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

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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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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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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If you’re feeling grumpy, try this trick

Click here to view your video

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Most of what happens in medicine is talk

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Interview with Michael Bungay Stanier- author of the Coaching Habit is available here.

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Your choices in medicine make the greatest difference

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We don’t know enough about those who come to doctors

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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.

NPS https://www.nps.org.au/news/thyroid-disease-challenges-in-primary-care

However they conclude that:

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

NPS https://www.nps.org.au/news/thyroid-disease-challenges-in-primary-care

I offer some more thoughts on video.

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