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Are you aware when you are flagging?

Are you aware when you are tired? Do you look at your reaction to any situation and wonder if it came from a place of fatigue? How do you deal with that?

When we are tired, we are attacked by ideas we conquered long ago. Friedrich Nietzsche

This study aimed to evaluate the variations in mood states and empathy that occur during the internship year. Consistent with our expectations, results of the first administration of the POMS and IRI demonstrated that interns in this cohort arrived with high levels of vigor, energy, and a well-established ability to demonstrate empathic concern. However, as early as November, we found that significant mood changes were already evident among our cohort. Interns became more angry and depressed. These data support previously reported findings that internship negatively affects personal well-being. Bellini et al

Fatigue and sleep deprivation, associated with long working hours and shift work, impacts on doctors’ personal safety, increasing the likelihood of occupational accidents, road traffic crashes and needlestick injuries. It also increases risks to patient safety through clinical errors. BMA

Picture by Dominique Archambault 

How do you prepare for disagreement?

Sometimes you might be asked for something that seems entirely pointless. In healthcare almost every speciality has examples of such challenging situations. In intensive care and oncology such issues are most poignant as patients may end up suffering before death:

In a retrospective review, we identified 100 patients of 331 bioethical consultations who had futile or medically inappropriate therapy. The average age of patients was 73.5 ± 32 years (mean ± 2 SD) with 57% being male. Fifty-seven percent of the patients were admitted to the hospital with a degenerative disorder, 21% with an inflammatory disorder, and 16% with a neoplastic disorder. The family was responsible for futile treatment in 62% of cases, the physician in 37% of cases, and a conservator in one case. Unreasonable expectation for improvement was the most common underlying factor. Family dissent was involved in 7 of 62 cases motivated by family, but never when physicians were primarily responsible. Liability issues motivated physicians in 12 of 37 cases where they were responsible but in only 1 of 62 cases when the family was (χ2 5 degrees of freedom = 26.7, p < 0.001).

Seth et al

This scenario may be avoided if it is anticipated as a ‘set play‘. List all the ways you may be adding to the person’s problems and consider how you might avoid contributing to a bad situation.

Picture by Isabelle

When did you last have dinner at our place?

We advise people about all sort of things- this is good for you, that will work for you, the other is bad for you…..But can you imagine yourself having a meal at that person’s home? Sitting in their car? Watching television in their sitting room? Shopping in their company? What’s it like walking in their shoes?

Picture by Jeff Kramer

How do you frame disappointment?

Things don’t always unfold as you might have hoped. What will you do when that happens next time? How do you plan to live with disappointment? You have two options: accept it or not. But what exactly happened the last time you were sorely disappointed? Did the person you met after getting bad news hear all about it from you? Did you get over it? How? If you are in healthcare did it impact on your work that day? Why or why not?

Picture by Kevin Dooley

How do you know your solution is the best?

Healthcare professionals offer solutions to problems. Doctors at community healthcare offer a solution to another problem every 10-15 minutes. Meanwhile the people seen there are making choices that seem entirely unrelated.

I’ll eat this, I’ll drink that, I’ll spend my money on this. I’ll work here. I’ll interact with these people. I’ll frame my problem like this…..

Some seemingly unrelated choices impact on the solutions offered by their health practitioner. It may be that people carry on making choices that undo all the benefits offered in prescribed, neatly packaged and costly labelled boxes.

If you are in healthcare how do you know the solutions you are offering are effective or even the best available? Could you do better?

Picture by World Bank Photo Collection

Do you use aids to help you explain?

If your job involves explaining complicated ideas- and let’s face it nothing is simple in medicine- do you use models or aids of any kind?

if not, why not? If you do what do you use and how do you know they work? How do you explain sciatica, heart disease, asthma, cancer?

Physicians cannot control all the reasons for patients pursuing legal atonement but they are able to determine the quality of their connection with them, by improving their communication skills and techniques. Law-suits for medical negligence can be lowered or prevented by taking steps to keep patients content, thus making them more compliant to the treatment, adhering to the medical policies and procedures. Tevanov et al 

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How do you end your meetings?

We know how to start a meeting- we stand up, shake hands, say hello, smile. But what’s the best way to end a meeting? It matters for one reason:

The peak–end rule is a psychological heuristic in which people judge an experience largely based on how they felt at its peak (i.e., its most intense point) and at its end, rather than based on the total sum or average of every moment of the experience. The effect occurs regardless of whether the experience is pleasant or unpleasant. Wikipedia

If you are a doctor this is all the more important because people generally don’t seek a meeting with you because all is well. They may be experiencing all sorts of unpleasant feelings. So how do you end that meeting? How do you know it’s working?

