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Do it as you’d want to experience it yourself

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Jerald WINAKUR podcast here:

Randi Oster podcast here:

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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:

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The question to ask at six minutes

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A question for anyone who seeks healthcare


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.


However they conclude that:

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


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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Can doctors learn from movie directors?

In any consultation involving health professionals there are two ‘actors’ the patient and the health professional. During that meeting each will have something to say and will say it in a specific way. The tone, the emphasis and the volume of their speech will offer information. The actor’s limbs and torso will reflect their thoughts and feelings during the meeting. Their hand gestures and their head movements will betray emotion.

These aspects are not be formally taught at medical school or at least not in the way that actors are taught their craft. And yet how the doctor plays their role in the consult will impact the outcome of that meeting with the patient.

As doctors or health professionals we can’t anticipate how the ‘other’ actor in the meeting will choose to present themselves in the meeting but we can learn to become much more aware of our own behaviour. How we position ourselves, the movements of our limbs, our facial expression, our gestures, our non-verbal response to the information received from the other. In most meetings we have very little time to make an impact in the desired direction and a failure to become self aware will undermine our efforts to be of help.

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Doctoring Warrants A Plan

Most people who attend a family doctor are unlikely to be seriously ill. Many however will benefit from making different choices about how they live because it is now normal to be overweight or obese, it is common to drink too much and take very little exercise. People who attend doctors may have a so-called minor illness which will improve in a matter of a few days without any specific intervention but they will also have many risk factors for long-term illness that would be better addressed now, and certainly before they manifest as diabetes, heart disease, cancer or dementia.

Therefore the aim of the game, if we want to call it that, is to trigger people to make changes in their lifestyle while there is still time. The doctor will be one of the two people in the room when these matters can be in focus. At the doctor’s disposal at that time are five assets; the doctor (or more explicitly the persona of the doctor); the room in which they meet; what they both can see, hear, smell, taste and feel in that space; the actions that can be taken which range from nothing through to a referral to another expert.

Before the interaction the doctor has to have a plan as to how the interaction will unfold. The Art of Doctoring requires close attention to each of the assets at the doctor’s disposal. It is crucial to have considered how these are to be deployed before entering the fray.

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