better health by designLearn More

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?

Picture by Army Medicine

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

Picture by Sarah-Rose

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?

Picture by Paola Kizette Cimenti

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?

Picture Catalina Schliebener

The doctor is a busy lady

My friend Alex is a good daughter. She would accompany her mother to the clinic for injections every two weeks. They would wait patiently in the waiting room before they were called in to have the treatment. Alex’s mother was a diabetic. Because of her treatment she needed regular meals. At one visit Alex went up to the reception desk and asked how long before it was her mother’s turn.

You see she is a diabetic and needs some food.

The response was jarring:

The doctor is a professor.  She is a very busy lady. She will see you when she is free.

Alex tells me that professor was a wonderful doctor and would have been horrified to hear that the receptionist had been so rude. Do you know what the person who saw you customer, client or patient just before you said to that person? Isn’t it your business to know?

Picture by Ronnie Scotch Finger

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.

Picture by Jörn Guy Süß

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

Picture by Viv Lynch

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

Picture by Fit Approach

Are you catering to those who need you?

40 years ago people older than 65 years of age were a minority in the population. In the very near future they will be a significant minority and for some service providers they will be the majority. Healthcare is a good example. However the population may be ageing but it is also changing.

This aging population has many options from which to choose and they are looking for more than just a particular retailer, restaurant, product or service. They want their purchase to count: to satisfy mental, emotional and even spiritual needs as well. Older consumers: Redefining Health and Wellness as they age.

How has this been factored into your plans for how you will respond?

Picture by Nicolas Alejandro