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How can medicine compete against the new normal?

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

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

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

Well that ain’t gonna happen

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

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

It is now normal:

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

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

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

Picture by Mario Antonio Pean Zapat

Why wearables don’t work and people don’t floss their teeth

Wearable devices are now a billion dollar business:

Fitbit Reports $712M Q415 and $1.86B FY15 Revenue; Guides to $2.4 to $2.5B Revenue in FY16. Press release.

In a wonderful article from the Washington Post the author reports:

Another friend, a woman in her 40s, explained: “I realized that there were a couple weeks where I took it off because it was making me feel bad when I was ‘failing,’ so why do that to myself?” Steven Petrow

Associated Press pointed out that:

One research firm, Endeavour Partners, estimates that about a third of these trackers get abandoned after six months. A health care investment fund, Rock Health, says Fitbit’s regulatory filings suggest that only half of Fitbit’s nearly 20 million registered users were still active as of the first quarter of 2015. Anick Jesdanun

This is consistent with what my patients are telling me. I’ve seen the same trend with relatives. But it is all very predictable because these devices fail on one fundamental count. People are not logical. Information alone does not lead people to make choices. Humans are driven by emotion and not just information. If that were not the case people would floss their teeth, not text while driving or borrow more than they can afford to pay.

Innovations that rely on people acting on information to improve healthcare outcomes have no longterm future. If we want people to change their choices we need to accept that information alone does not lead to behaviour change. Functional Magnetic Resonance Imaging studies of the human brain have identified that our brains are resistant to change even when the change might be in our best interests. Habits drive our behaviours and are as an old pair of slippers, comfortable, familiar and easy. Change requires us to activate other parts of our brain, expend energy, learn and adopt new habits. Change requires effort which most people find uncomfortable. As a result, change is avoided and the easiest thing is to refuse to heed the message and bin the device.

There are three stages to adopting new behaviours:

  1. Unfreezing current patterns/unlearning old behaviours.
  2. Changing/applying new behaviours.
  3. Embedding new behaviours.

Of these wearables provide information that might get us underway with the first step by getting us to question the status quo. However that is far from what is required to get us to adopt a diet and exercise regimen. This so-called ‘disconfirming data’ is not enough – we can easily dismiss it, ignore it, or deny its validity. Which most people seem to be doing because it isn’t enough to generate new habits. Two other factors that are also essential to get us to the next stage:

  1. We need to accept that something is wrong and
  2. We need to believe that we can do what is necessary.

The ‘something wrong’ is the problem. Many people who are overweight or obese don’t see themselves are having a problem because in most cases the condition is asymptomatic. They may be surrounded by people who are of a similar body habitus and are therefore resistant to any notion that this body shape is in any sense abnormal. Finally for many people the idea that they might be able to change their shape is hard to swallow as in many cases they do not see results after weeks of effort.

For innovators a fundamental message is that there is no quick fix to healthcare problems because fundamentally humans are feeling not thinking creatures and therefore not responsive to messages that only tackle part of the drivers for change.

Picture by Philippe Put

Please don’t ask for my time as refusal may offend

In an article from the Economist, the authors advise that we appear to perceive ourselves as short of time. Every minute of the day can be filled ‘doing’ something or several things simultaneously, often badly. We are also increasingly wedded to the demands of our mobile devices. People spend time texting while eating, driving and even on the loo. In fact it is estimated that we spend one third of our waking hours interacting with our phone.

In an experiment carried out at the University of Toronto, two different groups of people were asked to listen to the same passage of music. Before the song, one group was asked to gauge their hourly wage. The participants who made this calculation ended up feeling less happy and more impatient while the music was playing. Participants reported experiencing greater impatience while listening to the music when prompted to think about their time in terms of money.

This has some important resonance in healthcare where practitioners who earn a living through fee for service may, and often do, become impatient about engaging with researchers or academics. This is a significant problem because in countries where primary care is the first port of call for most people we desperately need research to ensure that the service offered is both evidence based and cost effective. But what is the order priority: appointments with patients, results of tests, administrative paperwork, continuing medical education, family commitments, surveys or recruitment to research? There is an opportunity cost to all of these activities.

Research in primary care is challenging not least because as has been observed repeatedly it is very difficult to recruit participants to trials in primary care. Practitioners are not funded by the paymaster to do research. Costing the recruitment to adequately compensate for the time taken to seek informed consent is prohibitive and the medical defense organisations do not indemnify doctors to do research.

