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Simply correcting myths may be counterproductive- context is everything

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The spritely 80 year old man who sat in my consulting room was adamant.

No thanks doctor every time I get a flu jab I get the flu. So not this year. Thank you.

That was the third time that day that I had heard this argument against the flu vaccine. It troubled me. The individuals most likely to benefit were refusing vaccination and some of them say the same thing every year. And yet authoritative advice is that:

In randomized, blinded studies, where some people get inactivated flu shots and others get salt-water shots, the only differences in symptoms was increased soreness in the arm and redness at the injection site among people who got the flu shot. There were no differences in terms of body aches, fever, cough, runny nose or sore throat. CDC

Nonetheless 43% of the American public believes that flu vaccine can give you the flu. In the same study it was found that:

Corrective information adapted from the Centers for Disease Control and Prevention (CDC) website significantly reduced belief in the myth that the flu vaccine can give you the flu as well as concerns about its safety. However, the correction also significantly reduced intent to vaccinate among respondents with high levels of concern about vaccine side effects–a response that was not observed among those with low levels of concern. This result, which is consistent with previous research on misperceptions about the MMR vaccine, suggests that correcting myths about vaccines may not be an effective approach to promoting immunization. Nyhan and Reifler

So it seems that providing information, no matter how authoritative,  is not enough to get people who are already opposed to being vaccinated to change their minds, in fact it may do the opposite! According to the theory of planned behaviour human actions are guided by three kinds of considerations:

  1. Behavioural beliefs ( beliefs about the likely consequences of their behaviour)
  2. Normative beliefs ( beliefs about the normative expectations of others)
  3. Control beliefs ( beliefs about the presence of factors that may facilitate or impede performance of the behaviour)

Therefore interventions that are aimed at providing information only do not work. We need to address attitudes, perceived norms and control if we are to see increased rates of immunisation. When this theory was applied to understanding how to improve flu vaccination rates it was concluded that:

Future studies could use social cognition models to identify predictors of actual vaccine uptake, and potentially compare these findings to predictors of people’s intentions to be vaccinated. Once identified, these factors could be used to craft targeted interventions aimed at increasing vaccine uptake. Myers and Goodwin

It seems that the intervention needs to be targeted and that there are several factors that identify people who intend to be immunised:

  • The employed,
  • Older people
  • Having a positive attitude to flu vaccination,
  • Scoring high on subjective norm, perceived control, and anticipated regret,
  • Intending to have a seasonal flu vaccination this year,
  • Scoring low on not being bothered to have a vaccination and
  • Believing that flu vaccination decreases the likelihood of getting flu or its complications and would result in a decrease in the frequency of consulting their doctor.

Those less keen on  vaccination may be from specific ethnic groups. The authors advise that

These racial disparities emphasise the need to involve stakeholders in the community and to reassure the community and address their concerns and resistance attitudes and beliefs.

Also people may also be more influenced by information obtained from peers and news media than information distributed by the government in print. Such “external” influences also need to be addressed in order to facilitate vaccination uptake. And so back to my patient, it seems that information alone would not change his mind- which was indeed my experience. In order change his mind we will need to target him in the context of his community, his family and his concerns. The battle for hearts and minds includes both hearts and minds. As always context is everything.

Picture by NHS Employers

The failure to communicate is costing us billions

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The Weekend Australian headline today, Sunday 24th April 2016 declared that

Healthcare waste costs $20bn a year

According to the graph on the first page of the paper there were 105-110 General Practitioners (GPs) or specialists in 2004. Although the number of GPs per 100,000 population has remained static there are now more than 130 specialists per 100,000 people . Therefore the rising cost of waste in healthcare runs parallel to the increase in specialists in the population. The source is quoted as the Australian Commission on Safety and Quality in Health Care.