Picture by Peter Lee

More can be done to help people who consult doctors

In general practice patients generally present with undifferentiated conditions. People come for help with a cough and not ‘pneumonia’, back pain and not ‘metastatic prostatic cancer’, fatigue and ‘not diabetes’. In a study published in 2015 it was reported that a diagnosis is not established in 36% of patients with health problems. According to the research team half of the symptoms were expected to resolve or persist as ‘medically unexplained’. In their summary the team concludes that:

The study highlights the need for a professional and scientific approach to symptoms as a phenomenon in its own right. Rosendal et al

We also know that the commonest symptoms relate to the musculoskeletal system, respiratory system and the digestive tract. As long ago as 1984 Gordon Waddell and colleagues made a similar point in the BMJ :

The amount of treatment received by 380 patients with backache was found to have been influenced more by their distress and illness behaviour than by the actual physical disease. Patients showing a large amount of inappropriate illness behaviour had received significantly more treatment (p <0 001).

They concluded:

We know that a standard medical history and examination provide a wealth of information not only about the disease from which the patient is suffering but also about how that particular person is reacting to and coping with his or her illness. What is necessary now is to devote as much time and effort to the study and understanding of illness behaviour as we do at present to the investigation of physical disease. Only thus can we put the art of medicine on to a sound scientific basis.

Decades later these words are prophetic and we find that the thrust of research is on the diagnosis and treatment of specific pathology rather than on how to help people to cope with persistent back pain, acute cough or ill defined abdominal pain. This continues to be a bone of contention between doctors and patients as was illustrated in a classic paper by Joe Kai writing about the management of illness in preschool children in general practice:

Parents expressed a need for more information about children’s illness. Advice about the management of common symptoms was insufficient. They sought explanation and detail that was specific and practical to help them make decisions about the likely cause of an illness, how to assess severity, and when to seek professional advice. They wanted to know of any implications of the illness or its treatment and the potential for prevention in the future. Most thought that being more informed would reduce rather than increase their anxiety.

In a literature review published in 2002 in the BJGP Hay and Wilson charted the progress of children under 4 who develop an acute cough:

At one week, 75% of children may have improved but 50% may be still coughing and/or have a nasal discharge. At two weeks up to 24% of children may be no better. Within two weeks of presentation, 12% of children may experience one or more complication, such as rash, painful ears, diarrhoea, vomiting, or progression to bronchitis/pneumonia.

The authors conclude that:

Illness duration may be longer and complications higher than many parents and clinicians expect. This may help to set more realistic expectations of the illness and help parents to decide when and if to reconsult.

By implication, as well as knowing when and how to investigate symptoms, it would help patients if doctors also routinely communicated the natural history of the commonest symptoms including and especially:

  • Acute cough
  • Acute low back pain
  • Rash
  • Depression
  • Sprain /strain

For example it has been demonstrated that the experience of individual doctors on this issue is unreliable. Writing on acute low back pain researchers from New Zealand suggests that 91% of patients stop consulting their doctor at 3 months after the pain starts and long before their symptoms have resolved. Also that only 1:5 patients are free of pain or disability one year after an acute episode of low back pain.

Picture by Tina Franklin

The country needs general practice to be the provider of choice

Ever since I came to Australia as a foreign graduate I have been obliged to work in a so-called ‘area of need’. Directly opposite one practice in such a location, there is a large shopping centre. I sometimes go across the road to get my lunch. I noticed several very busy outlets full to the brim with customers. Here is a price list of some of what they offer:

  1. Reflexology Foot care (20 mins) $40
  2. Deep tissue and relaxation oil massage 30 mins: $50
  3. Headache treatment (30 mins) $30
  4. Sciatica relief $45

The practice across the road is a ‘bulk billing practice’ (i.e. they do not charge more than the government subsidy). The practice feels that people ‘can’t afford to pay’. I often see the same people queueing up for the treatments mentioned above. Today ( Sunday 26th February) there is a full page add in local newspaper headed:

Hope has arrived for men over 40 with low testosterone. Now, as part of our national health drive , a limited number of Australian Men can get free assessment before 5/03/17.

A box on the page asks:

Do these symptoms sound familiar?

