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Archive for December, 2013

Exercise in older adults – time for a New Year’s Resolution?

30 Dec, 13 | by Toby Hillman

Via wikimedia commons

Exercise is good for you – but then we sort of know that already – The Earl of Derby had it right back in 1873 pointing out that

‘Those who think they have not time for bodily exercise will sooner or later have to find time for illness.’  

Take a look at this brilliant animation if you are in any doubt:

But, what about when you get a bit older – (over 65 to be precise)?  A paper in the January issue of the PMJ (Editor’s Choice so it is free!) has examined the current recommendations for physical activity in older adults (over 65), looks at the measurement of physical activity (in trials self-reported activity doesn’t seem to have the same benefits as objectively measured physical activity) and how to increase participation in exercise.

The conclusion is that yes, there are clear health benefits associated with physical activity in the over 65s, but also that there is a rapid drop-off in participation – 20% of men and 17% of women aged  65-74 managed the recommended amount and in the over 75s this dropped to 9% and 6% respectively .  The key barriers to participation in physical activity were ill-health, pain and injury.

The section of this review which caught my eye was the section on the importance of the physician when considering physical activity.

How important is it that physicians give these messages?  The review highlights some evidence that GPs can have a positive impact on participation in physical activity – simply giving advice can have an impact.  If that advice is tailored to the individual, and backed up with follow up from exercise professionals, then there is a positive benefit on uptake of physical activity – and perhaps more importantly, on hospitalisations in the subsequent 12 months.

Along with dietary modification, medication adherence, and smoking cessation, physical activity is another domain to be added to the growing list of behavioural changes which doctors of all types are now expected to facilitate.  But are we any good at it?  The evidence presented shows that actually mentioning the subject of concern is important ( for 38% of older adults in one study had no mention of exercise in consultations) but are we equipped to truly impact on the health behaviours of the patients we meet?

Often messages about health are from the perspective of the doctor, and we encourage patients to adopt behaviours which will deliver outcomes we are interested in (this paper examines diabetes care in this light) Perhaps unsurprisingly, patients often don’t appreciate their problems from the point of view of a national audit or a QoF point counter.  Patients tend to be more interested in outcomes which directly affect them. Even framing problems correctly may not be enough.

So what to do – simply repeating ourselves doesn’t seem to be that logical, so a different approach is required.

At a recent conference one of my colleagues asked a brief but powerful series of questions:

How many of you advise your patients to stop smoking?
How many of you prescribe smoking cessation medications?
How many of you have had training in motivational interviewing or behavioural change?

The answers were telling – the first two questions revealed a forest of hands – the third could barely summon up a shrubbery of positive responses…

As doctors, we are trained to understand pathological processes, to diagnose diseases, and prescribe drugs. Communication skills have come to the fore in training of late, but tend to be based on how to deliver a traditional message in a more palatable form.

To be truly effective agents of behavioural change, we need to acquire new skills. Our current skills tend to achieve adherence to medication regimes in the order of 50% (see a paper here on this)  The precise way forward is still debatable (this review looks at motivational interviewing for physical health) but will undoubtedly draw those of us who care for physical health problems closer and closer to psychological interventions – perhaps it is us physicians who really need to engage in a bit of behaviour change… perhaps a good resolution for the new year?

 

 

 

 

Is that a smartphone in your pocket?

15 Dec, 13 | by Toby Hillman

Smartphones are almost ubiquitous on the wards nowadays.  In a departmental meeting the other day a question popped up about the commonest reason for admission to hospital acute medical services.

Out came my smartphone, and after a search, and a tweet – almost instantly (and quickly enough to furnish an answer by the end of the session) answers came flying at me through the ether. (It depends on how you cut the numbers, but chest pain is the winner.)

Indeed, twitter is not the only useful educational tool I keep on my smartphone.  I have a number of apps (26 in fact) which can only be used for work purposes.

This paper ( epub ahead of print) looks at the proportion of Interns using smartphones in the Republic of Ireland.  Unsuprisingly the vast majority of interns use smartphones on a daily basis, and the most popular app was the BNF (which is free to NHS employees)

The questionnaire formalises what is common sense in terms of the utility of smartphones for communication within teams – with 87.3% reporting receipt or broadcast of a work related SMS message and 83.3% having made or received a call about work.

More important issues raised in the paper include the use of other smartphone functions – for example cameras, with 52% of those surveyed having taken a picture at work, and 22.% reporting taking a picture for work related reasons once a week.  This use and storage of sensitive information on a personal device is of concern, and that such proportion of doctors use these functions shows just how useful they can be.

What is not examined in this paper is the impact of increasing use of technology – and smartphones in particular on the clinical relationship between doctor and patient.

