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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

Picture by Bloody Marty

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