But there is nothing new about this story. This trend was demonstrated in previous decades. More primary care equals lower costs the formula isn’t complex. Reading the papers today we recall the late Barbara Starfield’s words:

Six mechanisms, alone and in combination, may account for the beneficial impact of primary care on population health. They are (1) greater access to needed services, (2) better quality of care, (3) a greater focus on prevention, (4) early management of health problems, (5) the cumulative effect of the main primary care delivery characteristics, and (6) the role of primary care in reducing unnecessary and potentially harmful specialist care.

The disappointing thing about the accompanying newspaper commentary was the suggestion that the solution is political. The journalistic analysis is that powerful lobby groups have managed to influence policy to the point where there is subsidised over servicing of the population. Specifically prostatectomies, colonoscopies, arthroscopies, cataract surgery, hysterectomies and CT scans.

In a country where general practice remains the gatekeeper to specialist services we need to figure out how we might be able to tackle the problem for the sake of the economy. The solution is to remain circumspect about another quick fix because we have learned that politics and the need to be popular with the electorate rarely delivers anything like a lasting solution.

In medicine people are referred or persuaded to have treatment or investigations and under the ‘big data’ is the story of ineffective consultations. One where either the patient is not examined or an adequate history taken, or where the risk and benefits are not explained to the patient in a way that informs the decision. After all if that were not the case which patient at very low risk would chose to have a colonoscopy?

What is the difference between managing a request for an antibiotic for a cold and managing a request for a CT scan for mechanical back pain? To those who are cynical about the chances of getting the message heard we might say wait. When there is sufficient pain the bureaucrats will beat a path to your door. There is no solution as effective as improving how we communicate with patients, anything else will paper over the hole, no the chasm, in the budget.

Picture by Christopher Blizzard.

Please don’t ask for my time as refusal may offend

In an article from the Economist, the authors advise that we appear to perceive ourselves as short of time. Every minute of the day can be filled ‘doing’ something or several things simultaneously, often badly. We are also increasingly wedded to the demands of our mobile devices. People spend time texting while eating, driving and even on the loo. In fact it is estimated that we spend one third of our waking hours interacting with our phone.

In an experiment carried out at the University of Toronto, two different groups of people were asked to listen to the same passage of music. Before the song, one group was asked to gauge their hourly wage. The participants who made this calculation ended up feeling less happy and more impatient while the music was playing. Participants reported experiencing greater impatience while listening to the music when prompted to think about their time in terms of money.

This has some important resonance in healthcare where practitioners who earn a living through fee for service may, and often do, become impatient about engaging with researchers or academics. This is a significant problem because in countries where primary care is the first port of call for most people we desperately need research to ensure that the service offered is both evidence based and cost effective. But what is the order priority: appointments with patients, results of tests, administrative paperwork, continuing medical education, family commitments, surveys or recruitment to research? There is an opportunity cost to all of these activities.

Research in primary care is challenging not least because as has been observed repeatedly it is very difficult to recruit participants to trials in primary care. Practitioners are not funded by the paymaster to do research. Costing the recruitment to adequately compensate for the time taken to seek informed consent is prohibitive and the medical defense organisations do not indemnify doctors to do research.

Therefore, it is often if not almost always, very challenging to conduct randomised clinical trials in that setting. Other methodologies, such as prospective observational studies may be more likely to yield data whilst at the same time acknowledging that this would not be classed as level one evidence. Nonetheless, we need to work within a paradigm in which neither patient nor practitioner is likely to participate or if they do attrition is substantial and threaten the validity and generalisability of the data.

We need more creative ways to test hypotheses and collect data in primary care. Methods that capture data from a substantial number of representative participants. Methods that generate a minimum disruption to the business of doctoring. Traditional research approaches are failing or are only really possible where doctors and patients have unlimited funded time. I don’t know where that is, meantime remain sceptical about results of trials that appear to have recruited and retained thousands of participants but where the practices were involved in a significant effort to recruit to research. In that scenario somebody has paid, always ask who and why.

