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The Art of Doctoring published on Jan 10th 2020

The book is available on Amazon

Moyez Jiwa, an experienced and thoughtful doctor, elevates with practical brilliance the lovely work that clinicians do. In sharp contrast to the grayness of industrial healthcare, he reimagines doctoring as performance art and proposes an elegant script to respond carefully to the suffering of each person. Bravo!

Victor Montori. Professor of Medicine at the Mayo Clinic in Rochester, Minnesota, USA.

Dr. Moyez Jiwa has written a practical guide for medical professionals to make authentic connections with their patients –and in doing so, spark enduring behavior changes that translate into better outcomes and happier lives. The Art of Doctoring left me feeling hopeful for the future of health care in a world where this book is on every provider’s shelf.

Amy Bucher, Ph.D., author of Engaged: Designing for Behavior Change and Vice President of Behavior Change Design at Mad*Pow

Behavior change is a complex science. Clinicians who desire to have lasting positive impact in their patients’ lives must consider the context of the each patient’s life. Successful, sustained health behavior change is driven by the individual [i.e. patient] who is ready for change, and The Art of Doctoring is written with an awareness of the role each patient plays in his or her own journey of living. The Theatre Model© is a brilliant way to frame a patient-provider encounter: Individuals choose who they enroll on their [health care] “theater cast” and how much influence, or how much of a role, each cast member will have. In addition, Jiwa calls out the paramount need for the office encounter to evolve and for the recognition that the patient be seen as “the most important person in the clinical encounter”. There exists a need for a board-certified coaches on the health care teams of the near future!

Nicole M. Guerton, MS, MCHES®, NBC-HWC, CIFT Wellness Coach | Mayo Clinic Department of Medicine | Healthy Living Program Assistant Professor of Health Care Administration | Instructor of Family Medicine

In his book The Art of Doctoring, Professor Moyez Jiwa has unlocked the secrets to creating better experiences for patients as well as the doctors who care for them. In each chapter, he uses very relatable patient stories to illustrate the art of doctoring and uses The Theatre Model© to skillfully peel back the curtain of medicine to reveal the essence of what it really means to be more than simply a good doctor, but to connect with your patient as healer. With more that 30 years’ experience, Jiwa is a leading voice in healthcare. This book is a must-read for anyone on the journey to unite both the science and art of medicine to create a better human experience.

Jake Poore, President and Chief Experience Officer, Integrated Loyalty Systems, Inc.
13538 Village Park Drive, Suite 120, Orlando, FL, USA 32837

Sir William Osler said that the practice of medicine is, “An art based in science.” Dr. Jiwa puts this into action in his book, The Art of Doctoring. He artfully describes how science can best inform a therapeutic ceremony that can be intentionally put into place to facilitate health in those we serve. He uses the best of science to teach the art. And what a wonderful artist he is. Anyone interested in cultivating their own healing arts would benefit from the wisdom this writing shares. I highly recommend it.

David Rakel, MD, Professor & Chair, University of New Mexico Dept of Family & Community Medicine, Author of, The Compassionate Connection.

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Making a diagnosis as a family doctor

The fact that it is often difficult or perhaps impossible to correlate the pathology and symptoms of coronary artery disease has led to a great deal of discussion and numerous explanations have been proposed.

Fred M Smith

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Do it as you’d want to experience it yourself

Click here to view your video

Jerald WINAKUR podcast here: https://www.journalofhealthdesign.com/JHD/podcasts/view/221

Randi Oster podcast here: https://www.journalofhealthdesign.com/JHD/podcasts/view/223

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We don’t know enough about those who come to doctors

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Why doesn’t my idea work?

The editorial in the BMJ that I reference in the video is here: https://www.bmj.com/content/341/bmj.c6175

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The question to ask at six minutes

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A question for anyone who seeks healthcare

References:

Bullshit jobs

The sorrows of work

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Are you good with people doctor?

He was talking on his mobile phone even as I ushered him along the corridor to the consulting room. He kept up the conversation even as we sat down. I took it all in as he raised his nicotine stained finger signaling he was nearly finished- the worn baseball cap perched atop his dirty hair. The missing incisor, the thread bare tee shirt and torn jeans. A pair of filthy unlaced trainers completed the look of someone who might have been sleeping on the streets for a week.

As a doctor I’m in the ‘people’ business. All whose life I hope to influence for the better are people. That’s a challenge because people come in all shapes and sizes, not to say ways of being and there is no question that their interactions with me are likely to influence my behaviour as much as mine does them.

The usual route to behaviour change in economics and psychology has been to attempt to ‘change minds’ by influencing the way people think through information and incentives. There is, however, increasing evidence to suggest that ‘changing contexts’ by influencing the environments within which people act (in largely automatic ways) can have important effects on behaviour. 

Dolan et al

How I choose to react in a meeting with someone else is an opportunity to exercise supreme agency. Nobody likes to think that their ‘buttons’ can be pushed without being aware and able to override and automatic responses.

Dolan and colleagues used the pneumonic MINDSPACE to summarise how this happens.

M: Messenger- we are heavily influenced by who communicates information to us. In healthcare information drives the action. That means that we take into account all manner of information within milliseconds of meeting a person. Size, shape, accent, smell, colour and draw conclusions that may or may not be valid.

I: Incentives: our response to incentives are shaped by predictable mental shortcuts such as strongly avoiding losses. What kind of losses are relevant to you- loss of time, loss of income, loss of control?

N: Norms we are strongly influenced by what others do. Entire books have been written about this in medicine but the paper I like to quote most is by Gabbay and le May. Yikes! who have I been talking to lately in the coffee room?

