Jerome Groopman’s bestselling book ‘How Doctors Think’ is about exactly what it means and a bit more, which is how patients can facilitate doctors to think.
Doctors are human and are prone to make mistakes. Most of the diagnostic errors result from cognitive / thinking errors rather than technical errors who work under time pressures. Will it be possible for doctors working under such time pressures to think about how they think?
There are three cardinal cognitive pitfalls – anchoring, attributing and availability errors.
Anchoring is seizing the main presenting symptom and making a snap judgment of a diagnosis.
Attributing is the stereotyping a patient that fits into previously known personality e.g. frequent complainer and hypochondriac so that attributing the symptoms to a benign condition.
Availability error is that since most recent patients with similar symptoms had no serious issues and I have a readily available diagnosis that can be given.
‘As healthcare professionals we talk about personalised care, person-centred care, personalised medicine, individualised care and precision medicine. These have distinct meanings, but are often confused as the same thing. By confusing these terms, the policy makers, researchers, healthcare workers, and the public miscommunicate. Patients and their doctors need the same lexicon, particularly as patients gain access to their digital personal health records. [BMJ Blog by Dr Jane Wilcock – LINK]
Personalised care refers to a wide holistic discussion with the patient, and at times their loved ones, which considers the patient’s context. It requires specific consultation and management skills.
Chair of RCGP states ‘We know that people with multiple long-term conditions account for about 50% of all GP appointments but the current 10-minute GP consultation just doesn’t allow us enough time to effectively address all their health and well-being needs. Our person-centred care approach suggests ways to give people more choice and control in their lives by providing an approach that is appropriate to the individual’s needs. A new RCGP video highlights this need and involves a conversation shift from asking ‘what’s the matter with you’ to ‘what matters to you’.
“Being person-centred is about focusing care on the needs of the individual. Ensuring that people’s preferences, needs, and values guide clinical decisions, and providing care that is respectful of and responsive to them”
“Personalised care means people have choice and control over the way their care is planned and delivered, based on ‘what matters’ to them and their individual strengths, needs and preferences.”
Personalised medicine describes a targeted treatment based on a patient’s tumour or genomic markers. In personalised medicine and cancer care it is easy to see how holistic management around the treatment of cancer, sometimes including end of life care, can be confused with specific therapeutic strategies if the terms are not better distinguished.
“Personalised medicineis a move away from a ‘one size fits all’ approach to the treatment and care of patients with a particular condition, to one which uses new approaches to better manage patients’ health and targets therapies to achieve the best outcomes in the management of a patient’s disease or predisposition to disease.” [LINK]
NRC of USA clarifies the situation, “However, there was concern that the word ‘personalized’ could be misinterpreted to imply that treatments and preventions are being developed uniquely for each individual; in precision medicine,the focus is on identifying which approaches will be effective for which patients based on genetic, environmental, and lifestyle factors. The Council therefore preferred the term ‘precision medicine’ to ‘personalized medicine.’
It would seem safer and clearer to describe these new advances more exactly as pharmacogenomics, defined by the USA National Library of Medicine as “the study of how genes affect a person’s response to particular drugs” and secondly as theranostics(or theragnostics).
Personalised medicine will provide opportunities to improve how we treat disease. Based on comprehensive genomic and diagnostic characterisation, different subtypes of patients within a given condition can be identified, and treatment can be tailored to the underlying cause, as illustrated above.
Wilcok staets that “In my view “personalised medicine” should be dropped as a definition for therapeutic and investigative advances. An improvement is the use of the term “precision medicine”, although “pharmacogenetics” and “theranostics” could be adopted as non-confusing terminologies and these terms better define the new branches of medicine. In this way, primary and secondary care specialists, social care workers and the public, and our patients would all understand the matter being discussed. I would ask national and international bodies to agree distinct terminologies and definitions, which clearly distinguish personalised patient-centred care from personalised or precision medicine by widely using terms such as pharmacogenetics and theranostics.
End-stage renal failure is a common sequelae of type 2 diabetes. ACEI and ARBs are the drugs routinely used for renal protection in diabetes.
Sodium-glucose cotransporter-2 (SGLT2) inhibitors are a newer class of hypoglycaemic agents that lowers blood glucose in patients with type 2 diabetes by increasing the urinary glucose excretion through the inhibition of SGLT2 in the proximal convoluted tubule where the glucose is reabsorbed. SGLT2 inhibitors reduce the renal threshold of glucose from 180 mg per deciliter (10 mmol per liter) to 40 to 120 mg per deciliter (2 to 7 mmol per liter), thereby effectively lowering blood glucose levels.