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Tailoring lifestyle advice as per patient experience design

16821469876_8d062d433d_zLots of people stop smoking every time the tax on cigarettes is raised. It has been said that:

‘A 10% increase in the price of cigarettes in developed countries will result in a 3 to 5% reduction in overall cigarette consumption.’

And in one study only 6% of people were confirmed as non-smokers one year after receiving advice in general practice.

So if we can dissuade enough people from compromising their health with financial disincentives what is the role of the doctor and primary care? What can a health professional do to help when a smoker with a nasty cough seeks advice, and or treatment? It could be argued that the person is aware that their habit has a bearing on the symptoms. Or that by drawing attention to the link with cigarette smoking that the doctor is heightening a sense of shame, self-loathing and guilt.

So what is the role of general practice or primary care in tackling the big issues —smoking, obesity and alcohol abuse? Are brief interventions delivered in this setting more harmful than necessary? What if innovations delivered by practitioners were even more effective than the modest 6% recorded in the past?

An innovation that I was involved in evaluating led to one in seven smokers quitting. An innovation we subsequently developed as an adjunct to the treatment of obesity may well be more effective than diet and exercise regimens used alone. However if these innovations are delivered in a primary care setting then there is a risk that some patients who access them might feel challenged by the having it drawn to their attention that their results are a reflection of their own efforts. Those who fail to achieve the desired results may become disheartened.

It takes an effort to give up a harmful habit and it is now possible to predict and demonstrate the results of our lifestyle choices in ways that appear to matter to us the most. The key for innovators in the’ patient experience design’ space is to ensure that we minimise the harm that could be done by ensuring that such innovations do what they say on the tin and that they are designed with safeguards. What is beyond dispute is that the prevalence of obesity is increasing at an unprecedented rate and every health care professional has a role in combating this issue, not just those with a public health perspective. Some people respond best to health messages that are tailored to their personal circumstances, and as healthcare practitioners, we have a duty to make those options available to them. If you are interested in staying abreast of innovations developed along these lines click here.

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Don’t trust data out of context

5331111591_5352e900cd_zIn the drive to solve healthcare problems, it’s tempting to tinker with the essence of what medicine has to offer. When we are trying to give patients answers we often fall back on what we can measure, like blood pressure, cholesterol levels and so on. It’s easy to offer people a number that is a barometer for their health. However it’s just as important to understand our patients and the context in which they seek help. What worries them about their current situation or problem? Can they earn a living whilst they have this problem? How are they coping?

If we rely too much on big data we are failing to recognise the role that the practitioner plays in facilitating the recovery from disease. A fundamental truth is that technical medicine- surgery and drugs have very little to offer most people who seek help. There is plenty of evidence that such interventions may even be harmful. There is no occasion when technical assistance alone will make any difference to a person’s distress. That is not to say that there is no place for surgery or powerful drugs. In most circumstances though it is the interaction between an interested practitioner, who gives their undivided attention, who enables the patient to understand and acknowledge the source of their distress that makes all the difference. The best medicine helps patients to find the resources within themselves to improve their circumstances or alter an unhelpful perspective on a difficult situation. Innovations that enable the patient and the practitioner to arrive at this point sooner rather than later are most likely to make a difference to patients.

Not everything that a healer offers can be replaced by facts and figures, or enhanced by gadgets or gizmos. In fact the true value of the encounter between doctor and patient cannot be audited. Failure to factor this truth into our attempts to innovate will lead to sterile and inevitably harmful efforts to improve the outcomes in healthcare. This is especially true when those innovations are a distraction to either the doctor, the patient or both. How are your attempts to solve problems disrupting the business at hand?

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How do we stop the war over antibiotics next winter?

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She was quite insistent and becoming irate:

Look I am a busy woman. Every time I get these symptoms I come in and get antibiotics and it gets better. Whenever I wait it just gets worse. I don’t have time to mess about so can you just look at the previous notes and prescribe what I usually get?

She had an upper respiratory tract infection. Her throat was mildly inflamed and she had a runny nose. No pyrexia. She sat bolt upright and ready for an argument.

