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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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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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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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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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Making it more likely you’ll be heard doctor

Background Good communication skills are integral to successful doctor–patient relationships. Communication may be verbal or non-verbal, and touch is a significant component, which has received little attention in the primary care literature. Touch may be procedural (part of a clinical task) or expressive (contact unrelated to a procedure/examination).

Aim To explore GPs’ and patients’ experiences of using touch in consultations.

Design and setting Qualitative study in urban and semi-rural areas of north-west England.

Method Participating GPs recruited registered patients with whom they felt they had an ongoing relationship. Data were collected by semi-structured interviews and subjected to constant comparative qualitative analysis.

Results All participants described the importance of verbal and non-verbal communication in developing relationships. Expressive touch was suggested to improve communication quality by most GPs and all patients. GPs reported a lower threshold for using touch with older patients or those who were bereaved, and with patients of the same sex as themselves. All patient responders felt touch on the hand or forearm was appropriate. GPs described limits to using touch, with some responders rarely using anything other than procedural touch. In contrast, most patient responders believed expressive touch was acceptable, especially in situations of distress. All GP responders feared misinterpretation in their use of touch, but patients were keen that these concerns should not prevent doctors using expressive touch in consultations.

Conclusion Expressive touch improves interactions between GPs and patients. Increased educational emphasis on the conscious use of expressive touch would enhance clinical communication and, hence, perhaps patient wellbeing and care.

Simon Cocksedge, Bethan George, Sophie Renwick and Carolyn A Chew-Graham
British Journal of General Practice

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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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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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Where are your finger prints in my care?

It is unlikely that you will be part of every encounter with the customer, client or patient whatever you do and wherever you work. A barista is not at the table with the customer is presented with their breakfast; a dressmaker isn’t at the checkout when the customer makes their purchase at a department store. Sooner or later you won’t be there in person. However it is likely that whatever you’ve contributed will have an impact. How do you define your role from this perspective in healthcare?

The participants—21 family physicians (fps), 15 surgeons, 12 medical oncologists, 6 radiation oncologists, and 4 general practitioners in oncology—were asked to describe both the role that fps currently play and the role that, in their opinion, fps should play in the future care of cancer patients across the cancer continuum. Participants identified 3 key roles: coordinating cancer care, managing comorbidities, and providing psychosocial care to patients and their families. However, fps and specialists discussed many challenges that prevent fps from fully performing those roles:

  • The fps described communication problems resulting from not being kept “in the loop” because they weren’t copied on patient reports and also the lack of clearly defined roles for all the various health care providers involved in providing care to cancer patients.

  • The specialists expressed concerns about a lack of patient access to fp care, leaving specialists to fill the care gaps. Easley et al

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Do something in your power to make a difference

It’s a small detail. If you are accompanying someone down a corridor as a healthcare professional- don’t stride ahead. Ideally walk alongside the person or let them lead the way if they know where you are headed. If they are wheeling a buggy and carrying a bag offer to help by wheeling the buggy.  Just try it. You might like how they respond. Apart from that you can learn so much about the person even before the consultation begins:

So instead of a doctor assessing a patient’s blood pressure, body mass index, chronic conditions, hospitalization and smoking history and use of mobility aids to estimate survival, a lab assistant could simply time the patient walking a few meters and predict just as accurately the person’s likelihood of living five or 10 more years—as well as a median life expectancy. Scientific American

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Quitting work may be the best thing you can do

 

Do you quit work? At least until it’s time to be back in the office, clinic, shop or hospital? Are you constantly taking calls and texts from work even on vacation?

Recreational travel may increase creativity by relieving workers from stress, providing diversifying experiences and increasing positive emotions. Consequently, vacations may boost creativity, apparent in a greater variety (flexibility) and originality of ideas after work resumption. de Bloom  et al

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