  • Sleep problems
  • Increased need for sleep/ feeling tired
  • Physical exhaustion /lacking vitality
  • Deceased muscular strength
  • Irritability
  • Nervousness
  • Depressive symptoms
  • Raised cholesterol
  • Erectile dysfunction
  • Lowered libido
  • Prostate symptoms

The advertisement claimed that:

Studies show that only 10% of men are receiving treatment for low testosterone.

Citing as evidence one academic paper. The other citations are to reports on a news channel. The conclusions of the academic paper are based on a survey of 2165 men attending a primary care clinic in the United States regardless of the reason for attendance. Hypogonadism was defined as follows:

Given the lack of a widely accepted single threshold value of TT to define hypogonadism, <300 ng/dl, which has been used in clinical studies of hypogonadal men, seemed a reasonable choice. (Mulligan et al)

On this basis man with testosterone, levels below 300ng/dl were classified as hypogonadal and their symptoms were attributed to that condition. The team concluded:

The difference in the occurrence of four of the six common symptoms of hypogonadism (decrease in ability to perform sexually, decrease in sexual desire or libido, physical exhaustion or lacking vitality, and decline in general feeling of well-being) was greater in hypogonadal vs. eugonadal patients (p < 0.05).

None of the men were examined for other causes of their symptoms or problems. And on the basis of this research, a clinic operating in Australia is marketing therapy that:

….stimulates natural testosterone production

There is no mention of the cost of this treatment anywhere on the advertisement. The only protection that we offer people in the face of this very questionable marketing are the services of a trained general practitioner able to help people navigate this minefield of nonsense designed to part people from their hard-earned money. However, we need to create an experience that competes effectively with the powerful commercial offerings that are triggering people to spend their money so that they are then considered ‘unable to afford to pay’ for better advice.

Picture by Angie Muldowney

Cases too complex for a specialism other than general practice

It was a Friday evening. It’s almost always a Friday when this sort of case presents. She was in most ways unremarkable. She smiled readily, wasn’t evidently confused and worked in a senior administrative role. She came after work. This was the story:

I have a pain in my shoulder that becomes intense in my left arm pit. I can hardly bear to touch my arm pit. My hand becomes numb and cold. Today it’s so bad I’m finding it hard to turn the steering wheel.

I had 15 mins to sort this out, no scans, no blood tests, no discussion with a ‘team’ of young doctors working to pass their exams. She was describing symptoms that may have indicated a neurological emergency. And yet none of it made sense. She hadn’t fallen or been involved in any other trauma. There was no rash, no swelling. She swung her left arm over her head without any difficulty. I could not detect neurological signs, reflexes were normal. No Horner’s syndrome. No breast lesion. No obvious sensory loss. Twenty minutes later I could find nothing in her records or in her presentation that gave me any clue to the cause of these symptoms. And yet she was clearly worried. Regardless of the outcome I had to achieve one thing- this person like every other person who seeks help from a general practitioner needed to know that she had been taken seriously. Not for us the option of sending her back to whence she came with a note:

No organic pathology. Refer elsewhere.

A number of possibilities came to mind. Top of the list was ‘brachial plexus neuropathy‘ or Thoracic Outlet Syndrome. There were no objective signs at the time of presentation and I had never seen this before albeit that I had read about it sometime while at medical school. But then that’s primary care. We are the first port of call for anyone entering the healthcare system and often they present too early for anything to have manifested objectively. Not for us the text book presentation. About this diagnosis we know that:

Damage to the brachial plexus usually results from direct injury. Other common causes of damage to the brachial plexus include:

  • Birth trauma.
  • Injury from stretching.
  • Pressure from tumours.
  • Damage from radiation therapy.

Brachial plexus neuropathy may also be associated with:

  • Birth defects.
  • Exposure to toxins.
  • Inflammatory conditions.
  • Immune system issues.

There are also numerous cases in which no direct cause can be identified.

We also know that:

Signs and symptoms of thoracic outlet syndrome vary from patient to patient due to the location of nerve and/or vessel involvement. Symptoms range from mild pain and sensory changes to limb threatening complications in severe cases. Physiopedia

Diagnosis is difficult, tests and examination can be normalprognosis is variable. By the time a diagnosis was made weeks later and she presented to a specialist everything was obvious. But on that Friday evening with a surgery full of patients I was on my own. My patient trusted that I would not let her walk out of there only to lose a limb. Assuming a benign cause she would be back and need more. This was the start of a longterm relationship and how I managed this episode would set the tone for the duration.

While improvement may begin in one to two months, complete functional recovery may not be achieved for up to three years or longer in some cases. Tsairis et al

Picture by Mahree Modesto