It doesn’t happen that way every time. The patient is usually prepared to allow her doctor to make the call but occasionally it’s not that easy. According to the literature, a third of the public still believe that antibiotics work against coughs and colds. We have seen quite clearly that offering a prescription with the advice to take the antibiotics if the symptoms don’t improve rapidly may help reduce the numbers who take antimicrobials unnecessarily. We know that in at least one study 38% of people may be prescribed an antibiotic this year.  More than one in ten will not complete the course.

How many take the drug as prescribed, e.g. three times a day? And why is it that younger people are less likely to complete the course all the while acknowledging that they understand the importance of taking the medicine as prescribedThe context in which people seek antibiotics may help to inform how doctors manage the call for antibiotics. The answer to the challenge thus far is to mount a public health campaign:

We could focus a ‘Do not recycle antibiotics’ message towards the higher educated, young women who are more likely to store and take antibiotics without advice. McNulty et al

An upper respiratory tract infection is an unpleasant experience. Having a ‘cold’ that lasts a few days may seem trivial to some healthcare practitioners or policy makers but to the patient, it is very far from trivial. In a brilliant paper describing work with 719 people, Longmier demonstrated that neither doctors nor patients can accurately predict how long an upper respiratory tract infection would last or how severe the symptoms are going to be. In an intriguing conclusion to their study they said:

Clinicians should not use their predictive assessments or their patients’ predictions when advising patients on the expected course of a URI (Upper Respiratory infection).

The average duration of symptoms  for URI is 7–10 days, with a minority of patients experiencing symptoms for more than 3 weeks. Antibiotics will do nothing to improve symptoms. Therefore, the problem can be framed quite differently. How you feel on the day you consult your GP is not a good predictor of how long you are going to be miserable with this ‘virus’. Your GP might tell you it’ll all be better in a week and that might sound okay alternatively she might say this will go on for two weeks or more and that might sound disastrous. In any case, she is not likely to be right.  So we go back to the scientists who suggest:

As we cannot accurately predict when the URI will end or how bad it will be, our best clinical tools for patients with URIs are empathy, reassurance and education on the self-limited, short-duration nature of viral upper respiratory tract infections. Longmier et al

To my patient my sympathetic demeanour and rehearsed speech about viruses was not satisfactory. What this patient wanted more than anything else was to be free from her symptoms. I was curious as to why but she was not in a mood to talk about it.  It seems that regular paracetamol in combination with chlorphenamine and phenylephrine may be helpful as are nasal decongestants.  Over the counter cough medicines are not. No doubt there is more literature on the topic of effective symptom relief however, no papers suggest that any treatment entirely rids the patient of symptoms immediately. The key question still remains- why do people insist on and or stop antibiotics before completing the course? If we could demonstrate that people stop antibiotics because their symptoms improve after regular use of effective symptom relief then such evidence may be helpful in any discussion with patients about antibiotics. We then reframe consultations on URIs to offering advice on symptom relief. We offer a solution more aligned to the context in which the patient is presenting. Let’s acknowledge that a cold is an unpleasant experience and not as seems to be suggested to the public a minor nuisance not worthy of our attention.

Picture by Marquette Laforest

Age, occupation and prognosis may filter what the patient hears

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I’m booked in for a check up tomorrow with the doctor who looked after me and called the ambulance so I can thank her in person. My bike doesn’t seem to have a scratch! Tony and Wayne

The experience of an illness, accident or emergency can heighten the trust in a medical practitioner. Primary prevention is more problematic.  People who are asymptomatic and being urged to alter their lifestyle or take antihypertensives may be more dubious:

Well I mean would you trust them with your life? Or would you trust them you know, when you’ve got a bit of a cough? You know, there’s a bit of a difference. You can trust somebody to take a splinter out or whatever but ah, I mean, even if you’ve made some sensible comments, if you’re going to start playing around with anything serious, you know, brain or the heart or whatever, you’d like to know a bit more about it—you’d like to see him in action and…Meyer et al

Three factors appear to influence the attitude; age, socioeconomic status (SES) and prognosis. Our research was conducted with reference to cardiovascular disease. Generalisations in medicine are not safe however these data offered some helpful pointers.