The CREDENCE trial [Ref] showed that SGLT2 inhibitors in combination with ACEI and ARBs reduce cardiovascular events and renal disease in patients with type 2 diabetes and renal impairment. The NEJM 2019 original article that reported the CREDENCE trial is available at this LINK
A quick take video by the NEJM explains the CREDENCE trial in less than two minutes. [LINK]
BMJ Evidence-Based Medicine journal delivers the verdict in plain language summarizing the full-text article to one page.
In his latest book, ‘Deep Medicine’ Dr. Topol describes how medicine is broken today and how artificial intelligence can help make healthcare human again.
In an interview with The Guardian, Dr Topol was asked about the review report he did for the NHS-UK. LINK
You were commissioned by Jeremy Hunt in 2018 to carry out a review of how the NHS workforce will need to change “to deliver a digital future”. What was the biggest change you recommended? ‘I think the biggest change was to try and accelerate the incorporation of AI to give the gift of time – to get back the patient-doctor relationship that we all were a part of 30, 40-plus years ago. There is a new, unprecedented opportunity to seize this and restore the care in healthcare that has been largely lost.’
Topol goes on to explain that most people have the view that machines and computers will dehumanize medicine. He thinks otherwise. Deep Medicine consists of three things:
(a) Deep phenotyping – comprehensive understanding of every person at every level. Biology, microbiome, anatomy (from scans), physiology (from wearables such as watches), genome etc..
(b) Deep Learning – The best example is Radiology. It is estimated that up to 30% of scans read by radiologists miss certain findings. if machine learning included so that scans are also read very fast by machines and help radiologists the error rate will be decreased very significantly.
(c) Deep Empathy – When the time consuming and extremely complicated things such as the previous two items are dealt with by AI-based technologies, the doctor will have enough time to show deep empathy and restore the doctor-patient relationship. This will bring about the medicine we practiced maybe a few decades ago.
Listen to this 5-minute video clip by Dr. Topol that describes what Deep Medicine is, LINK.
Dr. Eric Topol is the editor in chief of Medscape. He is a Cardiologist and a Geneticist with an interest in how technology affects health. Among his many roles he is founder and director of the Scripps Research Translational Institute in California. He has previously published two books on the potential for big data and tech to transform medicine, with his third, Deep Medicine, looking at the role that artificial intelligence might play. He has served on the advisory boards of many healthcare companies, and last year published a report into how the NHS needs to change if it is to embrace digital advances. (The Guardian)
Artificial Intelligence (AI) is the ability of a digital computer or computer-controlled robot to perform tasks commonly associated with intelligent beings. AI has become the buzz word in medicine, computer science, and engineering. Machine learning, in artificial intelligence the discipline concerned with the implementation of computer software that can learn autonomously.
It can be difficult to approach a colleague if you have concerns about their wellbeing because of a change in their behaviour. Abi Rimmer asks experts how best to handle this situation.
a) small gestures make a BIG difference
b) Take your doctor hat off
c) Don’t be embarrassed to ask
Small gestures make a big difference
Lucy Warner, chief executive of the NHS Practitioner Health Programme, says, “If you’ve noticed a change, then this situation has probably been around for some time and may already have become a fairly serious problem. Doctors are very good at focusing on the patient in front of them and neglecting their own health. There are lots of reasons why doctors don’t seek help, both personal and logistical.
“The best thing you can do is speak up. Ask, ‘Are you ok?’ or ‘You don’t seem yourself. Do you want to talk?’ The smallest gesture can make the greatest difference. If you don’t want to speak to them directly, write a note and slip it to them. Let them know they’re not alone—we all have days when the world gets to us. You might be surprised how people open up when given the chance. Your small suggestion of help might be just what they need to take the steps towards seeking support.”
“Doctors are often concerned about the impact that seeking help could have on their career and registration. Importantly, the GMC is unlikely to want to get involved if someone is seeking treatment for a health condition. There are so many great confidential places to go —their GP, the NHS Practitioner Health Programme, NHS GP Health, and BMA Counselling (you don’t need to be a member), or peer support like Doctors Support Network and Sick Doctors Trust. We all want to help and no one needs to feel alone—please let your colleague know that.”
Take your doctor hat off
Karen Stacey, wellbeing lead for the trainee committee of the Association of Anaesthetists, says, “Everyone is entitled to a bad day but if you notice a change in your colleague’s behaviour you should keep an eye on them. If you see a more sustained change, consider how you can help. The first step should be to speak to them in person with a genuine expression of concern. As doctors, we are problem solvers, meaning we may forget to listen. Be patient, non-accusatory, and take your doctor hat off; you’re asking as a friend.
