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Do you take the shortest route to add value?

Every thriving business adds value. If it didn’t it would not exist. Healthcare shares many points of difference with any other service but none is more remarkable than the  ability to forge connections via the physical examination. It meets our fundamental need when we are ill.

Treatment that uses direct touch can have a depth and potency that can have a great therapeutic impact, which provides some explanation for why so many people are seeking out their own “professional touchers” or are filling the waiting rooms of physicians, waiting for the doctor to find the cause of the pain and make them better. In the process, they are touched. When the patient is assured that the work of the professional toucher is free from infringement, that sexual contact is clearly out of bounds, and that the patient can say “no” to any intervention the body-work practitioner proposes, then the patient can have the experience of trust and physical touch in the context of a controlled respectful relationship. Sharon K Farber

If you are a healthcare professional in what proportion of cases don’t  you perform a physical exam? Why?

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How do you steer people away from trouble?

From time to time you will notice that your customer, client or patient is taking risks. How do you hope to steer them away from trouble? It’s more than what you say because information alone does not change minds.

It’s probably happened more than once: You spend a lot of time trying to convince someone that their opinion on a particular issue is wrong. You take pains to make sure your argument is air-tight. But instead of coming around to your point of view, your conversation partner pushes back, still convinced of her ultimate rightness. Elizabeth Svoboda 

In healthcare when people are overweight, smoking, drinking too much or have other risk factors for longterm illness it may be helpful to know who to try to advise. Not everyone is ready to change. In practice few practitioners give much thought to ‘who’ is ready.

In addition you might want to consider when to attempt to broach the subject:

Think about an event, an insight, an experience, a conversation that forever changed how you are or how you operate in the world. Although a small minority of people might mention something that happened in therapy, or a classroom, or formal learning experience, the vast majority of cases occurred after recovering from a challenging or even traumatic event—the death of a loved one, a major failure or disappointment, a crisis or catastrophe, a relationship or job ending, a threatening illness, or something similar. Jeffrey Kottler

You might want to ponder where people are most often open to review their ideas.

My favorite saying, obtained from Dr. Primack’s office, is “What you do today is important, because you are exchanging a day of your life for it”. So make it count, and learn how to be the best you that you can be. Swanson and Primack

Finally and perhaps most important- how you will attempt this most challenging of manoeuvres.

  • Many patients who smoke are sceptical about the power of doctors’ words to influence smoking since most know about the dangers, make their own evaluations, and feel that quitting is down to the individual
  • Opportunistic antismoking interventions should be sympathetic, not preaching, and centred on the patient as an individual
  • Repeated ritualistic intervention on the part of doctors may deter patients from seeking medical help when they need it
  • Smokers can be categorised as “contrary,” “matter of fact,” or “self blaming” in their reaction to antismoking advice
  • Doctors can tailor their approach according to the type of patient.

Butler et al BMJ

Whatever you do it does warrant some thought. In healthcare the stakes couldn’t be higher:

Current public health policy stresses the potential of cumulative, small changes in individual behaviour to produce significant advancements in population health. The Behavioural Insights Team or ‘Nudge Unit’ advocates for changes in health behaviour through manipulations of small environmental cues. The movement in the National Health Service (UK) to ‘make every contact count’ recognises the opportunity that practitioners have to improve public health through supporting behaviour change in the millions of people with whom they come into contact. It seems an appropriate moment to harness recent advances in behavioural science in the battle against the rising tide of Non Communicable Diseases threatening to engulf us. Kelly and Barker

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The green laces may not be a daft idea

Researchers from Harvard University have just published a study entitled The Red Sneakers Effect. They conclude that:

A series of studies demonstrates that people confer higher status and competence to non- conforming rather than conforming individuals. These positive inferences derived from signals of nonconformity are mediated by perceived autonomy and moderated by individual differences in need for uniqueness in the observers. An investigation of boundary conditions demonstrates that the positive inferences disappear when the observer is unfamiliar with the environment, when the nonconforming behavior is depicted as unintentional, and in the absence of expected norms and shared standards of formal conduct.

It is unlikely that sneakers and torn jeans will impress people when consulting a healthcare professional. However if that practitioner wears green shoe laces or eye catching socks it might not do his or her credibility any harm.

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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?

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I’ve no idea!

The proportion of people with symptoms that defy diagnosis in healthcare is substantial.

