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Steep hill but nice view

On this beautiful earth it is not long before you have to climb a hill to enjoy the view. Where in your job is extra effort required to get to the end of the day? What makes it harder? Could it be the voice in your head telling you that this particular ‘hill’ was specifically designed to make life harder for you? Is it because you were not anticipating any ‘hills’. Are you on the wrong road? Do you need to get fitter? Is hill climbing not for you? Could it be that the view is not worth the effort?

Here’s a perspective from Jonathan Mead

Picture by  Tejvan Pettinger

Can you stand to be bored?

Ever since the invention of the smartphone boredom has been banished. But at what cost?

Our results indicate a moderate relationship between smartphone addiction and a self-reported decrease in productivity due to spending time on the smartphone during work, as well as with the number of work hours lost to smartphone use. Smartphone addiction was also related to a greater amount of leisure time spent on the smartphone and was strongly related to a negative impact of smartphone use on daily non-work related activities. These data support the idea that tendencies towards smartphone addiction and overt checking of the smartphone could result in less productivity both in the workplace and at home. Duke E

Can you give that customer, client or patient your undivided attention with one eye on your phone? Is it worth considering if you have a problem?

Picture by Graeme Paterson

Why do you keep me waiting?

We often have to wait in line to be served. In healthcare that happens a lot. If you had to wait an hour or more every time you needed something from somewhere would you continue going there? Why or why not? Does queuing have to be  fact of life in healthcare? How long before someone works out it isn’t necessary and offers an alternative? What will happen to those places that fail to keep up?

Although appointment systems are often designed to avoid doctor idle time (without considering patient waiting time), it is possible to reduce patient wait time without significantly increasing doctor idle time.

Picture by Michael Dales

For sustained behaviour change: show don’t tell

BACKGROUND:
This randomised controlled study evaluated a computer-generated future self-image as a personalised, visual motivational tool for weight loss in adults.
METHODS:
One hundred and forty-five people (age 18-79 years) with a Body Mass Index (BMI) of at least 25 kg/m2 were randomised to receive a hard copy future self-image at recruitment (early image) or after 8 weeks (delayed image). Participants received general healthy lifestyle information at recruitment and were weighed at 4-weekly intervals for 24 weeks. The image was created using an iPad app called ‘Future Me’. A second randomisation at 16 weeks allocated either an additional future self-image or no additional image.
RESULTS:
Seventy-four participants were allocated to receive their image at commencement, and 71 to the delayed-image group. Regarding to weight loss, the delayed-image group did consistently better in all analyses. Twenty-four recruits were deemed non-starters, comprising 15 (21%) in the delayed-image group and 9 (12%) in the early-image group (χ2(1) = 2.1, p = 0.15). At 24 weeks there was a significant change in weight overall (p < 0.0001), and a difference in rate of change between groups (delayed-image group: -0.60 kg, early-image group: -0.42 kg, p = 0.01). Men lost weight faster than women. The group into which participants were allocated at week 16 (second image or not) appeared not to influence the outcome (p = 0.31). Analysis of all completers and withdrawals showed a strong trend over time (p < 0.0001), and a difference in rate of change between groups (delayed-image: -0.50 kg, early-image: -0.27 kg, p = 0.0008).
CONCLUSION:
One in five participants in the delayed-image group completing the 24-week intervention achieved a clinically significant weight loss, having received only future self-images and general lifestyle advice. Timing the provision of future self-images appears to be significant, and promising for future research to clarify their efficacy.

Trials. 2017 Apr 18;18(1):180. doi: 10.1186/s13063-017-1907-6.

Picture by Rene Passet

What’s the shortest route to where you want to go?

As the conference season begins we note that response rates in the order of 10-20% are not unusual in primary care research. Hardly generalisable. And yet we need sustainable and workable solutions that will promote health and well being in an ageing demography with increasing multimorbidity. Researchers take note the traditional gatekeeper in primary care, the general practitioner is occupied just keeping up with demand. There is no time to recruit, to seek informed consent or to deliver interventions that are being tested in a traditional randomised trial. At one time membership of networks with ‘committed’, well meaning practitioners were considered essential to successful research. In 2017 relying on anyone or any organisation that purports to guarantee recruitment rates or ‘collaboration’ seems at best naive and at worst risky.

Health requires people to make different choices. Eat better, drink less, take more exercise, jettison bad habits, consider when and where to seek medical advice. The traditional model of healthcare is evolving. The evolution is driven by technology that has fundamentally changed our experience of many if not all things. People consider themselves more time poor than they ever were.

The ability to satisfy desires instantly also breeds impatience, fuelled by a nagging sense that one could be doing so much else. People visit websites less often if they are more than 250 milliseconds slower than a close competitor, according to research from Google. More than a fifth of internet users will abandon an online video if it takes longer than five seconds to load. When experiences can be calculated according to the utility of a millisecond, all seconds are more anxiously judged for their utility. The Economist

The lesson for those hunting for better ways to reach people is to consider the least that can be done to get there. The answer may be waiting in all of our pockets.

Picture by Toshihiro Gamo

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.