Therefore, it is often if not almost always, very challenging to conduct randomised clinical trials in that setting. Other methodologies, such as prospective observational studies may be more likely to yield data whilst at the same time acknowledging that this would not be classed as level one evidence. Nonetheless, we need to work within a paradigm in which neither patient nor practitioner is likely to participate or if they do attrition is substantial and threaten the validity and generalisability of the data.

We need more creative ways to test hypotheses and collect data in primary care. Methods that capture data from a substantial number of representative participants. Methods that generate a minimum disruption to the business of doctoring. Traditional research approaches are failing or are only really possible where doctors and patients have unlimited funded time. I don’t know where that is, meantime remain sceptical about results of trials that appear to have recruited and retained thousands of participants but where the practices were involved in a significant effort to recruit to research. In that scenario somebody has paid, always ask who and why.

Picture by M01229

Business R&D approaches may be the salvation of healthcare

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There are lots of get rich quick ideas around. Just as there are lots of people who will tell you they can fix the healthcare system. But as the song goes:

There’s a guy works down the chip shop swears he’s Elvis
But he’s a liar and I’m not sure about you. KM

What really works requires knowledge of the business you want to fix, especially when you know what happens when the rubber hits the road, not a decade ago, not even five years ago but last Friday afternoon.

There are opportunities to improve every aspect of healthcare but that requires accepting one fundamental point:

People don’t really care whether their actions will please you or not.

People won’t change to please their doctor, their pharmacist, their mother or their government. They will adopt an intervention because it helps them do what they want to do for themselves. The opportunities lie in understanding how to work within these parameters. This is fundamental when it comes to business and people have made significant headway adopting this paradigm. Here are some ideas that demonstrate the power of knowing something about the needs and wants of the target audience:

  1.  Peerby from Amsterdam enables people to borrow expensive items from their neighbours, rather than splashing out on new products.
  2. Fortaleza Tour in Panama City is a walking tour set up by rehabilitated graduates of the Esperanza Social Venture Club — an organization dedicated to demobilizing Panama’s street gangs, integrating their members into society, and improving the area’s economy.
  3. Peru’s black vultures are well known locally for their natural aptitude for garbage location. In that country by fitting a flock of them with GoPros, the authorities collect real-time GPS data and enable the people to find the illegal dumps across the city of Lima.
  4. The UNPF is currently flying condoms, birth control pill and other medical supplies to the Upper East Region of Ghana using a fleet of long-flying drones.
  5. Many of the hosts on Airbnb are vacation property managers with multiple lettings. There are a number of startups offering management platforms and services that enable them to optimize their sub-letting business. Now, Parakeet is a platform that enables hosts to manage and monitor their property remotely via a cloud-based dashboard and keyless entrance system.

There are numerous examples of such out-of-the-box thinking. These innovations allow people to continue as before, to access equipment they hardly ever use but sometimes need, use their knowledge of a neighbourhood to make a living, use nature to monitor the environment, deploy technology to allow people to make personal choices and facilitate ownership of investment properties. The key aspect in each case is keen observation and insight.

This is needed in healthcare, local solutions that can be scaled to improve outcomes without imposing burdens on patients or practitioners. Nobody is as well placed to make these advances than those who already deliver and or avail of the services.

Picture by Cris

Don’t trust data out of context

5331111591_5352e900cd_zIn the drive to solve healthcare problems, it’s tempting to tinker with the essence of what medicine has to offer. When we are trying to give patients answers we often fall back on what we can measure, like blood pressure, cholesterol levels and so on. It’s easy to offer people a number that is a barometer for their health. However it’s just as important to understand our patients and the context in which they seek help. What worries them about their current situation or problem? Can they earn a living whilst they have this problem? How are they coping?

If we rely too much on big data we are failing to recognise the role that the practitioner plays in facilitating the recovery from disease. A fundamental truth is that technical medicine- surgery and drugs have very little to offer most people who seek help. There is plenty of evidence that such interventions may even be harmful. There is no occasion when technical assistance alone will make any difference to a person’s distress. That is not to say that there is no place for surgery or powerful drugs. In most circumstances though it is the interaction between an interested practitioner, who gives their undivided attention, who enables the patient to understand and acknowledge the source of their distress that makes all the difference. The best medicine helps patients to find the resources within themselves to improve their circumstances or alter an unhelpful perspective on a difficult situation. Innovations that enable the patient and the practitioner to arrive at this point sooner rather than later are most likely to make a difference to patients.

