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What factors trigger an urgent and appropriate medical consultation?

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There are circumstances in which it is critical for a patient to consult a doctor sooner rather than later. Imagine someone with symptoms of a stroke or a myocardial infarction ( heart attack), or with a breast lump.

In these circumstances timely intervention may be life saving. These circumstances are often the subject of public health campaigns and perhaps one of the most popular attempts to improve health care outcomes or reduce costs. Predictably such attempts are not universally successful. That may be because the issues are rarely considered from the patients’ perspective, because a solution is imposed from what seems to help ‘some people’, possibly those who might have consulted a doctor anyway.

Our help seeking behaviours are subject to the same three factors that Fogg speaks of in his behaviour model. Motivation is contingent on the person’s understanding of his or her risk to adverse outcomes. Ability is the person’s perception of access to treatment that may be life saving and finally, and crucially, triggers are factors that compel the person to make the effort to consult a doctor when they have the most to gain.

Therefore there are four possible scenarios:

High motivation and high ability to access health care.

This is ideal. In these circumstances a ‘signal’ trigger will suffice. Think ‘red traffic light’ .  Therefore someone who is bleeding or  experiences crushing central chest pain or develops sudden onset weakness on one side of their body, will quickly act to do what is necessary. Alternatively they might do the needful, as in the picture, when they are prompted by a relative or friend. Unfortunately it cannot be assumed, as it often is, that everyone is in this boat.

A health promotion campaign might be considered successful if five percent of the target audience make long–term changes in overt health behaviour. Rogers and Storey

There are three other less ‘easily’ remedied situations.

High motivation but poor access.

For these people ‘red lights’ will do nothing but cause frustration. What is needed is well publicised improved access to skilled care providers. For many people in specific areas of many countries access to health care is poor and it is reflected in inequity of outcomes for what is, anywhere else in the country, a preventable cause of morbidity and premature mortality. There is real scope to innovate here, perhaps the most promising avenue is online  or telephone access to care providers or innovations that better integrate care providers at the point of presenting symptoms especially within primary care.

Low motivation and easy access.

On the face of it this might be easily fixed simply by ‘educating’ people. However the empirical evidence is that such campaigns have limited ( as opposed to ‘no’)  effectiveness. Often the causes of low motivation are  many and varied. What speaks to one community or individual may not resonate with others and the scope for frustration or patchy results are very high. If this were not the case our jails would not have quite so many inhabitants. Law breaking like poor health is a complex issue and no solution including the death penalty will promote the most desirable behaviour. People don’t always respond to dire warnings. One strategy is to make the alternative action ( i.e. non consulting) less desirable than consulting. However such solutions fly in the face of patient autonomy.

 Low motivation and poor access.

Bad news. These individuals are unlikely to respond to anything. Changing attitudes is unlikely to follow ‘educational’ campaigns unless and until the issue of access to health care is sorted out. There are many individuals who have poor access to health care. The reasons for this are far too diverse for any strategy to be universally successful. If there were a simple way to do both then any of the triggers in the other of these four quadrants  might suffice. Fortunately only a minority of people are in this category but there are enough here to ensure that the idea of universally good outcomes for everybody is a utopian dream. Innovation, however well meaning, is set to fail some individuals most of the time.

Picture by amy_kearns

Primary care is not a panacea

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Barbara Starfield’s thoughts still resonate with many of us who work in primary care. Primary care serves to reduce costs in a health care system essentially by keeping people out of hospital.  However, recently there have been attempts to tinker with how the sector is configured in many countries where one would have assumed that no adjustment was necessary.

The demand for general practitioner services continues to rise. It may be tempting to assume that the drivers for this trend are the same as they have always been: infections, gluttony, sloth, ageing, substance abuse, accidents and genetics. And yet the literature records that practitioners know very little about their patients biography. So what does primary care actually do and what does this tell us about the way forward?

We know that seeing a general practitioner is not going to ‘cure’:

  • Divorce
  • Child abuse
  • Boredom
  • Debts
  • Loneliness
  • Poor parenting
  • illiteracy

Seeing a general practitioner for ten or fifteen minutes, even quite frequently, isn’t going to change these circumstances. Perhaps a perceived failure to improve outcomes for people living with these problems is the driver for reform of the sector in parts of the world. At best primary care might help people to cope, at worst it might add to problems through iatrogenesis. Then there is a possibility that our inability to cope has a biological basis and that attempts to deal with the symptoms alone may be misguided. After all such thinking led to at least one Nobel prize for medicine.

If primary care needs to be reformed than the first issue is to recognise the limitations. For those who live in relative poverty, those with multimorbidity, those with competing priorities in complex lives more of the same primary care cannot be the only response to degenerative and chronic conditions.

