resulted in a financial burden on the patient or to referral for less than ideal treatment.

E:Effort

Some consultations required referral to, or discussion with,specialists or the organisation of tests and subsequent follow up with results. Some patients required referral to a very specific service- this was sometimes omitted. Although it is possible this was due to lack of knowledge it is also likely that such services were not available to those practitioners. In the case of practitioners from rural areas this was almost certainly the case.

Trigger

P: Recognising the patient

In a significant proportion of cases doctors missed the diagnosis. Unfortunately not every practitioner offered the best treatment options.  Others focused only on the cancer as a cause of the symptoms. The intervention we offered improved diagnosis but not management of cases.

K: Knowledge of options

It was not clear from our data if doctors were aware of the treatment options for all scenarios in these circumstances.

Summary

There is  scope to ensure that people are more supported after a diagnosis and treatment of a potentially life threatening condition. They often present with problems that are not unique to those with the condition. Doctors may have to spend more time with them in these circumstances and also need to be more proactive in assessing their needs. In many cases reassurance is all that may be required by a knowledgeable practitioner. In other cases access to the most appropriate treatment will determine the degree to which practitioners can be responsive to needs. Motivation is high, ability could be improved and a trigger that identifies the patient and their options may help to ensure that practitioners fulfill their obligation to support people in these circumstances.

Picture by Andrew Currie.

The power of the pregnant pause

313238312_3c0b16565f_zJohn made an appointment recently. Never seen him before. He shook my hand enthusiastically as he strode into the room. A forced smile. Lots of eye contact. A need to look brave. I remember noticing his hand was a bit wet and his deodorant was working hard. He had flu like symptoms, runny nose, dry cough, sore throat. He had taken a few days off and needed a certificate for this employer. That didn’t explain his anxiety.  He seemed to have come to the right conclusion about his symptoms. I examined his throat, listened to his chest, took his temperature and agreed it was probably ‘a virus’ and that he should be fit for work before the end of the week. Then he hesitated. A pregnant pause. Seemed a bit unsure and blurted out those immortal words

There is just one other thing.

I was expecting it. I’ve seen this before. Adult males who exhibit signs of anxiety in a seemingly ‘routine’ consultation. If I’d looked closely I’d have noticed the dilated pupils and slightly rapid pulse. Sometimes ‘John’ comes with a request for a ‘full body check up’. Nonchalantly declaring that he’s getting older. Occasionally he brings his wife or partner, or perhaps they bring him. But when he comes alone the potential agenda is quite short- an embarrassing problem- impotence or sexual indiscretion and a need to be screened for ‘those other infections’, prostatism or something like what brought John in.

I have a very itchy sore bottom.

A life long problem it seems. Been using creams for years. Not helping. Bleeding a bit too. He knew what was coming. Hence the anxiety. The erythema and excoriations around his perineum verified the history. He left with a prescription for a steroid cream and a request to make a review appointment. It wasn’t as difficult as he had imagined. I clearly had heard all this before and he was pleased to be congratulated for being brave enough to ‘do the right thing’. The smile was now genuine. The prescription tucked away into his top pocket. It doesn’t take a lot to work out that there is more to the patient’s need for medical attention then meets the eye. The ‘Flu thing’ is what he tells people why he needs to see a doctor. In reality it’s a lot more serious- not the eczema that remains undiagnosed but the fear that the ‘itch’ is never going to go away and can’t be brought up in polite conversation despite ruining his life. It’s worth offering every man the pregnant pause. They might spit it out, if you’ve done your job right till that point.

Traditional masculine traits intersect with other physiological, sociological and cultural aspects of men’s lives when deciding to seek help. Andrology Australia

Often the patient wears the hidden agenda on their sleeve. No data or app necessary, just be interested enough to notice.

Picture by Drew Leavy

Care is not delivered in a vacuum

3798267293_030d8688bd_zGeneral practitioners (GPs) are the most used health service providers in Australia. In 2010–11, an estimated 14.5 million people aged 15 years and over (82%) had seen a GP at least once in the previous year, with 11.8 million seeing a GP more than once.  At that time in 2011 that there were 43,400 general practitioners in Australia, 43% were women and they worked an average of 42 hours. An earlier census reported that the average age of a GP was 49.3 years with almost one in three older than 55 years. Yet studies seldom report the impact of this demography on the professional advice offered in practice. If it is relevant to tailor health care advice to the ideas and expectation of the patient or client than by corollary it is relevant to consider the personal experiences of the healthcare professional who offers a service. We know for example that lectures, guidelines and protocols aimed at doctors may have less influence on whether a patient receives evidence based care than staff room conversations, peer pressure, the views of opinion leaders or the impact of personal experience within an individuals circle of influence. In research on innovations delivered in the consultation, the clinician is a significant confounding variable. A fact that is rarely mentioned in the limitations of the study.

