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Assuming a persona might help to arrest Covid

‘The Art of Doctoring’ available from Amazon books

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Telehealth is not fit for purpose in primary care

As a response to Covid-19 in Australia there is the scope to consult a doctor by telephone or video. The appointment is scheduled at a specific time and the doctor will ask your name, date of birth and address to confirm your identity. Some practices will offer these consults to people who are not eligible for the government rebate for a private or insurance fee.

The type of problems presented to doctors vary from acute to chronic illness. There might be requests for repeat medications or a discussion about test results. Reflecting on the variety of problems presented it is evident that in many cases people are seeking to talk to doctors about issues that need a face to face appointment to be managed safely.

Do you know what this tiny red spot is on my eye lid?

I just want a referral to a psychologist. I don’t want to talk about why on the phone.

My two year old daughter had a rash yesterday. It’s getting better I just need a note to say she can go back to child care.

I think I’ve got meningitis, but it’s getting better today. What do you think?

I had a migraine yesterday and need a day off work.

I think my daughter has nappy rash.

I’ve got iron deficiency anaemia. Another doctor far away did the test for me. I don’t like eating meat and I don’t like taking iron tablets. I’ve googled it and I want a injection of iron. Please leave a script at the desk for me.

It may be true that the patient should not travel to the clinic if possible to reduce any risk of infection. On the other hand it may also be true that the convenience of having an appointment when it suits has made it all too tempting to present problems that need an in person visit. It is often impossible to diagnose the problem based on an exchange over a crackly telephone line with patient who may not be able to hear or speak the language fluently. The patient may believe that a doctor who they know has been paid for the service will satisfy them with a script, certificate or referral in the way that any other telephone service operates. However the model for Uber Eats or Amazon does not fit healthcare where the need for information exceeds just the name, address and date of birth.

Covid will change everything including the way we consult doctors however not all changes will be for the better and telehealth consults that nurture unrealistic expectations will do more harm than good. It is rarely possible to meet the needs of all patients who might possibly have a telephone call with a doctor. In a trial of telephone consults more than 60% of patients needed to be seen face to face. If then those patient are advised that they must be seen in person, notwithstanding Covid the reality that the doctor is unable to meet their expectations may become a source of dissatisfaction and stress for all concerned. The art of doctoring is primarily an in-person activity. Telephone consults are adding to the challenges in primary care at the most stressful time.

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Playing Tennis With Snow Boots On

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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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:

Randi Oster podcast here:

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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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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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