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What stories do you tell?

We all have stories about what we do for a living.  We tell them all the time- even if we don’t recognize that we are telling stories.  They communicate how we feel about our work. Do your stories convey the impression that you are stressed out, bored, bullied, treated unfairly and in general can’t wait to retire? You realise that this is also your self talk and that ultimately you will magnify these experiences. On the other hand if you started telling stories about experiences that energized you, made you feel valued and creative then you might notice more about your job that seems to resonate with what you want and how you want to feel.

At 9 o’clock one bright morning a 32 year of man had been waiting for an hour in a busy clinic. He was called into the doctor’s office. Covered in tattoos, he was a muscular man whose tanned skin suggested a life outdoors. He wore a high vis vest and heavy steel capped boots.

I’ve had a toothache since three o’clock this morning doctor and I need to get to work

He said rubbing his jaw. His doctor was curious, it was odd that a man who seemed very robust in every other way, was getting ready to go to work would wait for an hour in a busy clinic complaining about toothache that started a few hours ago. But of course that wasn’t the whole story. The doctor watched him rubbing his jaw and the side of his neck.

Where did the pain start?

In my chest doctor, it was like someone was sitting on my chest, I felt a bit nauseous and it seems to have settled in my jaw and the side of my neck. I think it’s going into my shoulder now.

Half an hour later the man was in hospital being treated for a heart attack. His decision to get to a doctor might just have saved his life and his doctor’s curiosity paid of.

Picture by Jonathan Moureau

What I’m taking is better than anything you can suggest

We don’t know why some people respond to some treatments.  Helen produced a bottle of cough medicine from her handbag.

This stuff is magic. It cures my cough every time.

You recall a recent paper which concluded:

Across Europe, there are large variations in the recommendations made by healthcare professionals for the treatment of acute cough. This has arisen through custom and practice based on the evidence of historical studies performed to standards well short of what would be considered legitimate today. Acute cough is particularly difficult to study in a controlled setting because of the high rate of spontaneous remission and a large placebo effect. Morice and Kardos

What do you say? Whatever you say and however you frame it is worth considering before it happens- because Helen isn’t the only one taking what might be considered a placebo.

Picture by _Val_

What happens after they leave?

What happens after you sell your product to your customer or client? They drink the coffee, drive the car or wear the coat until it’s time to get another one. It’s a bit different in healthcare because the story doesn’t end with the person taking the tablets on one day. Fred is 65 and he has diabetes. His blood sugar readings are high despite weeks of ‘dieting’.  There is no doubt that he needs drug treatment. At the same time his cholesterol levels and blood pressure are not satisfactory. He is going to need multiple medications. He is not sure why because he has no symptoms. What do you tell him? How do you frame this new reality for Fred? How will this impact on his life? He likes going on long holidays now that he has retired in fact last week he  booked a six week cruise for later in the year. He enjoys a beer and chips while watching television at night. He hasn’t been to a gym-ever. He still smokes a few cigarettes every day. He doesn’t like eating vegetables unless they are fried. His wife Joanne is ten yours younger and they still have ‘date nights’. He needs to stay driving his car as they live out of town. He is looking forward to the birth of his fourth grandchild this year. It’s reported to be a girl, the first grand daughter. He has heard that some of these medicines give you diarrhea and can make you impotent. According to his friend some cholesterol tablets give you muscle pain. What happens now doctor? How will you address Fred’s concerns about this new situation?

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You can’t fix what you don’t know

Georgia has been waiting to see you for over an hour. She has been ignoring the pain in her side for days. Initially she hoped it would just go away. There is too much else to deal with. Josh her partner lost his job last week. Her mother had a stroke 3 weeks ago. Her dad is barely coping with caring for his disabled wife. The children are going to a new school this year and Emily (9) is having trouble settling into the new class. Meanwhile Georgia was hoping for a promotion at the office. With Josh out of work they need the money and it looks like she might now need to spend her weekends helping dad to manage at home. The pain in her side has got steadily worse and now it’s disturbing her at night. She mentioned it to her friend who forced her to make this appointment. Georgia doesn’t know her doctor well. She just wants this nightmare to end. She imagines this might be a urine infection but surely that wouldn’t last this long? She doesn’t want to think about the other possibilities. She especially doesn’t want to think about the lump she found in her right breast last month. She hasn’t told Josh she was coming to the clinic today and gave a vague impression that she needed to come to this end of town to collect something for work. She doesn’t want Josh to worry even though she thinks he might have noticed her holding her side while making the children’s lunch last night. Please let it be a urine infection so that a course of antibiotics will fix it. Georgia isn’t ready to handle any more bad news. A quick visit and a prescription is all she expects.

In 2 national, nonprobability online surveys of 4510 US adults, most participants reported withholding at least 1 of 7 types of medically relevant information, especially when they disagreed with the clinician’s recommendations or misunderstood the clinician’s instructions. The most commonly reported reasons for not disclosing information included not wanting to be judged or hear how harmful their behavior is. Levy et al

The outcome doctor is up to you but it all hinges on you being able to get the picture. Georgia isn’t sure she is going to tell you any of this even though she desperately needs someone to make it alright. Will you notice? Are you set up to receive the signals?

Picture by Drew Leavy

What happens next is up to you

Healthcare more than any other service warrants taking the long view. Supposing a toddler becomes feverish overnight. Mum and dad (assuming they are living together) are likely to fret about that child all night. No one will sleep well. The following day the parents will continue to worry that their baby is ill. Friends or family will be consulted. It is possible but not certain that a grandparent may be able to offer some relief with childcare.

Researchers in the United States have found that a third of children under the age of six receive up to 10 hours of care a week and that 47% of all grandparents with grandchildren (under 13 years) living nearby provide some childcare . Although more grandmothers (54%) provided child care it was found that grandfathers (38%) also made a significant contribution. In the United Kingdom it has been estimated that up to half of working parents rely on grandparent care for their children. It was also found that although grandparents were prepared to provide some child care, and at times even reduced their working hours to provide it, they did not want to give up their jobs. Australian Institute of family studies

The partner who has to go to work the next day will be distracted and anxious. The childcare arrangements, if that’s the norm will be on hold as one parent may take time off to be at home. The parents will visit a pharmacy (drug store) and acquire whatever is recommended in the hope that the child will recover quickly. That is unlikely as even a viral illness can make a child unwell for several days. Eventually they will seek medical advice. Phone calls will be made and appointments requested. Parent or parents and toddler will travel and wait in line to see a doctor. They will eventually wheel the toddler into a health practitioners room. If that person is you what happens next is up to you.  Most likely the child will have a viral illness, be teething or have some other minor illness. But to this family this will have been a stressful and worrying couple of days. How you respond will form their impression of your service and make a bad situation an opportunity to learn about caring for a sick child or add to the  drama.

Picture by Andrew Seaman

What’s on display where you work?

What do your customers, clients or patients see in your shop, café or clinic? Why was it put on display? Does it add value? Does it distract? How do you know?

“People draw opinions about who we are and how we operate based on what our space looks like, sounds like and even smells like,” says Jen Zobel Bieber, a New York-based life coach. Forbes

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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.

Picture by Kaleb Fulgham

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

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

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

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

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

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

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

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

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