Picture by M01229

Observations of healthcare workers may be better than big data

Apparently when a message is put alongside a cardboard cut-out of a person it is more likely to be noticed and actioned. How the message is relayed to the ‘customer’ matters. This has implications for the sort of results we seek in health care. I am sure the reader could think of many ways this observation can be deployed to improve outcomes in healthcare, just as retail and law enforcement organisations use the concept to communicate with their customers. For example, would you consider having a full sized cardboard representation of a doctor in your practice encouraging people to have their children immunized? Richard Wortley offers some other interesting insights and strategies for behaviour change albeit in the context of law enforcement. What healthcare needs is interventions and ideas, whatever their provenance.

The observations and insights of your staff and colleagues are often, if not always, more valid than so-called ‘big data’. Big data sets are often used for some other purpose (e.g. healthcare administration) and then extrapolated to understand why people are referred inappropriately or prescribed the wrong drugs. More often than not without reference to the people who collected the data in the first place. It is even more fashionable to ‘link’ this data to other information collected for yet another purpose ( e.g. cancer registry). The results may lead to dubious conclusions and wide-ranging policy changes endorsed by a professor or two who have never been on the shop floor, or at least not recently.

‘Big data’ may be easy to collect, despite the limitations of its validity, it offers substantial numbers for a statistician to ‘crunch’. National conferences are now themed on ‘big data’, there are substantial grants available to those who choose this ‘methodology’ for their research endeavours. Meanwhile, the local and contextualized reflections and observations of those delivering health care are seldom accorded the same credibility. The desire for a fast and cheap solution to the increasing cost of healthcare drives funders to throw dollars at anyone who promises a quick-fix and can cite a p-value.

Here the business literature may be relevant:

The study identified a number of factors that influence the success or inhibit progress in terms of performance and sustainable improvement. The findings identify what companies perceive to be inhibitors and enablers for sustainability, within 21 companies who have conducted process improvement (PI) activities using a common intervention approach…..The general and cultural nature of the identified enablers indicates that managers perceive progressing PI activities are reliant on a change of culture within their organisations in parallel with “up‐skilling” the technical knowledge of employees for change to be successfully enacted. The lack of specific processes to change culture, identified in the enablers, also indicates that managers do not know what to do to change their cultures or how best to deal with the inherently challenging and demanding nature of process improvement with shop floor operators. Rich and Bateman

Sounds like healthcare. Perhaps the methodologies deployed in successful care studies hint at a better approach. No big database was dissected in this example which resulted in sustained business performance in an Australian company:

Using data collected through in-depth interviews, the case study describes how the company progressed from an earlier initiative based on quality control to the present initiatives that emphasize customer focus, product development, and innovation. Several important insights are drawn from the case study, including the importance of aligning the quality programmes or initiatives with a clear strategic focus. Prajogo and Sohal

Stand by for the launch of a new academic forum which will focus on the patient experience as the driver of innovation.

Picture by Aranami

 

Innovating for one of the climate’s biggest public health challenges

4265056770_b589d0437a_zIn a cohort of U.S. women, we found that sun exposures in both early life and adulthood were predictive of BCC and SCC risks, whereas melanoma risk was predominantly associated with sun exposure in early life. Wu et al

Furthermore according to the editor of Nature in July 2014

It is accepted that sunscreens protect against squamous cell carcinoma, and this work [research] suggests that they also protect against melanoma.

This message is not getting through to those who might be able to influence public opinion

To win the U.S. Open, tennis players must overcome fearsome opponents, grueling matches and searing heat. But for some, none of that causes quite as much angst as the prospect of rubbing on a gob of white lotion. Of all the accessories that players have at their disposal, sunscreen may be their least favorite. Some don’t wear it at all. Some apply it before daytime matches, if somewhat begrudgingly. But nobody seems to like it. Brian Costa and Jim Chairusmi

The ambient temperature in many parts of Australia early this year will be well over 30 degrees with a UV index of 11- in other words, extreme. Intelligent and well-informed young men and women may be found fully exposed to the midday sun and for hours on end. Many will not be wearing sunscreen, a hat or sunglasses. This can be observed on the beaches, on the tennis courts and on the cricket field.

The message to seek protection from harmful UV rays needs to be crafted in the context to which it is being targetted. It needs to take account of the ideas of young people who are resistant to messages that appear to impose limitations on what they can do:

Tennis players tend to sweat profusely, especially during day sessions at the U.S. Open, where high temperatures and humidity are typical. When the heat mixes with sunscreen, the sweat can form a gooey substance that gets into players’ eyes and onto their hands, affecting both their vision and their grip.

