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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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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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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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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?

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Trust me

Is there anything about how you appear today that might reduce your credibility with your client, customer or patient? Does anything about you diminish the impression you’d like to create?

A majority of participants reported that wearing an easy to read name tag (77%), neat grooming (65%), and professional dress (59%) were important when first meeting a family member’s ICU physician, while a minority felt that physician sex (3%), race (3%), age (10%), absence of visible tattoos (30%) and piercings (39%), or wearing a white coat (32%) were important.

Third, we affirmed that regardless of dress, professionalism, neat grooming, and a clear name tag are perceived as a requisite by patient families. These results suggest that while families may not express preferences for how physicians dress, there may be subconscious associations with well-recognized physician uniforms including white coats and scrubs. Given the importance of effective communication in the ICU, physicians may want to consider that their attire could influence family rapport, trust, and confidence. Selena Au

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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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