Many medical students now take notes on their mobile device – often sitting in a clinic room tap tapping away at a screen.  I am sure that most are being diligent and using technology to enhance their learning, but I have no guarantee.  I wonder how I would feel as a patient if a student in my consultation seemed to be organising a night out, or looking up the latest football results?

Indeed – I use a smartphone in consultations with my patients on a regular basis – I have predicted spirometry calculators, risk scores, and the very useful BNF app to turn to when required.  I always tell the patient what I am doing, but I am concerned that this intrusion of technology might put some patients off, or somehow leave them with questions about my bedside manner.

There has been some research into the use of electronic health records in primary care consultations – here looking at the new triumvirate in consultations, and here  how software design can influence how the computer develops a ‘face’ in the consultation.

Some advice on the use of computers in consultations – and how to use them to enhance rather than detract from a consultation has been offered here.

So – I think we have to accept that smartphones are here to stay – and that their utility in clinical practice means that they are going to be more and more prominent on our wards and in our consulting rooms as time goes on.  The rules of engagement when introducing smartphones into routine clinical practice are yet to be defined, but you can be certain that basic manners will be a good place to start.

However, two key points for clinicians will remain:

Listen to your patient – he is telling you the diagnosis.

and

The art of medicine consists in amusing the patient while nature cures the disease.

 

Proper preparation and planning…

2 Dec, 13 | by Toby Hillman

There is a basic assumption that medical schools prepare medical students to become doctors.

One might expect that medical schools prepare medical students to broadly similar standards, and that by extension, their students would be broadly prepared for practice when they emerge blinking onto the wards each August.

In a fascinating paper, Goldacre, Lambert and Svirko have analysed the latest responses to a questionnaire sent to each and every newly qualified doctor (from UK medical schools) registered with the GMC in 2008 and 2009.

The responses show an overall improving perception of preparedness amongst our most junior colleagues.  In 1999/2000 only 36.3% of medical graduates agreed or strongly agreed that their training had prepared them for practice, and in 2008 and 2009 this was 53% and 49.4% respectively.

So, things are getting better . Why they seem to be getting better is not clear.  Is training really improving the preparedness of graduates, or is the increasing level of supervision in the workplace protecting today’s FY1s from the worst ravages that previous generations were exposed to?

However, in spite of the improvements, can it really be true that we are barely able to equip half of our medical graduates to feel prepared for work when we unleash them after 5, 6 or even more years of training and education?

And what are the responders unprepared for?  The questionnaire offered some domains for further comment.  In 2008/2009 responders felt unprepared in terms of:

  • clinical knowledge 17.5%
  • clinical procedures 21.3%
  • administrative tasks 31.8%
  • physical/emotional/mental demands 26.4%
  • interpersonal skills 2.7%

Reassuringly the proportion of responders who felt their unpreparedness was a ‘serious’ problem was low at 2.7%, and was a ‘medium-sized’ problem for a further 22.6% (again, a reduction on similar cohorts in previous years)

In addition to the analysis offered in the main paper, the online supplementary data reveals even more stories -for example, one medical school increased preparedness in their students from 33% in 1999-2005 to 62 and 61% in 2008 and 2009, and yet one school continues to have graduates that feel unprepared – with only 24% feeling prepared in 2009, and similarly only 30% in the 1999-2005 period.

So – what is the message here?  There are almost too many conclusions one could leap to, but for me there are some urgent points which need addressing:

1:  There is unwarranted variation across medical schools.

It may be hubris on the part of the full list of graduates from medical school 12, but more than 80% of the graduates of 2008 and 2009 felt well prepared, and yet in comparison, from school 16, 38% strongly felt that they were under prepared.

This kind of variation is not unexpected given the variety of courses, curricula and training opportunities available to the different medical schools in the UK, but for over a third of graduates to feel strongly that they were underprepared for practice demands further attention.  This attention is vital, as the data shows that over time schools can improve, and the domains for which FY1 doctors felt least prepared for are all vital to maintain a safe, efficient and effective workforce (administrative tasks and physical / emotional resilience)

2.  We are not preparing our students for they key aspects of the jobs they are taking on.

The finer details of the survey show that of the domains graduates feel least prepared for, administrative tasks, and the physical/emotional/mental demands of the job rank highly (figure here).

The authors argue that preparedness for administrative tasks could be seen as ‘trivial’ and do not comment further on the physical, emotional or mental impact of working as a junior doctor. Clearly medical schools are not responsible for all of the factors which affect preparedness for practice, but it is vital that as a profession we start to value our most junior colleagues – even before they start to work with us, and ensure that they are developing the tools to help them cope with the demands of what can be a very stressful career.

With proposals to move the date of full registration with the GMC to that of graduation from medical school, the concept of preparedness amongst medical graduates has never been more topical, and if some of our institutions are falling as short as they seem to be in preparing the next generation of doctors, some action is required.

 

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