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Scans and X-ray requests convey something to the patient

Respondents

Carly Flumer

BJ Miller

Eric Last

Mike Rabow

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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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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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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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Frailty begins in the forties

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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A global and urgent need to change our behaviour

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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COVID-19 will impact more than those with the virus

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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If you’re feeling grumpy, try this trick

Click here to view your video

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Your choices in medicine make the greatest difference

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The Art of Doctoring published on Jan 10th 2020

The book is available on Amazon

Moyez Jiwa, an experienced and thoughtful doctor, elevates with practical brilliance the lovely work that clinicians do. In sharp contrast to the grayness of industrial healthcare, he reimagines doctoring as performance art and proposes an elegant script to respond carefully to the suffering of each person. Bravo!

Victor Montori. Professor of Medicine at the Mayo Clinic in Rochester, Minnesota, USA.

Dr. Moyez Jiwa has written a practical guide for medical professionals to make authentic connections with their patients –and in doing so, spark enduring behavior changes that translate into better outcomes and happier lives. The Art of Doctoring left me feeling hopeful for the future of health care in a world where this book is on every provider’s shelf.

Amy Bucher, Ph.D., author of Engaged: Designing for Behavior Change and Vice President of Behavior Change Design at Mad*Pow

Behavior change is a complex science. Clinicians who desire to have lasting positive impact in their patients’ lives must consider the context of the each patient’s life. Successful, sustained health behavior change is driven by the individual [i.e. patient] who is ready for change, and The Art of Doctoring is written with an awareness of the role each patient plays in his or her own journey of living. The Theatre Model© is a brilliant way to frame a patient-provider encounter: Individuals choose who they enroll on their [health care] “theater cast” and how much influence, or how much of a role, each cast member will have. In addition, Jiwa calls out the paramount need for the office encounter to evolve and for the recognition that the patient be seen as “the most important person in the clinical encounter”. There exists a need for a board-certified coaches on the health care teams of the near future!

Nicole M. Guerton, MS, MCHES®, NBC-HWC, CIFT Wellness Coach | Mayo Clinic Department of Medicine | Healthy Living Program Assistant Professor of Health Care Administration | Instructor of Family Medicine

In his book The Art of Doctoring, Professor Moyez Jiwa has unlocked the secrets to creating better experiences for patients as well as the doctors who care for them. In each chapter, he uses very relatable patient stories to illustrate the art of doctoring and uses The Theatre Model© to skillfully peel back the curtain of medicine to reveal the essence of what it really means to be more than simply a good doctor, but to connect with your patient as healer. With more that 30 years’ experience, Jiwa is a leading voice in healthcare. This book is a must-read for anyone on the journey to unite both the science and art of medicine to create a better human experience.

Jake Poore, President and Chief Experience Officer, Integrated Loyalty Systems, Inc.
13538 Village Park Drive, Suite 120, Orlando, FL, USA 32837

Sir William Osler said that the practice of medicine is, “An art based in science.” Dr. Jiwa puts this into action in his book, The Art of Doctoring. He artfully describes how science can best inform a therapeutic ceremony that can be intentionally put into place to facilitate health in those we serve. He uses the best of science to teach the art. And what a wonderful artist he is. Anyone interested in cultivating their own healing arts would benefit from the wisdom this writing shares. I highly recommend it.

David Rakel, MD, Professor & Chair, University of New Mexico Dept of Family & Community Medicine, Author of, The Compassionate Connection.

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