Clinicians rarely accessed and used explicit evidence from research or other sources directly, but relied on “mindlines”—collectively reinforced, internalised, tacit guidelines. These were informed by brief reading but mainly by their own and their colleagues’ experience, their interactions with each other and with opinion leaders, patients, and pharmaceutical representatives, and other sources of largely tacit knowledge. Mediated by organisational demands and constraints, mindlines were iteratively negotiated with a variety of key actors, often through a range of informal interactions in fluid “communities of practice,” resulting in socially constructed “knowledge in practice

Gabbay and le May

D: Defaults- we ‘go with the flow’ of preset options. In this situation I always do these tests or I don’t consider that option or that ‘type of person’ always responds to this treatment. Are you aware of your default mode?

S: Salience- our attention is drawn to what is novel and seems relevant to us. The challenge is that whilst that might alert us to something of interest it might also send us down the proverbial rabbit hole. ‘Common things are common’ as medical educators like to tell us. There may be something novel about almost anyone we meet but that does not mean it is the reason why they need our help on this occasion.

P: Priming – our acts are often influenced by subconscious cues. Markham Heid alerts us to some of these prejudices. Gender and racial bias are the most problematic but one you don’t hear often is prejudice founded on bad teeth. I imagine tattoos and body piercings might have found their way on this list.

A: Affect- our emotional associations can powerfully shape our actions. This is one to watch- how are you feeling today? What did that person say or do to put you in this mood? What impact might that have on your interactions with people who are going to need you to explain their situation?

C: Commitments- we seek to be consistent with our public promises and reciprocate acts. Perhaps that’s a good thing but it still implies ‘automatic’ behaviours and that can go awry.

E: Ego- we act in ways that make us feel better about ourselves. Having trained in a competitive environment for all of their career health professionals need to be aware when the need for validation impinges on their encounters with people who need help. There are no medals for lifelong selfless service of others.

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Why am I having this test doctor?

Jonathan consults his doctor regularly and each time he comes to the clinic he expects to go next door for a blood test or X-ray. Like many people he believes that a positive test means he has a specific condition and a negative test implies that all is well. So he has come to conclusion that a doctor who doesn’t order a test is not doing his job.

No test is that good. A ‘positive’ test often requires more investigations or a repeat test to rule out the rabbit being pursued down the proverbial hole. A test is only a useful tool in the hands of the doctor who factored the risk of a specific diagnosis. Therefore a teenager with a severe sore throat, fever and fatigue is likely to have Glandular fever and a positive test is likely to have a high positive predictive value.

On the other hand being tired all the time is more likely to be related to some non-physical cause such as stress, lack of sleep or worry than it is to an under active thyroid gland or anaemia. And yet test ordering is a common outcome in consultations. For example ‘hypothyroidism’ or an under active thyroid gland is thought to be present in 3.8% of the population. The majority of those with the condition are older females. In a study where doctors were given feedback about their test ordering Thyroid function tests were the commonest test ordered with up to 21 per 1000 patients having the test. When doctors were offered feedback about test ordering the number of patients in the practices receiving the feedback reduced but not significantly. Australian experts advise that:

Signs and symptoms of hypothyroidism may vary depending on patient characteristics and the severity of dysfunction. Classic symptoms include fatigue, weight gain, cold intolerance, arthralgia, constipation, menorrhagia, irregular menstrual cycles, and dry skin and hair. Physical signs include coarse skin and hair, bradycardia and goitre but these may be absent in mild hypothyroidism.

NPS https://www.nps.org.au/news/thyroid-disease-challenges-in-primary-care

However they conclude that:

Requests for thyroid tests are increasing, although in many cases clinical need is not evident.

NPS https://www.nps.org.au/news/thyroid-disease-challenges-in-primary-care

I offer some more thoughts on video.

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Do your feet betray you doctor?

As I watched the medical student take a history I noticed his scuffed shoes but more especially where his feet were pointed during the meeting. He sat with both feet on the ground but with his knees pointed towards the desk to his side, leaning away from the patient. Afterwards the patient and I agreed that this was not the best consultation. His legs were just one of several things that weren’t quite right.

We know that our faces display our feelings. During their training doctors are taught to become aware of where their patients are gazing and to study facial expression.

What is much less often the topic of any lectures or instruction is how to sit or to consider where your feet are pointed during a meeting. Just as the patient’s body language is leaking clues- so the doctor’s body language is either reinforcing the notion that they are alert and interested or that they are bored, challenged or simply in a hurry to get on to the next thing on their list.

The legs are the farthest limbs away from the brain – and therefore far from the attention of others. Because we never truly care or focus on what others do with them, we also tend to neglect what we do with ours. This neglect leaves a lot of room for the keen observer to notice hidden thoughts and attitudes that are not clearly visible anywhere else in the body.

Study Body Language

The best advice seems to be to sit with both feet on the ground pointed at the other person.

Placing both feet on the ground with a “standard” gap between them is the most basic, normal position you can think of. Just like with hands-to-the-sides posture it serves as a neutral but powerful starting point. It’s stable, focused and lacks any other nonverbal “noise” – so it’s very effective for formal and focused conversations

Study Body Language

In the context of a professional meeting there are a host of other basics.

  • Lean towards the person you are talking to but not with your hands on your thighs as if you are about to stand.
  • Don’t sit with your knees wide apart or firmly together.
  • Keep your shoes on.
  • Don’t rest your leg on your knee.
  • Don’t cross your ankles or your legs.
  • Don’t stretch your legs out in front of you or fold them under the chair.

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