We need to understand and adapt to the perspective of those to whom the public health message needs to get through. There may be other ways to deliver the messages that are more potent. Watch these videos:

  1. The sun damages your looks
  2. It can harm your vision

Therefore, within Foggs model, the motivation to seek protection from UV light could be targetted better. Ability to apply sunscreen or wear sunglasses also needs more attention. Technology may have more to offer with more user-friendly products. Equally making the equipment currently on the market more readily available when and where they are needed will also help. Finally, it may be worth considering a trigger for the behaviour. Something that gets motivated people with the ability to perform the action to then act on a regular basis. The recipe for such behaviour is typically the traffic light. Red means stop every time. The teenager who gets on the cricket field with sunglasses and sunscreen in his bag needs to be triggered to wear them without mum or dad’s nagging voice to remind him. The behaviour needs to be anchored to something familiar- e.g. stepping onto the sand or grass and the message delivered at a teachable moment. The trigger of television advert is not enough for behaviours that need to be repeated. There is still scope to develop an effective innovation by an enterprising researcher based on the principles of patient experience design. I hope it is you.

Picture by Colin J

No we can’t

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Oh yes doctor, we would like to have you present at our conference. In fact we would like you to run a three hour workshop and do a plenary. And sorry no we don’t pay speakers. We offer budget travel and basic accommodation.

I couldn’t believe what I was hearing. The preparation for this would take weeks. According to the glossy brochure the conference was to be held at an expensive venue overseas and the delegates would be paying handsomely to attend. The young man who called me couldn’t see anything wrong with asking me to work on his business at the expense of my employer in order to make a profit for his company. My response as far as he was concerned was unexpected. Which means he was probably used to hearing:

Yes

Academics give it away for a plane ticket and a cheap hotel room. They are just so pleased to be noticed.

The word for 2016 has to be:

No

  • No to urgent and not important
  • No to someone else’s priorities
  • No to time wasters
  • No to projects that don’t serve the mission
  • No to lack of self respect

If you are being asked, as you will be daily, to give up your time and pay an opportunity cost to be distracted then your boss has the right to ask difficult questions at your annual appraisal.

  • What did you accomplish today?
  • How does this work towards the mission of your team?
  • What tangible can you show when you reflect on progress this week?

Learn to say

No.

Here are some different ways to say it. Practice today. Say it politely but say it emphatically.

No, Nein (German), Non ( French), Hapana (Swahili), Naheen ( Hindi).

If you practice it judiciously then you are less likely to hear it said to you.

Picture by Michael Sissons

Yet more reasons GPs should not be distracted by pay for performance

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There is no doubt that doctors make mistakes. Mostly people forgive them, the charitable view is that it’s because people recognise that their doctors are human and by and large are trying to do a good job. The issue becomes most problematic when the error might cause a delay in the diagnosis of a condition that is best treated sooner rather than later. And especially when the red flag symptoms of that condition are well documented.

Late in 2014 Devesh Oberoi interviewed men who had presented to a specialist late with symptoms that were later diagnosed as cancer. One of the interviews suggested that the delay might in part be due to a late referral:

I spoke to my GP …that time … and. … I was concerned about the symptoms. I told him that I had seen some blood on my toilet paper and he said … umm … yeah that … since it is fresh blood it could be piles (haemorrhoids) or something. Patient with Rectal carcinoma.

Such delays are widely reported in the literature with some experts calling for better research to establish why the diagnosis of cancer is sometimes late in primary care.

Last week our team published secondary data from an experimental study in which we report that the diagnosis of cancer can be missed even when the presentation is straightforward and there are no distracting issues in the consultation (e.g. co-morbidity, psychiatric illness or social problems). One in eight ‘cases’ presented as short video vignettes to doctors in the study failed to elicit a response that included a referral to a specialist or investigations to establish the diagnosis of cancer. What’s also of concern is that where the management decision was to prescribe something, it was hard to see the benefit. In some cases it might even have resulted in harm. Where the decision was to investigate, the indications for some of the investigations were not immediately apparent. Delays may also have occurred in those investigated if the findings were negative or misleading.

None of this is new. Numerous audits have established similar patterns including one we published in 2004 in which three reasons were given for a failure to recognise patterns of cancer:

  • A failure to consider the diagnosis of cancer. ‘Blinkered’ approach in assessing patient.
  • Inappropriate or incomplete investigation.
  • False-negative investigations.

Despite such findings some policy makers think that it is appropriate to pay GPs to focus more on preventive health; to drive payment structures to reflect this public health agenda and distract doctors at the front line of the health service from their core business, namely giving a patient, who consults very briefly, their undivided attention. Doctors need to reflect when they have failed in someway to deliver a satisfactory outcome especially in cases of life threatening illness. That requires a renewal of the commitment to the process of history taking and examination and to updating the skills to make the diagnosis of conditions that are best treated ASAP. When done properly this is time consuming. When doctors are otherwise incentivised to either collect data or tick boxes the result can be less than satisfactory. That it may be already unsatisfactory even before we are driven to adopt practices for which there is very little proven benefit should lead to a rethink.

In relation to pay for performance the King’s Fund reported in 2010:

What evidence does exist suggests that significant improvements have been made in some areas – particularly for diseases such as diabetes, heart failure and chronic obstructive pulmonary disease –but less progress has been made for depression, dementia and arthritis, and these require a more collaborative care model for a higher quality of care to be achieved.

Alternatively it may be that what we can’t afford is to pay GPs to do better at something at the cost of deskilling them in other aspects of their work.

Picture by David Goehring