Primary care clinicians work in “communities of practice,” combining information from a wide range of sources into “mindlines” (internalised, collectively reinforced tacit guidelines), which they use to inform their practice. Gabbay and le May.

Consider for example a recent report that the diagnosis and treatment of malaria by doctors was derailed by the influences described above. What is also recognised is that when doctors become sick or treat their own families they don’t necessarily follow clinical guidelines. What then might make it more likely that doctors provide evidence based care for chronic and complex conditions? With one in three doctors over the age of 55 it is likely that many general practitioners, their partners, families and friends will experience the onset of chronic illness- diabetes, low back pain, depression, cancer etc. They are also going to be invited for screening- colorectal and breast cancer. Their attitudes and experiences may well predict how their patients will be treated. For example in a study in which doctors were asked their views on screening their patients for alcohol abuse, the authors, Anders Beich and colleagues did not report on the alcohol consumption of the participating doctors or their experience of alcoholism in their close family or friends. One participating practitioner was quoted as having said:

To me, just asking everybody about their drinking habits is in part comparable to if I had to do a rectal examination on all patients that came to see me.

Therefore the doctor is a key stakeholder in the process of health care not just by virtue of a professional role but also with respect to his or her personal history and prejudices. This has implications for diagnosis but also for treatment. Patients need to be seen and heard. When the doctors senses are impaired by personal history it is possible that their assessment of needs,  symptom severity or risk may be limited.  What may help innovators is empirical evidence that addressing this question in a defined setting may help deliver better outcomes for patients.

Picture by ReSurge International

Are ‘triggers’ the best health innovation?

9212656123_07027098e1_zPrimary care practitioners are expected to achieve a lot in their short interactions with patients or clients. The limited time available has a significant impact on satisfaction, outcomes and patient safety. In this context the question of developing innovations to support people to adopt different choices and reduce risk of chronic diseases, improve well being or reduce morbidity warrants careful consideration. The challenge is to innovate for impact on problems that are multidimensional and may be difficult to address with a ‘magic bullet’. There are many examples of topics that have been advocated as the purview of primary care practitioners they include-promoting weight loss and smoking cessation, reducing salt consumption, advocating safe sex, discouraging teenage pregnancy, encouraging exercise and a host of other issues where ‘prevention’ is touted as the best solution. Occasionally ‘health promotion’ in primary care is encouraged with financial rewards where time pressure is already a concern. In reality the evidence for health promotion in primary care is equivocal. Secondly and perhaps more to the point the drivers for behaviour change are more effectively addressed through taxation, legislation, public health campaigns, non government organisations, schools, parents and the media. Nonetheless when the rubber hits the road and a person develops early signs of chronic disease there is an opportunity to encourage that person to address the risks, albeit that nothing can guarantee longevity or good health.

At an individual level how do you activate behaviour change in people who just won’t seem to budge? For effective behaviour change three things have to occur at the same time:

1.   the person must be motivated

2.   the person must have the ability, or perceive they have the ability, to take action

3.   an appropriate trigger (or prompt) must be applied.

Without all three behaviour will not change.

Motivators are those which are an inherent part of the human experience everywhere:

  • sensation – pleasure/pain
  • anticipation – hope/fear
  • social cohesion – social acceptance/rejection

Of these, probably anticipation, is the only one which might conceivably be addressed relatively quickly. However:

Evidence of a direct correlation between risk perception and self-protective behavior is ambiguous at best. Rimal and Real

Recanting warnings about the dire consequences of persistent alcohol abuse are unlikely to result in abstinence in the vast majority of cases.

Ability may be even more problematic. There are two ways to amplify ability – enhance ability to perform the behavior, or make the behaviour simpler to do. In practice medical practitioners may struggle to achieve this in the context of a busy clinic. Enhancing a patients ability to control their weight for example means making it easier for that person to eat just enough. Michael Wu, breaks ‘simplicity’ down further, he identifies:

  • effort resources (physical and mental effort)
  • scarce resources (time, money, authority, permission, attention) and
  • adaptability resources (capacity to break norms – personal/routine, social, cultural)

In reality this can rarely be achieved within a few minutes in a medical consultation. There are two ways to amplify ability – enhance ability to perform the behavior, or make the behaviour simpler to do. Fogg offers the following insight:

Simplicity is a function of your scarcest resource at that moment. Think about time as a resource, If you don’t have 10 minutes to spend, and the target behavior requires 10 minutes, then it’s not simple. Money is another resource. If you don’t have $1, and the behavior requires $1, then it’s not simple.

