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The questions you ask in a doctor’s room matter

Respondents

Carly Flumer

David Rakel

Eric Last

Kimberly Richardson

Dana Deighton

Special mention Michael Bungay Stanier

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What’s on display in a doctor’s office matters

Respondents

Carly Flumer

Eric Last

BJ Miller

Dana Deighton

Hala Durrah

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The prescription at the end of the consultation

Respondents

Rick Davis

Carly Flumer

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A meeting between doctor and patient takes planning

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The respondents to this question have all previously been guests on the Health Design podcast.

Dr. Eric Last

Dr. Steve Trumble

Hala Durrah

Kimberly Richardson

Lesley Kailani Glenn

Carly Flumer

Rick Davis

Experts asked if your doctor knows enough about you

In a new series for the Journal of Health Design I had the pleasure of asking my guests a series of questions following our previous conversations. This is the first of those questions.

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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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Tame Your Advice Monster Doctor

Giving advice without considering the context or the receptivity to that advice may be akin to prescribing drugs without checking for potential drug interactions or allergies. At best it may be unhelpful and at worst it can cause harm.

In his book on ‘The Advice Trap’, Bungay Stanier asks us to consider the circumstances in which we are tempted to issue advice. There is a very helpful table on page 43 in which he outlines the type of person and the type of situation in which we are tempted. Doctor’s reading the book would clearly recognise the risk: Someone apparently seeking advice and time is short; someone who doesn’t ask for advice when there is a lot at stake; and someone who challenges you and ‘that thing’ keeps recurring.

What is the evidence that doctor’s advice to lose weight achieves any results? A startling conclusion from a recent study:

There were no significant interactions between Health Care Professional’s (HCP) advice and attempts to lose weight. Obese adult’s attempt to lose weight, and not HCP’s advice to lose weight, was a predictor for healthy eating behaviors. Interventions in medical practices should train HCPs on effective strategies for motivating obese patients to adopt healthier lifestyle

Preventive Medicine

The issue of health promotion needs to take account of the circumstances of people’s lives and the complexity of the aetiology of many such problems:

Social ecological models that describe the interactive characteristics of individuals and environments that underlie health outcomes have long been recommended to guide public health practice. The extent to which such recommendations have been applied in health promotion interventions, however, is unclear. The authors developed a coding system to identify the ecological levels that health promotion programs target and then applied this system to 157 intervention articles from the past 20 years of Health Education & Behavior. Overall, articles were more likely to describe interventions focused on individual and interpersonal characteristics, rather than institutional, community, or policy factors. Interventions that focused on certain topics (nutrition and physical activity) or occurred in particular settings (schools) more successfully adopted a social ecological approach. Health education theory, research, and training may need to be enhanced to better foster successful efforts to modify social and political environments to improve health.

Shelley D. Golden, MPH and Jo Anne L. Earp, ScD

You may enjoy my podcast with Michael Bungay Stanier

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Preparation is key to the consult in medicine

It may be helpful to consider what we know about anger in medical practice. you may also enjoy my conversation with Ron Epstein

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Why does a haircut cost more than a visit to a doctor?

These conversations with Diana Anderson and Cheryl Janis may be relevant in this context.

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