Picture by Mike Smail

How to make data more valuable

The 1st of July 2014 will be forever etched in my memory. On that date I woke up and peered across the bed to the window. Realising by the half light it was just past dawn I wondered why there was another body in the bed. It should have been at the gym. So I turned over and put my arm around her. I registered she was looking straight at me. She then uttered the words no man wants to hear who hasn’t planned for it. ‘Happy anniversary darling’. In the micro seconds it took my male brain to weigh up a response, her female intuition had already worked out my dilemma and laid the charge. ‘You’ve forgotten haven’t you?’  Guilty. I had forgotten. The rest of the day was spent demonstrating that 1. I loved her and 2. regretted forgetting our special (and easily remembered) date. It would have been so much easier to focus on one rather than both. A stitch in time and all that.

Later in the week I received what looked like a court summons with an official looking government stamp on the envelop. The letter inside read:

Dear (first name, last name),

Did you know that around 80 Australians die each week from bowel cancer? ..blah, blah , blah,…inviting people turning 50….blah, blah,.. faecal occult blood test kit with instructions…sent to you in the next few weeks…blah blah. If you are already being treated for bowel cancer contact….during business hours.

Yours sincerely,

Scanned signature

Chief Medical Officer.

Not ‘Happy birthday this is a big one mate!’ Not ‘We want you to stay healthy and happy’. No connection with me. Just a cold request to take a government funded test now that I have reached an age when my bowels are more likely to turn on me. Were they concerned about me or the statistics? This lack of connection may be part of the reason most people fail to participate in what is a life saving program.

Still later in the week my reception staff told me that a patient had left something for me in the staff room. Also being an Indian he anticipated my penchant for curries and had prepared a small feast as a thank you. Instant connection. I felt appreciated. I pulled out my pen and drafted him a note. The government invitation on the other hand, though it may save my life didn’t have the same impact. Sure I’ll take the test but only because I know it’s a good idea.

People who chose to share intimacies with us want to know that we really see them and that they matter. Medical practitioners and general practitioners in particular document all sorts of information about their patients; height, weight, gender, waist circumference, family history, alcohol and tobacco consumption, sexual orientation, menstrual history, temperature, blood pressure, pulse, heart sounds, medications, allergies, etc. How about their date of birth? Anniversaries of births, deaths and marriage? Why don’t we collect and use this information to make a connection? What I would have appreciated from my doctor in April this year was a hand written card that said something like:

Happy Birthday Moyez! Thank you for letting us be part of your life. We wish you health and happiness always. Don’t forget your wedding anniversary 01/07/2014! This year you can help keep yourself in good shape by taking the bowel cancer test, someone will write to you about that soon. To mark the very special occasion of your 50th birthday we have donated $20 to Medecins sans frontieres  Australia (http://www.msf.org.au/). Please stay in touch and call us if we can do anything to help you stay in good shape this year.

If a practice manager at an average Australian general practice searches their database for every 49 year old who visits the practice, I guess the list would contain a 100 souls at most. A 50th birthday card would cost the practice less than $25 including the donation. The goodwill that would generate would be priceless and make all of our lives better. As experts have noted:

GPs who initiate discussions about screening with underserved population segments in particular (e.g., those aged between 50 and 55, men, and people from a non-English speaking background) are in a unique position to decrease inequity in health outcomes and improve morbidity and mortality from bowel cancer. Carlene Wilson

 

Quantified self – the downside

The manufacturers of wearable health tech devices are set to make millions if not billions. Wearables are relatively cheap adjuncts to existing technology. But what difference will they make to the health and well being of the average user?  We have been offered a preview of what these devices can do- monitor your heart rate, blood pressure and blood glucose. Keep track of your respiratory rate, calorie expenditure and sleep patterns. Detect cardiac arrythmias and abnormal brain electrical activity. It sounds good, but so what? If you experience a significant drop or severe rise in blood pressure you are going to notice even before you check the readings- you will feel very unwell. Similarly low blood sugar and dysfunction of the respiratory or cardiac system. Do we really need our smartphone to tell us we aren’t taking enough exercise and eating too much? Or that it’s time to see a doctor urgently? I agree with Jay Parkinson:

The exclusive-to-human part of our brain evolved so we can be creative and manipulate the world around us so we can invent things like the iPhone. And now, the creators of the iPhone want to give us the tools we need to badly do what evolution solved for us hundreds of millions of years ago.

Here’s the problem with this technology in practice:

About 10 percent are “quantified selfers” with an affinity for this kind of feedback; just by looking at the numbers, they are motivated to be more active. An additional 20 percent to 30 percent need some encouragement in addition to tracker data to effectively change their behavior. Kamal Jethwani

Therefore the vast majority of people who buy a wearable device right now will not benefit from that purchase. Those who do, might be amenable to other interventions. Unfortunately much of the data is meaningless or has no impact on long term decisions about health and well being. Sure, a trend in high blood pressure over a few weeks might indicate a need for treatment but a single high reading might be an anomaly or simply confirm that you are excited. Worrying about every little bleep on the chart is not going to add to your quality of life but will detract from it. For a sustained and beneficial change in life style people need more than data. They need motivation and help to workout the benefits of making different choices. They need the undivided attention of a practitioner who understands their needs and assists with a bespoke plan.

