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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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Why should you always examine the patient?

In the second question in our two-minute question series Dr. Moyez Jiwa, host of the Health Design podcast asks if the clinical examination is a crucial part of the experience when visiting a doctor.

The respondents have all been featured in our podcasts. You an hear the longer conversations here:

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The biggest challenge is sustainability

My interview with Marie DeLuca is here.

Also Andrew Goldstein was interviewed here.

Health advocacy is being formalized as a professional activity for physicians across North America, but the accommodation of this activity into conceptions of daily practice has been controversial and confusing. There appears to be a lack of clarity around what a physician should do as a health advocate and how this should manifest in daily practice. In this article, the authors explore how the medical community has characterized the health advocate role and the roots of the debates regarding its place within training and practice, using the example of the CanMEDS Health Advocate Role. They argue that the confusion might be a result of subsuming two distinct activities, agency and activism, under the rubric of health advocacy. They propose that these activities and their associated skills are sufficiently distinct as to merit separate discussions. Agency involves advancing the health of individual patients (“working the system”), and activism involves advancing the health of communities and populations (“changing the system”). The authors suggest that distinguishing between agency and activism within health advocacy provides opportunities to explore their distinct goals and skill sets in a manner that will advance the debate about health advocacy, a conversation that remains critically important to the medical profession.

Dobson et al

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

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), fibrinogenfibronectinalpha-enolasetype II collagenimmunoglobulin 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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To what extent will telemedicine survive this pandemic?

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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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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