Older patients, lower SES patients and patients with established pathology are more likely to trust, and are less likely to question medical advice. Meyer et al

Our research also suggests that:

Participants who perceived themselves at risk of a poor or uncertain outcome were unlikely to express doubts about medical advice. Meyer et al

Therefore, context is critical when crafting an approach to the patient. Does the patient wish to be involved in decision making or would your presentation of multiple options with the relevant probabilities for each outcome make a bad situation worse? At a time when there is a push towards ‘patient self-management,’ the data suggests that some patients prefer a traditional approach with the doctor recommending a treatment modality. Older people in deprived areas top the list, the demographic that is at highest risk of chronic and complex health conditions. Unfortunately getting this wrong when the patient wants to be more involved may destroy the relationship between patient and clinician.

…he’s always explained—look whatever I’ve gone to see him for he’s explained, he’s gone into details. He, he doesn’t write anything off without doing tests for, for further examinations—whatever. And through the process of elimination as opposed to my previous GP who had the approach of, ‘ah it’s nothing—you’ll be alright’. Meyer et al

We need to understand the business of doctoring as an integral part of designing solutions aiming to optimise patient experience. We need doctors to step up as codesigners. Treatment is often determined locally within the appropriate context rather than a one-size-fits-all. The solution to healthcare challenges starts with having a good General Practitioner whose work is supported by good research in primary care.

Picture by Tony and Wayne

Someone’s son or daughter

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There is increasing evidence that overweight and obesity exists in the context of families. There may be something about family dynamics that engenders or maintains the problem with excess weight gain.

  •  A 2004 study in the Journal of Pediatrics found that the biggest factor that predicted overweight in children was if the parents were also overweight.
  • Two-thirds of parents underestimate the BMIs of their children, especially when their children are overweight or obese.

Some data has even suggests trends according to relationship of the adults in the household:

  • Children raised by two co-habiting biological parents had the highest rates of obesity, at 31 percent.
  • But if those parents were married, the children had one of the lowest obesity risks, at 17 percent.
  • Children residing with an adult relative had a high (29 percent) likelihood of becoming obese.
  • But if that adult was their single father, they had a very low risk—just 15 percent.
  • The children of single mothers and those of co-habiting (not married) step-parents had similarly high rates of obesity, at 23 percent.

Furthermore:

Non-poor children living with married step-parents had a 67 percent higher risk of obesity compared to similar non-poor children raised by married biological parents.

The authors of the study couldn’t explain why children in married parent households had lower probabilities of obesity.

The final word is:

Information on children’s health and nutrition must reach not only mothers, but the other caregivers (relatives, fathers, step-parents) with whom mothers and children regularly interact. It is also important to ensure that caregivers are in agreement about issues of nutrition and physical activity for children. Augustine and Kimbro

Once again stressing that innovations to tackle obesity need to consider the context in which the person with the problem is presenting for help. That person is someone’s son or daughter. What else are they coping with? Could anything you have done reduce their status to someone who fails to appreciate the first law of thermodynamics? If so, are you going to make a bad situation worse?

Picture by Niccolo Caranti

Healthcare is not akin to internet shopping

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It’s encouraging when the patient asks you for your card after consulting about their warts. It suggests you have earned their trust and the next time they present you can expect to hear about something more worrying.

With regard to primary care there are those who believe there is money to be made by providing access to any doctor, anytime over the internet. However, the first commercial failure of this approach has just come to light. HealthSpot was featured in the New York Times, the BBC news and the HuffPost tech. According to posts on the internet:

HealthSpot Inc. told its largest pharmacy chain customer, Rite Aid Corp., that it would “cease operations” as of Dec. 31, and its telemedicine stations have shut down in Rite Aid pharmacies in northeast Ohio and the Dayton area.