It may be the reason why it has been tempting to issue prescriptions in response to lifestyle related risk factors for chronic disease . However pharmacology is yet to solve all of mankind’s problems. That brings us to triggers. Fogg defines three kinds of triggers for three different contexts:

  • sparks – a motivating trigger, applied where there is high ability but low motivation
  • facilitators – enabling triggers, applied where there is high motivation but low ability
  • signals – a prompt, applied where both motivation and ability are high

Therefore within a primary care context a trigger could be efficiently delivered to some people. For example it has been demonstrated in Australian primary care motivation is high:

Fifty six percent of patients intended to lose weight in the next six months. Females, younger patients, those with a level of education of trade certificate and above or those with high cholesterol had significantly higher odds of intending to lose weight. “Health” was the top reason for wanting to lose weight in normal weight (38%), overweight (57%) and obese (72%) patients. Yoong et al

On the other hand ability may be limited:

Australian consumers have a poor understanding of energy and kilojoules and tend to perceive higher energy products as healthier and providing sustained energy. Watson et al.

Therefore in this context an enabling trigger or prompt may be effective. An innovation can underline ‘why’ to someone who knows ‘what’ and ‘how’, even if it means stimulating them to find out how. Here’s one that worked for us for a similar problem. Finally, and to reiterate, innovation has to be easily adapted into the workflow in primary care as per normalisation process theory.

Picture by Nottingham Trent University

Personal choice versus social responsibility- compassion before all.

9363012140_4304b8498b_zAt 52 years of age Suzy knows better. She is unemployed and divorced, again. She takes her antihypertensive only very occasionally. She is obese. Often sleeps rough, drinks far too much especially when flush with social security payments and is frequently at the emergency department with injures following a binge drink or a fight. Her destiny is to become a statistic.

Nothing is more evident in the statistics of public health than the role played by individual health behavior in contributing to accidents, illness and disease. Daniel Callahan

In a now classic series of studies Lester Breslow and his associates revealed that men who successfully adopted seven good personal health habits had lower morbidity and mortality rates than those who followed six; those who followed six of the habits had better health and mortality outcomes than those who followed five; and so forth. Kayman, Bruvold, and Stern demonstrated that individuals who develop their own diet and exercise plans are more successful at achieving and maintaining weight loss that those who play a more passive role. Each year, millions of smokers successfully quit the habit (albeit usually after several attempts), and most who do quit do so on their own.  Individuals have a fundamental right, based on the principle of autonomy, to choose health-related behaviors. Yet, with this right, so it is argued, comes a responsibility to make wise choices. Herein lie the strongest case for innovations targeted at the individual.

It is often supposed that given information people will make the right choices. Suzy knows that when intoxicated she is likely to injure herself, she has been advised that she is at significant risk of cardiovascular disease and is aware that her junk food diet is likely to maintain her BMI at 35. She has had bariatric surgery but she had the surgery reversed. Knowing is not enough. So one point of view says:

Being ill is redefined as being guilty. MH Becker

At the same time epidemiologists such as S. Leonard Syme have pointed out that people at progressively lower socioeconomic status (SES) levels have correspondingly less opportunity to control the circumstances and events that affect their lives. Conversely, for individuals at higher levels, factors like higher income and greater discretion, latitude, and control over their lives may contribute to a more generalized sense of “control over destiny, ”which, in turn, may translate into enhanced health behaviours and health outcomes. Suzy  could be, and is, stigmatised. Conservative governments have used the rhetoric of personal responsibility for health to justify cutbacks in needed health and social programs. Only this week the Australian Government was urged to consider a proposal in which

about 2.5 million welfare ­recipients on “working-age ­payments”, including disability support pensioners and carers, would be forced into a cashless world where 100 per cent of their payments were income-managed and they were banned from purchasing “prohibited” goods. The Australian.

