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It’s not the symptoms, it’s the context.

The Art of Doctoring May 23, 2020

More on the Art of Doctoring in my conversation with the one and only Baktash Ahadi

Objective. People with RA have episodes of worsening disease activity (flares) that prompt them to seek clinical review or medication change. This study explored patients’ perspectives of flare that prompts them to seek medication review.

Methods. Fourteen focus groups across five countries comprised 67 RA patients. Transcripts were analysed by several researchers and a patient, using inductive thematic analysis.

Results. Patients use flare for five different scenarios, including flare that prompts medical help-seeking, where six themes were identified. In ‘Symptoms and early warnings’, pain is intense (wanting to die), constant and persistent and considered a key feature. Systemic features predominate, including fatigue, feeling generally ill (flu-like), physical and cognitive shut-down and social withdrawal. Warning signs (prodrome) comprise fatigue and flu-like symptoms. ‘Self-management of intensifying symptoms’ includes pacing, heat/cold, rest and increasing medication, often without medical advice. Patients ‘Define this as uncontrollable flare’ when clusters of unprovoked, persistent symptoms halt their ability to run daily life, until prompted into ‘Seeking help when symptoms can’t be contained’. Underpinning themes are ‘Individual context’ (e.g. different symptom clusters) and ‘Uncertainty’ (e.g. when to seek help). Patients report that the current patient global visual analogue scale (VAS) does not capture flare.

Conclusion. Patients use flare for multiple events and seek help for complex clusterings of intense, unprovoked symptoms that defy self-management, not necessarily captured in joint counts or global VAS. Flare terminology and definition have implications for clinical practice and trials, therefore further research should establish a professional/patient consensus.

Hewlett et al

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The Art of Doctoring May 23, 2020

Could the greatest hope for primary care be in a laboratory?

The Art of Doctoring May 14, 2020

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by inflammation and damage of the joints affecting about 0.5% of the general population. Early treatment in RA is important as it can prevent disease progression and irreversible damage of the joints. Despite the high diagnostic value of anti-citrullinated protein antibodies (ACPA) and rheumatoid factor (RF), there is a strong demand for novel serological biomarkers to further improve the diagnosis of this abundant disease. During the last decades, several autoantigens have been described in RA including Ra33 (hnRNP A2), fibrinogen, fibronectin, alpha-enolase, type II collagen, immunoglobulin binding protein (BiP), annexins and viral citrullinated peptide (VCP) derived from Epstein Barr Virus-encoded protein (EBNA-2). More recent discoveries include antibodies to carbamylated antigens (anti-CarP), to peptidyl arginine deiminase type 4 (PAD4), to BRAF (v raf murine sarcoma viral oncogene homologue B1) and to 14 autoantigens identified by phage display technology. This review provides a current overview of novel biomarkers for RA and discusses their future potential to improve the diagnosis of the disease.

Trouw and Mahler

See also my podcast with Sam Mazin

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The Art of Doctoring May 14, 2020

Playing Tennis With Snow Boots On

The Art of Doctoring May 4, 2020

Medical students and doctors use narrative skills on a daily basis. Taking a history from a patient, summarising a case for senior colleagues, and recording or reading a patient’s notes all require the construction of a meaningful chronological sequence, with important events included and less important ones omitted. Similarly, when doctors compare and contrast clinical presentations and cases from their own experiences, write up case reports, or document patients’ own accounts, they rely on narrative to structure their thoughts and conclusions

Hurwitz et al. BMJ 2012

My interview with Barbara Hirsch on Narrative Medicine.

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The Art of Doctoring May 4, 2020

In Doctoring Vocation Above All

The Art of Doctoring April 26, 2020

My interview with Karen Smith is here.

My interview with Andrew Goldstein is here.

I, like so many of those who filled the first ranks of family practice, often described my career choice as a calling, a vocation, something more than a meal ticket. It was a source not only of pride and conviction but also resentment and resistance to change. By mid career I was largely out of step with new movements in family medicine that veered from the generalist approach toward focused fellowships, added qualifications, and office practices that opted out of obstetrics and hospital work. As often happens, it was a patient of mine who brought the issue into focus and showed me the potential that lay in each encounter. We long for connection—doctor and patient alike—and for the skill and compassion to express it without judgment or self-denial. There is no higher calling.

David Loxterkamp, MD

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The Art of Doctoring April 26, 2020

Frailty begins in the forties

The Art of Doctoring April 19, 2020

Background: There is little known about pre-frailty attributes or when changes which contribute to frailty might be detectable and amenable to change. This study explores pre-frailty and frailty in independent community-dwelling adults aged 40–75 years.