A total of 567 new complaints of chest pain, fatigue, dizziness, headache, edema, back pain, dyspnea, insomnia, abdominal pain, numbness, impotence, weight loss, cough, and constipation were noted, with 38 percent of the patients reporting at least one symptom. Although diagnostic testing was performed in more than two thirds of the cases, an organic etiology was demonstrated in only 16 percent. Kroenke

The practice of medicine has always been characterized by uncertainty. Yet, attempts to study tolerance for uncertainty in medicine have been few, and limited to its influence on specialty preferences and test-ordering behavior. In particular, studies have not investigated how the process of socialization into the medical profession affects tolerance for uncertainty. Geller et al

So if you are in healthcare how do you respond to the person with the wierd rash, the strange cough or the recurrent tummy ache?

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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.

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Do you mind if I don’t take your advice?

Your customers, clients or patients are free to choose. Despite your most earnest desire to save them from themselves they may choose to pass on your advice today. Is that alright? They may decide never to give up on the donuts, to stop smoking or head to the gym. As a consequence they may continue on the way to chronic illness. Do people have responsibilities from the ethics point of view?

Autonomous patients do have duties most of which are left out of mainstream medical ethics. Some of these duties flow from the obligations all persons have to each other; others are the
responsibilities citizens have in a welfare state. More specifically, patients have duties corresponding to those that render doctors captive helpers. Patients have to- morally have to do their best to ensure that they minimise this captivity and enable doctors to be willing helpers. Although doctors remain captive in the face of acute or life-threatening illness, it is not unethical for doctors to free themselves from this captivity in cases that fall short of life or death. Draper and Sorell

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Do you advise or dictate?

What do you advise most people who seek your help? What will solve most of their problems? It was interesting to read an article this week suggesting that junk food may be associated with depression. In her commentary Megan Lee notes:

Depression has long been treated with medication and talking therapies – and they’re not going anywhere just yet. But we’re beginning to understand that increasing how much exercise we get and switching to a healthy diet can also play an important role in treating – and even preventing – depression.

For many of the most coveted outcomes in healthcare three things are paramount:

  1. Eat less
  2. Exercise more
  3. Don’t smoke

Simple focus. Not easily translated in practice because selling a healthy lifestyle is tricky:

Interviews with 130 mothers of lower social class provided the basis for studying their views on the desirability of general practitioner intervention in their lifestyle habits; the study used both quantitative (questionnaire) and qualitative (interview) techniques. The majority of women were in favour of counselling on specific topics by the general practitioner but the qualitative data also revealed that most respondents expected the issues to be relevant to their presenting problem. Moreover they were keen to assert their right to accept or reject the advice given. Stott and Pill

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Show and tell

Nothing is as compelling as seeing a vision of  yourself in the future. Increasingly healthcare professionals have the scope to offer people a vision of the future. It’s possible to display projected changes on avatars, websites or infographics. How might you show people what might happen in the foreseeable future?

Recent literature shows that new technologies can be used to promote patient engagement. The present contribution focuses on Virtual Worlds (VWs), namely virtual environments that multiple users can experience together thanks to the use of avatars. Indeed, VWs offer interesting opportunities for patient engagement interventions on two levels. On the individual level, customized avatars are known to have relationships with users’ inner experience and Self-conception, so that they may constitute a peculiar additional tool for psychological assessment. Moreover, they are able to promote healthy behaviors thanks to a strong vicarious reinforcement (Proteus effect). On the collective level, VWs constitute an ideal platform to support the emergence of collective flow states (Networked Flow) which are related to the patients’ creative activity and well-being. Healthy Avatars, Healthy People: Care Engagement Through the Shared Experience of Virtual Worlds

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Do you miss opportunities to forge a connection?

There are very few services in which the customer or client has physical contact with the service provider. Hairdressers and masseuse are the exception. These ‘therapists’ often relate hearing things that are seldom confided in others:

A questionnaire, specially designed to measure the mood change was filled in by 359 women at their arrival in different hair‐salons and after having received various hair care services. The results show that hair treatments increase all the positive dimensions of mood and decrease all the negative ones. Picot -Lemasson et al

Patients expect that some form of bedside evaluation will take place when they visit a physician. When physicians complete this evaluation in an expert manner, it can have a salutary effect. If done poorly or not at all, in contrast, it can undermine the physician–patient relationship. Studies suggest that the context, locale, and quality of the bedside evaluation are associated with neurobiological changes in the patient. Recognizing the importance of the bedside evaluation as a healing ritual and a powerful diagnostic tool when paired with judicious use of technology could be a stimulus for the recovery of an ebbing skill set among physicians. Verghese et al

If you are a healthcare professional and there are opportunities to forge a connection with your patient do you leverage that capacity? Does every person who sees you have some sort of examination? Why or why not?

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