Meanwhile concerted efforts have been made to support Suzy to lose weight, drink less and take more exercise. Clearly none have succeeded so far. Suzy may turn things around despite previous failures. On the other hand if she is forced to use her social welfare payments for food she may trade food for alcohol, and it’s unlikely to be a fair trade. Suzy’s response to life, may be a factor of the attitudes she comes across on the street. How do you innovate against disdain?

There is no question that her poor choices have landed Suzy in trouble. But no one who takes the time to listen could possibly believe she doesn’t want better. One day we might find the trigger for a radical change. In the meantime what Suzy needs most is someone on her side. She needs continuity of care, someone who understands the complexities of her deeply troubled life, someone who knows the actors and can interpret her cries for help, often couched in somatic terms. As her clinician she deserves my undivided attention anything that comes between us would detract from the chance that she will one day reinvent herself. ‘Suzy’, as described, doesn’t exist- but the elements of her story are true for many who seek help from their general practitioner.

Picture by Kat N.L.M.

Innovating without inventing something new

9562611683_cd9584baca_zI’m a pathologist, which means that I run the lab, and I’m continually shocked by all the unnecessary lab work that comes my way. Doctors have to find something wrong with you, because preventative measures aren’t sexy. They know that you’re more likely to appreciate them if they tell you something’s wrong, than if they tell you to stop drinking 40 oz sodas. Humans of New York

This week a report was released that documents changes in Australian GPs’ ordering of X-rays and scans in the decade 2002- 2012. The report includes an evaluation of the quality of GP test ordering against available guidelines. The team compared two periods: Apr 2002- March 2005 inclusive (Period 1) and April 2009 to March 2012 inclusive (Period 2). Three factors were found to be relevant:

  • The number of encounters between doctors and patients
  • The number of problems managed at encounters
  • The rate of ordering tests in the management of problems encountered

It was not surprising that people are attending doctors more often and that they are presenting more problems than before. However the rate of imaging tests ordered significantly increased from 8.7 per 100 encounters in Period 1, to 10.2 per 100 in Period 2. Extrapolation of this result suggests an average 8.45 million imaging tests ordered by GPs per year in Period 1 and 12.23 million per year in Period 2, an increase of 44.7%, equating to approximately 3.78 million more orders per year over the 3 years in Period 2 than in the years of Period 1. With respect to the guidelines current ordering behaviour for new back problems, shoulder sprains/strains, knee problems, and knee sprains/strains, has room for improvement, according to the researchers.  The results were not entirely unexpected. There has long been a concern about unnecessary test ordering. In a paper published in 2008 unnecessary laboratory tests may be defined as those that have a ‘vanishingly small’ chance of:

  • revealing any unexpected pathological process.
  • contributing to the diagnosis of the cause of a patient’s presenting symptoms.
  • assisting in the monitoring of the progress of a known pathological process.
  • helping to assess the management of a known disease process.

An interesting insight is offered:

The millions of dollars spent on unnecessary tests are, in [doctors’] minds, balanced against the tens of millions involved in adverse court judgments.

In this context I recently asked colleagues what test they would perform on me if I presented as ‘tired all the time’, adding that I had no physical signs, was not depressed and was not taking anything (prescribed or otherwise) that would account for my fatigue. The answer was unanimous-‘Thyroid function test’. This was based on published advice on the approach to such patients:

However, even though laboratory evaluations rarely play a crucial role, they should be used to exclude underlying organic illness.

So, I asked my colleagues how they would interpret the findings if my results were found to be just over the limit of normal. What, in their view was the probability that I have hypothyroidism? ‘High’ came the answer. ‘We would put you on thyroxine.’ The published data suggests that the positive predictive value of tests on people in this context is  less than 12%. Which means it is highly unlikely that I have anything physical wrong with me, much less that I need to take thyroxine. At a time when there is an increasing demand for GP services, it is going to be helpful for colleagues to be aware of the positive predictive value of the tests they order and to share that information with patients before recommending tests. The article listing laboratory tests to screen for a host of highly unlikely conditions assumes that the doctor has spoken to and examined the patient and that the indications for the tests are based on specific clinical findings.  In most cases the patient who has a life limiting pathology does not look or feel well. However every patient needs to know what the test results mean- they are often meaningless and place the patient in harms way. The approach in the Dutch paper to postpone tests for 4 weeks resulted in benefit to people with unexplained fatigue who may otherwise have been harmed by further investigation of equivocal test results. The study is testimony to what  can be achieved by practitioners sharing information with patients while harnessing the power of observation, applying a little bit of science and dispensing a tincture of common sense.

Picture by Send me adrift.

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.