Not everything that a healer offers can be replaced by facts and figures, or enhanced by gadgets or gizmos. In fact the true value of the encounter between doctor and patient cannot be audited. Failure to factor this truth into our attempts to innovate will lead to sterile and inevitably harmful efforts to improve the outcomes in healthcare. This is especially true when those innovations are a distraction to either the doctor, the patient or both. How are your attempts to solve problems disrupting the business at hand?

Picture by Lara Lima

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

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

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

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

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

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

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

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

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

Picture by Ben Hussman

 

Why your employer might already be considering replacing you

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According to the Australian Bureau of Statistics

While it may seem as if Australians are working longer hours than ever, the average actual hours worked per employed person have decreased over the past 32 years. However, the average actual hours worked by full-time and part-time employed people have both increased (although average actual hours worked by full-time employed people have been decreasing since 2000). This total decrease, but component increase, can be attributed to the changing full-time to part-time composition of the workforce.

Sometimes there’s no choice, that critically ill patient, that urgent project, that last minute adjustment to an important document or the call to support the team. You burn the midnight oils. But when it isn’t any of the above why do you work longer hours then you are paid to work?

I remember working ludicrous hours.

As a junior doctor it was considered necessary that doctors with a barebones grasp of medicine should spend ridiculous hours on the wards, with no rest, hardly any food and no life outside of the wards to gain clinical experience for a lifetime in medicine. I don’t think those experiences contributed one jot to my clinical expertise. Then there were the hours demanded of GPs by the government, which required doctors to provide care for patients 24-7 regardless of whether the doctor was in any fit state to perform the day after the night before.

I am forever thankful for those opportunities to learn because I grew determined to control my own working life. It was challenging. Challenging only because it meant ceasing to meet the expectations of other people.

When the choice of how long you work is your own the reasons you work long hours become more interesting.

Occasionally it is because you fail to focus on what is important but not urgent, until as a consequence of your lack of investment in priorities you end up fire fighting and dealing with only the urgent and important.

Sometimes it is because you believe that you do not have the resources you require to do you job.  So you invest your own time and sometimes resources and let your employer off the hook. Because tackling the employer is perceived to be either dangerous or frustrating.

I have also seen people doing it because by earning more but being less available to their families they maintain their preferred lifestyle. Private schools, foreign holidays, big mortgages and new cars come at a price.

In all cases working longer hours ultimately comes at the expense of productivity. That means being less creative. In the end what we need, in medicine or any other calling are problem solvers rather than automatons. Is what you do for your employer sustainable? What happens if you fail to turn up for work tomorrow? What happens if you need to take time to be with a loved one or fall ill? Can you keep this up forever? If you aren’t thinking about it your employer is and that might mean that they are already considering how to replace you with an even more reliable machine.

Picture by A. Strakey

Your idea could save lives

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You don’t have to see the same doctor twice. In fact you don’t even have to go to the same practice. Come to think of it you don’t even have to go to a practice. In many countries including where I work you can dial-a-doc. He or she will turn up Uber taxi style. All you have to do is make the call. There is a cost of course. That’s the whole point. But is medicine a special case? Choice is a good thing but is there a down side to the commercialisation of health care?

Suppose you experience some worrisome condition. Something that isn’t painful but shouldn’t be ignored. Let’s say you notice blood in your pee. You might go to a doctor eventually because you, quite rightly, decide you need to find out what’s causing it. You go to the first doctor who can see you. It might not be the one you’ve seen before and if you are worried enough you might even go across town to someone who can ‘fit you in today’. The doctor might order a test or two. Possibly ask you to provide  sample of your urine, perhaps organise some blood tests and may be recommend a scan. The next day the blood is not so obvious and you think there is no need for all this fuss. Either that or you have the tests and they come back negative or you decide that there is no need to make another appointment with the doctor when the blood seems to have disappeared. You breathe a sigh of relief and leave it there. No need to worry. But of course there is. Painless frank haematuria warrants thorough investigation.

Understand, however, that hematuria may be intermittent in patients with significant urologic disease and a repeat urinalysis should be obtained if the clinical suspicion is present. American Urological Association.

If you are a doctor reading this:

  • How does your practice deal with the possibility that people may fail to follow up positive test results?
  • What is your policy for people who have negative test results in the context of significant clinical signs or symptoms?
  • How do you take into account the possibility that a patient may fail to attend for investigations for reasons various?