And this after announcements in Mar 2015 that Internet provider Cox Communications was pouring money into HealthSpot, a telemedicine kiosk provider. At the time the Internet provider was reported to suggest that this could be:

As important to health care as ATMs have been to banking.

There was an expectation that doctors would virtually diagnose ailments such as allergies, bronchitis, the flu, earaches and ear infections, fevers, rashes, and sinus infections.

The model was nicely illustrated in this video.

But something appears to have gone drastically wrong and according to journalists attempts to reach the HealthSpot CEO have been unsuccessful. Commentators have been speculating that what may have contributed to the demise. An interesting comment was reported by Neil Versel

Jason Gorevic, CEO of telemedicine company Teladoc, expressed his belief that there are three critical elements to success in this industry segment: the technology platform, clinical capabilities and consumer engagement. “Consumer engagement is hard to do,”

And that may be the crucial point- the patient experience was not baked into the design of this innovation. The limitations of telemedicine in the context of primary care may be far greater than is being acknowledged by people who have very little insight into the business of doctoring.

Three years ago our research concluded:

Patients with minor self-limiting illnesses and those with medical emergencies are unlikely to be offered access to a GP by video. The process of establishing video consultations as routine practice will need to be endorsed by senior members of the profession and funding organizations. Video consultation techniques will also need to be taught in medical schools. Jiwa et al.

A minor illness provides an opportunity for the doctor to bank social capital, something that both will rely on when the symptoms presented at a future consultation suggest a life-threatening pathology.

Photo by C.C. Chapman

Why the common cold must be seen in context

imageI was there to buy sunscreen. The pharmacy assistant served the next customer.

I’d like something for a cold. Something to stop the runny nose and help me sleep at night.

Upper respiratory tract infections are the commonest reason that patients consult doctors in primary care. What can doctors do about these infections? In the vast majority of cases nothing. And still they come in there hundreds of thousands. Will you go to work the next time you catch a cold?

If not why not?

Surely regular paracetamol is about all you can take and it’ll get better ‘in a few days’. That’s what the chemist told her customer and I nodded in agreement.  But perhaps we are missing the point. For many people the runny nose and aching limbs is more than they can cope with on top of boredom, anxiety and that hour long commute on a crowded bus to work at a job that only just pays the bills. What with the sleepless night, the wheezy toddler, the noisy neighbours, the hang over and the barking dog.

In the case of sickness absence an employer may demand a ‘doctor’s note’.  This infection more than any other medical condition teaches us that context is everything in medicine. For the medical practitioner it’s not a case of treating an infection, it’s about seeing the patient within the backdrop of their lives. The common cold offers an uncommon opportunity to connect with people when they are expressing something that they may scarcely be able to articulate in words. Something that impacts on their experience of all discomfort and disappointment they may experience.

When we frame the epidemiology of respiratory tract infections as a microbial assault it’s like attempting to navigate a route with reference only to ‘Google Earth‘. The impact on human behaviour is only discernable in finer detail. Perhaps people consult doctors in these circumstances when there are many other things that are wrong in their lives. The medical response to upper respiratory tract infections can best be crafted with reference to Patient Experience Design. The patient requires more than platitudes about a ‘viral’ illness that doesn’t respond to antibiotics.  The time out may offer an opportunity to reflect on more fundamental problems. The best response in medicine may be to acknowledge the ‘troublesome’ symptoms and accept the reasons for consulting without harming the patient with unnecessary drugs. To do this well and to promote a more resilient attitude to discomfort requires an understanding of what people need when they are suffering but not moribund. Those with upper respiratory tract infections who seek help are not malingerers because more than a virus causes their morbidity. As well as an opportunity to stimulate reflection on what ails them more generally it is a teachable moment to instruct on self care.

Picture by William Brawley