Methods: Participants were recruited through local council networks, a national bank and one university in Adelaide, Australia. Fried frailty phenotype scores were calculated from measures of unintentional weight loss, exhaustion, low physical activity levels, poor hand grip strength and slow walking speed. Participants were identified as not frail (no phenotypes), pre- frail (one or two phenotypes) or frail (three or more phenotypes). Factor analysis was applied to binary forms of 25 published frailty measures Differences were tested in mean factor scores between the three Fried frailty phenotypes and ROC curves estimated predictive capacity of factors.

Results: Of 656 participants (67% female; mean age 59.9 years, SD 10.6) 59.2% were classified as not frail, 39.0% pre-frail and 1.8% frail. There were no gender or age differences. Seven frailty factors were identified, incorporating all 25 frailty measures. Factors 1 and 7 significantly predicted progression from not-frail to pre-frail (Factor 1 AUC 0.64 (95%CI 0.60–0.68, combined dynamic trunk stability and lower limb functional strength, balance, foot sensation, hearing, lean muscle mass and low BMI; Factor 7 AUC 0.55 (95%CI 0.52–0.59) comprising continence and nutrition. Factors 3 and 4 significantly predicted progression from pre-frail to frail (Factor 3 AUC 0.65 (95% CI 0.59–0.70)), combining living alone, sleep quality, depression and anxiety, and lung function; Factor 4 AUC 0.60 (95%CI 0.54–0.66) comprising perceived exertion on exercise, and falls history.

Conclusions: This research identified pre-frailty and frailty states in people aged in their 40s and 50s. Pre-frailty in body systems performance can be detected by a range of mutable measures, and interventions to prevent progression to frailty could be commenced from the fourth decade of life.

Gordon et al BMC Geriatrics.

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The Art of Doctoring April 19, 2020

To what extent will telemedicine survive this pandemic?

The Art of Doctoring April 12, 2020

Advances in medicine during wars

Our research findings prior to the pandemic were guarded about the potential of video consults:

Background: There is unequal access to health care in Australia, particularly for the one-third of the population living in remote and rural areas. Video consultations delivered via the Internet present an opportunity to provide medical services to those who are underserviced, but this is not currently routine practice in Australia. There are advantages and shortcomings to using video consultations for diagnosis, and general practitioners (GPs) have varying opinions regarding their efficacy.

Objective: The aim of this Internet-based study was to explore the attitudes of Australian GPs toward video consultation by using a range of patient scenarios presenting different clinical problems.

Methods: Overall, 102 GPs were invited to view 6 video vignettes featuring patients presenting with acute and chronic illnesses. For each vignette, they were asked to offer a differential diagnosis and to complete a survey based on the theory of planned behavior documenting their views on the value of a video consultation.

Results: A total of 47 GPs participated in the study. The participants were younger than Australian GPs based on national data, and more likely to be working in a larger practice. Most participants (72%-100%) agreed on the differential diagnosis in all video scenarios. Approximately one-third of the study participants were positive about video consultations, one-third were ambivalent, and one-third were against them. In all, 91% opposed conducting a video consultation for the patient with symptoms of an acute myocardial infarction. Inability to examine the patient was most frequently cited as the reason for not conducting a video consultation. Australian GPs who were favorably inclined toward video consultations were more likely to work in larger practices, and were more established GPs, especially in rural areas. The survey results also suggest that the deployment of video technology will need to focus on follow-up consultations.

Conclusions: Patients with minor self-limiting illnesses and those with medical emergencies are unlikely to be offered access to a GP by video. The process of establishing video consultations as routine practice will need to be endorsed by senior members of the profession and funding organizations. Video consultation techniques will also need to be taught in medical schools.


Jiwa M, Meng X. Video Consultation Use by Australian General Practitioners: Video Vignette Study J Med Internet Res 2013;15(6):e117 DOI: 10.2196/jmir.2638 PMID: 23782753 PMCID: PMC3713911

The geography of large and relatively underpopulated countries like Australia makes it attractiveto use increasingly cheap information technology to improve access to general practitioners. People are already using the internet to access many other services. However, there are some moderating influences on the use of video-consultations in general practice. These include technical limitations, patient confidentiality concerns, regulatory issues as well as the willingness of general practitioners to consult patients other than face-to-face. Theories predict that a relatively small cadre of innovative doctors are those most likely to try video-consultations for routine consultations. However, much will depend on research that demonstrates that video-consultations are unlikely to harm patients or increase the risk of litigation; on the scope toincorporate diagnostic equipment on home computers; on the financial incentives offered to doctors and on the public proclamations of opinion leaders on the question of video-consultations.