In some countries it is easier to track people who fail to turn up or return after tests. In other countries it is up to the practice to have a fail-safe mechanism. In healthcare, occasionally, the ‘customer’ falls between the cracks and the consequences can be a delayed diagnosis or worse. First and foremost  it requires the service provider to know the circumstances in which it is prudent to go the extra mile. If you work in a place where it may be possible that people might be harmed by the way they use healthcare services what are the circumstances in which you take more precautions? What do those precautions look like? It might be that your approach could scale to protect more people who wish to exercise choice.

Picture by Mark Wilkie

Meet the emotion that drives fresh ideas

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Whose choices would be limited by the adoption of your ideas?

  • Users
  • Your boss
  • Funders
  • Your employer
  • Government
  • God
  • All of the above

If the answer included any of the above you will experience the mother of innovation aka frustration. The same can be said of job satisfaction or happiness. Frustration is a powerful emotion to be greeted as the most effective teacher. It can literally drive you to think again so that eventually, some but not all people who experience it will find wisdom if not satisfaction lurking on the other side. Those who refuse to learn her lessons remain in the classroom unhappy. First work out which is the horse and which is the cart.

Two notable examples:

Instagram is changing the way we eat:

While looking at pictures of food can provoke a physiological reaction that makes the observer hungry, taking pictures of food can be an effective means of sticking to a diet. Menulog

Google searches are helping to identify epidemics of infections disease.

One way to improve early detection is to monitor health-seeking behaviour in the form of queries to online search engines, which are submitted by millions of users around the world each day. Ginsberg et al

In both cases the driver- Instagram and Google do not require the user to deploy their services specifically in order to achieve the requisite goals above. Innovations that depend on any one using a tool to solve one specific problem, for someone else, are going to meet our friend frustration.

People’s fundamental needs have been described long ago. First and foremost people need food, fresh air and rest. Then they need to feel their future is secure. After that they want to feel a sense of connection with others and to be valued in their social circle. Then and only then will they to compelled to creatively solve problems for other people.

Neither Instagram nor Google was set up only to help tackle obesity or infectious diseases. Both serve more fundamental needs in human society. How do your ideas fit in this paradigm? Is your latest innovative idea designed to be useful in very limited circumstances? In that case it will be of value to only a limited market and you will please a few people a little of the time. If that’s okay you will you have avoided frustration otherwise it’s back to the drawing board.

Picture by Brent Moore

Do you know if you stand in the way of your own success?

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Whose is the voice that helps you decide? Whose is the voice you listen to always? For you there is only ever one person in the room even though the room may be packed. In the end it is your own voice that will determine the outcome because without your input a team will only achieve partial victory or worse.

What is your self-talk?

This is dreadful. It’s a catastrophe. A disaster. We’ll never achieve this. It won’t work. It’s all too hard. We don’t have time. We can’t. We won’t. It’s always like this. What does he really want? We are going to fail.

Listen carefully to your prophecy. Because if you think you can or if you think you can’t- you will be right.

Catastrophe, Disaster, Never, won’t, can’t, don’t, always.

To dramatically improve the prospects for success revise this language. That doesn’t mean becoming a Pollyanna. Here’s an alternative dialogue

This is interesting. It’s a challenge. It’s a small hiccup. It’s an opportunity. What can we learn from this? How can I contribute? Can we make this better? Can we help this become a victory for everyone?

If you can’t change what you are saying to yourself at work then you have to ask three questions:

  • Why am I here?
  • Have I said this before?
  • Am I the problem?

If your self-talk is negative then the chances are that you are neither fulfilled nor satisfied with your role on this team. Your duty is to find out why and fix it or find an alternative place to be where your skills will bring you joy. Ultimately you are responsible for you. A free person’s happiness can never depend on the actions of others. If you don’t feel you fit where you work and decide to quit your colleagues may be disappointed. But they will also respect you for your insight.

Tomorrow you should indicate that you are on-board by voicing the alternative dialogue. Because sooner or later someone will over hear your negative self-talk (it’s not as private as you think) and you will find yourself removed from a seat at the table either figuratively or physically. In healthcare there is no room for those who are not fully committed to improving outcomes. The best place to begin to improve outcomes for patients is nurturing a can-do attitude. It costs nothing to make this change if required. Tony Teegarden offers a helpful short presentation on this issue.

Picture by Kevin O’Mara