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What do you already know before you consult your patients?


I tried this experiment today- given only a person’s name and address from a phone book what can you find out about them from the internet?

Location and state of home: Using Google street view I can see where the person I selected lives, or at least what her home looked like in May 2014. The house is a bungalow with a double garage, the garden is unkempt, and litter is strewn on an overgrown lawn. The fence with the neighbours is in a poor state of repair and has pieces of junk leaning against it. There are multiple old cars in the driveways or on the grassed areas of all the homes along the street; this suggests that there are many youngsters over the age of 18 living nearby.  The neighbour’s bin, which is on the kerbside, is full to overflowing, so it looks like the photo was taken on bin day. There are no children’s toys in the garden or on the lawn or anywhere in neighbouring yards. I can see a car on the driveway and Google has not blacked out the number plate. It is a new but cheap and small hatch back. At least one neighbouring home has a ‘for rent’ sign outside it. From Google earth I can see that none of the homes in the immediate neighbourhood have a swimming pool and that this home occupies most of the plot on which it has been constructed. From Google maps I can work out that she lives 10 minutes drive away from a doctors clinic, 11 minutes from the largest shopping centre, 7 minutes from the railway station (39 minute walk), 6 minutes from various fast food outlets and 15 minutes walk from the leisure centre. The house is not within a short stroll to any major amenities; there are no shops or cafes nearby. There are no bus stops on the street.

From I can see that this home sold for over $300,000 in 2011 and that it occupies 500 square meters of land. The estate agent described it thus:

A good sized home with 4 bedrooms, 3 separate living areas, a huge kitchen meals area complete with bench space, 5 hotplates and dishwasher as well as wall oven. Ducted heating, reverse cycle air con, 2 bathrooms (ensuite to master) and a 2 car carport as well as a large driveway complete this house. Catching a train to work? Well, you are only 5 minute drive to the town CBD and station. Schools and buses are nearby and petrol station around the corner for your fuel, milk and bread will give you convenience plus.

I can see inside the house and note that there is Jacuzzi in the back yard. The real estate site tells me that families with adult children occupy one in five properties in this area and that one in ten people living here are retirees. According to sixty nine percent of home locally are owner-occupiers and the average age of people here is 40-59. If this person has a mortgage they are likely to be paying just under $600 per month or if renting $350 per week. Manufacturing is the largest employer in the area. As this person is female, she may be a widow or a divorcee.

Facebook: I also note on Facebook that there is someone by the name of this person from this town. I couldn’t be sure if this is the same person. It is unlikely as the person on Facebook looks quite young and the vintage of the name is more likely to be of a person in their 40s. Google didn’t have any information on this person and this suggests she doesn’t hold a senior position in employment locally and hasn’t been in the news for any reason.

Would any of this information help in a consultation with this person as a patient?

What I already know leads me to suppose that this person is working, probably locally and has a modest income. She probably lives with other adults, possibly her children and moved into the home in 2011 when the property was sold. Given the poor state of the garden it is likely the home is rented.  In addition from her medical records I will know her age, her occupation, her current medications and any significant past medical history. That’s even before I set eyes on her.

The information above will be of limited value if she presents with a minor self-limiting illness, except that she may be very keen to get a medical certificate because she will not want to risk losing her job. She probably has a modest income and may be at risk of work related stress. She may also find it difficult to attend the clinic during office hours unless she works close to the clinic. This is unlikely. If in middle age she has a chronic illness and she requires to attend the clinic regularly or she needs to go to a gym four times a week then her address is going to be a significant risk factor. Secondly the cost of medications and the availability of quality food may be a challenge to an individual living in this location. Matters would be worse if she can’t drive for any reason. Some research our team has just completed suggests that people who are at increased risk from the adverse consequences of diabetes, and possibly other chronic conditions, tend to live in close proximity to one another. Therefore if my computer was to alert me, in addition, that this address is in such a hot spot area, then the information I have freely gathered from the internet and from my own clinic records before I see her may offer useful insights into my patient’s circumstances. It may be that we would have to work hard to find someway to help her cope with the rigors of a demanding medical problem should it exist. Of course all of this is speculation, the best thing I can do is to ascertain the whole truth by giving her my undivided attention when she attends. Nonetheless if I didn’t have to spend a lot of time playing detective I would be much better placed to understand her needs.

Picture by Duncan Hull

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.