Information that we need right now, which our built in human senses may not already have alerted us to is another issue; microscopic haematuria (blood in the urine) proteinuria (protein in the urine), faecal occult bleeding (blood in the faeces), raised intraoccular pressure (high pressure in the eye ball) and changes in moles, breast or testicles will prompt doctors to investigate for sinister causes. Investigations that might lead to the early diagnosis of some costly and treatable or life limiting condition. Acquiring this information doesn’t require you to wear a device continually for a year. The business case for manufacturing devices to do that isn’t as compelling because of a limited market. Enthusiasts for wearables argue that:

Studies are beginning that examine the data from wearables, which is much more granular data about human activity than scientists have been able to access previously. This will answer questions like: how much of an increase in activity, of what type (moderate or cardio-challenging) leads to what degree of health benefit? Todd Hixon

What we may also discover is that there are probably side effects associated with wearable devices. Psychological harm may be associated with prolonged and heightened anxiety and obsession with self. What we won’t discover (and this is a guess) is that there is a short cut to losing weight that doesn’t require any significant effort. We might also discover that there are limited indications for wearable devices and that the market for them is much smaller than we envisage. Parallels exist with some parts of the pharmaceutical industry which has begun to promote ‘illnesses’ that would benefit from it’s offerings. So called disease mongering. We may well find ourselves being circumspect about wearables in the way that we have misgivings about drugs:

…drugs approved for devastating illness, such as clinical depression, are indicated for milder conditions, such as shyness, which is now dubbed ‘social phobia’. Howard Wolinsky

Data is no more the answer to all problems than are drugs. The indications for collecting data have parallels with the indications for prescribing drugs and how and why that data is collected merits thought. Those who promote the use of wearables need to question a trend which isn’t without a downside.

Innovating to save precious time

When I was at medical school Pendleton’s book on the consultation was required reading. Pendleton maintained that one of the tasks in the consultation was to consider ‘at-risk factors’. It’s one item on an otherwise long list of tasks to be completed. Today it is often the case  that a discussion of  those ‘at-risk factors’ take over the focus of the consultation. Doctors are urged, even rewarded for moving the agenda to- diet and exercise, responsible drinking, colorectal, breast and cervical screening, hypertension, safe sex….the list is endless. The impact of having the doctor’s agenda up front and central in the consult is what has been described as

High controlling behaviours.

Ong et al.

The resultant style of consultation is described thus:

It involves… asking many questions and interrupting frequently. This way the doctor keeps tight control over the interaction and does not let the patient speak at any length.

Recently medicolegal defense organisations have taken to issuing advice against this pointing out that when the patient does not feel they have been heard they are more likely to complain. Research has shown that patients don’t ask for much. They won’t take long to spit out the reason for their visit. In one study:

Mean spontaneous talking time was 92 seconds (SD 105 seconds; median 59 seconds;), and 78% (258) of patients had finished their initial statement in two minutes.

Langewitz et al.

Allowing the patient to speak first is a good start. Then how do we support practitioners to earn a living by also attending to those topics for which they must tick a funder’s check box? Tasks introduced by policy makers as if the primary care consultation was replete with redundant time. In some ways it’s like what happens when you buy a new television, it’s not long before the sales assistant wants to sell you insurance and other products- ‘just in case’ but really because their commission depends on it. What we need in medicine is to stop eating into the time it takes to explore a patient’s ideas, concerns and expectations, time needed to examine the patient and express empathy. We need cheap, agile, intuitive and creative solutions that will quickly offer the patient an indication of their risk from whatever the latest public health issue happens to be- smoking, influenza, prostate cancer…but also the benefits and why they might want to consider ‘taking the test’, accepting ‘the jab’, or changing the habit.  My colleague Oksana Burford invested three years testing one such innovation. What Oksana realised is that in the end it’s the patients choice and the key is to introduce the idea of change in a way that speaks to her but only when she is ready to hear the message.

The reasons why primary care is selected to relay public health messages is that people trust their health care provider and are more likely to comply if that practitioner recommends it. However that does not mean that we should assume the patient can only get the necessary information from one source. What the practitioner can do is sign post where that information can be found and effectively convey why the choice being recommended is better than the status quo. I recommend the food swap app– its downloaded free and saves a lot of time which can then be used to deal with the reason the person had come to see me in the first place. There is lots of room for innovation but it should meet the needs of the patient and the practitioner.