Jiwa et al Quality in Primary care

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The Art of Doctoring April 12, 2020

Covid will impact all of our health

The Art of Doctoring April 4, 2020

Homebound status is associated with poorer physical and mental health, as well as disability in the elderly. We aimed to examine the prevalence and the role of homebound status on mortality in a representative sample of the French non-institutionalized population. This study included 7497 people aged 65 and over who were interviewed in 1999 and 2001 about the consequences of health problems on activities of daily living. Homebound status was defined as staying permanently inside the home, excluding an accident or a temporary illness. The influence of the homebound status on two-year mortality was assessed in a logistic regression model adjusted for the main confounders (age, sex, living as a couple, physical and mental impairments). The prevalence of homebound status was 4.7% (95% CI: 3.9–5.4) in this study. The number of homebound elderly was estimated at 421 000 in France. The prevalence of homebound status increases with age and reaches 33.9% in people aged 95–99 years (95% CI: 13.1–54.6). Compared to non-homebound subjects, homebound elderly were more likely to be female, widower, to live alone and to have had a former low level job. Homebound status was associated with a number of physical and mental impairments. It increased the risk of dying within two years with an adjusted OR 3.45 (95% CI: 2.66–4.46). Homebound status should be considered as an indicator of frailty and used in the identification of old people likely to benefit from preventive interventions.

Herr et al. Homebound status increases death risk within two years in the elderly: Results from a national longitudinal survey

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The Art of Doctoring April 4, 2020

A global and urgent need to change our behaviour

The Art of Doctoring March 29, 2020

Public engagement in ethically laden pandemic planning decisions may be important for transparency, creating public trust, improving compliance with public health orders, and ultimately, contributing to just outcomes. We conducted focus groups with members of the public to characterize public perceptions about social distancing measures likely to be implemented during a pandemic. Participants expressed concerns about job security and economic strain on families if businesses or school closures are prolonged. They shared opposition to closure of religious organizations, citing the need for shared support and worship during times of crises. Group discussions elicited evidence of community-mindedness (e.g., recognition of an extant duty not to infect others), while some also acknowledged strong self-interest. Participants conveyed desire for opportunities for public input and education, and articulated distrust of government. Social distancing measures may be challenging to implement and sustain due to strains on family resources and lack of trust in government.

“Listen to the People”: Public Deliberation About Social Distancing Measures in a Pandemic
Nancy M. Baum , Peter D. Jacobson  & Susan D. Goold

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The Art of Doctoring March 29, 2020

COVID-19 will impact more than those with the virus

The Art of Doctoring March 22, 2020

The December, 2019 coronavirus disease outbreak has seen many countries ask people who have potentially come into contact with the infection to isolate themselves at home or in a dedicated quarantine facility. Decisions on how to apply quarantine should be based on the best available evidence. We did a Review of the psychological impact of quarantine using three electronic databases. Of 3166 papers found, 24 are included in this Review. Most reviewed studies reported negative psychological effects including post-traumatic stress symptoms, confusion, and anger. Stressors included longer quarantine duration, infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma. Some researchers have suggested long-lasting effects. In situations where quarantine is deemed necessary, officials should quarantine individuals for no longer than required, provide clear rationale for quarantine and information about protocols, and ensure sufficient supplies are provided. Appeals to altruism by reminding the public about the benefits of quarantine to wider society can be favourable.

Brookes et al The Lancet Volume 395, Issue 10227, 14–20 March 2020, Pages 912-920

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The Art of Doctoring March 22, 2020

Making it more likely you’ll be heard doctor

The Art of Doctoring March 13, 2020

Background Good communication skills are integral to successful doctor–patient relationships. Communication may be verbal or non-verbal, and touch is a significant component, which has received little attention in the primary care literature. Touch may be procedural (part of a clinical task) or expressive (contact unrelated to a procedure/examination).

Aim To explore GPs’ and patients’ experiences of using touch in consultations.

Design and setting Qualitative study in urban and semi-rural areas of north-west England.

Method Participating GPs recruited registered patients with whom they felt they had an ongoing relationship. Data were collected by semi-structured interviews and subjected to constant comparative qualitative analysis.

Results All participants described the importance of verbal and non-verbal communication in developing relationships. Expressive touch was suggested to improve communication quality by most GPs and all patients. GPs reported a lower threshold for using touch with older patients or those who were bereaved, and with patients of the same sex as themselves. All patient responders felt touch on the hand or forearm was appropriate. GPs described limits to using touch, with some responders rarely using anything other than procedural touch. In contrast, most patient responders believed expressive touch was acceptable, especially in situations of distress. All GP responders feared misinterpretation in their use of touch, but patients were keen that these concerns should not prevent doctors using expressive touch in consultations.

Conclusion Expressive touch improves interactions between GPs and patients. Increased educational emphasis on the conscious use of expressive touch would enhance clinical communication and, hence, perhaps patient wellbeing and care.

Simon Cocksedge, Bethan George, Sophie Renwick and Carolyn A Chew-Graham
British Journal of General Practice

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The Art of Doctoring March 13, 2020
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