“If the opportunity arises, suggest how they might seek help. Listen first, suggest second. One chat is unlikely to solve the problem, but being a supportive and understanding listener is invaluable when someone is facing a challenging time.
“Not everyone will want to discuss their problems, but it’s important that they speak to someone. If you’re unsuccessful with your approach, but remain concerned, speak in confidence with a senior colleague. This could be anonymous initially, if you wish to confirm whether to take this matter further.
“Hopefully, your colleague’s educational supervisor will have an existing relationship with them, and may already know of current circumstances. They can approach them directly, and, depending on the circumstance, seek advice from the training programme director. There are many sources of help available for a variety of problems, and many are now tailored to medical professionals.
“As workaholic superheroes we can be our own worst enemies. Seeking help is a sign of strength, not weakness. Look out for your colleagues—they are your work family and you never know when you might need them.”
Don’t be embarrassed to ask
Peter Ilves, retired GP and associate and master trainer at 4 Mental Health, says, “We all like to believe that we’d be alert to colleagues who are struggling or becoming unwell. Certainly, I’d hope that colleagues would notice if I were that person. But the signs can be subtle so we must be attentive and ready to respond in a compassionate and appropriate way.
“It’s important to ask if there is something we can do to help and be ready to ask a second time if they seem hesitant. Many of us shy away from that first encounter, but reaching out sooner rather than later could save a life. When doing this, always approach with compassion and kindness. Doctors find it difficult to ask for help and steer away from sharing problems and their emotional distress. This culture needs to change across healthcare.
“Once a connection is made, explore whether your colleague is already being supported. If not, persuade them to talk to people they trust, occupational health, or their GP. If they seem in crisis or you think they may be at risk of suicide, ask. Please don’t let embarrassment stop you exploring that potentially life saving question. Remember, your colleague may need urgent assessment. See the newly launched BMJ Best Practice module on suicide risk management if you are unsure what or how to ask.1
“Your colleague will also benefit from a safety plan—pre-planned lists of strategies, ways to make a situation safer, and people to contact for support. This is the mental health equivalent of a seatbelt. See stayingsafe.net.”
Every day, there are more than 1 million new cases of curable sexually transmitted infections (STIs) among people aged 15-49 years, according to data released today by WHO. This amounts to more than 376 million new cases annually of four infections – chlamydia, gonorrhoea, trichomoniasis, and syphilis.
On average, approximately 1 in 25 people globally have at least one of these STIs, according to the latest figures, with some experiencing multiple infections at the same time. STIs are preventable through safe sexual practices, including correct and consistent condom use and sexual health education.
From 2017 National STD/AIDS Control Programme (NSACP) Report – LINK
The estimated number of people living with HIV (PLHIV) as of end 2017 is 3500 (3000-4200). This is a slight reduction from the 2016 estimation figure of 4000. Total PLHIV diagnosed and alive are 2391.
“Digital health, or the use of digital technologies for health, has become a salient field of practice for employing routine and innovative forms of information and communications technology (ICT) to address health needs.
The term digital health is rooted in eHealth, which is defined as “the use of information and communications technology in support of health and health-related fields”. Mobile health (mHealth) is a subset of eHealth and is defined as “the use of mobile wireless technologies for health”.
Mesko et al defines digital health as “the cultural transformation of how disruptive technologies that provide digital and objective data accessible to both caregivers and patients leads to an equal level doctor–patient relationship with shared decision–making and the democratization of care” [Ref] As technological innovations become inseparable from healthcare and as healthcare systems worldwide are becoming financially unsustainable, a paradigm shift is imminent.
In an era that that ‘evidence-based medicine’ is facing challenges from many fronts, the benefits of blood pressure control have been shown to decrease morbidity and mortality and increase lifespan. The evidence is strong and there is no disagreement among clinicians and researchers.
However, there is considerable uncertainty and debate as to how much reduction is needed in systolic blood pressure among the leading guidelines that look at the same evidence. The JNC 2018, AHA/ACC and now NICE guidelines vary with the recommendations.
The page below gives the summary of guidelines available from JNC 8 (2014), ACC/AHA (2107) and ESC/ESH (2018)
Guidelines for Management of High Blood Pressure in Adults
In 2014, panel members of the Eighth Joint National Committee published the results of their evidence review and deliberations about the prevention, detection, evaluation, and treatment of high blood pressure.
The 2014 guideline offers recommendations for the management of hypertension in:
People older or younger than age 60 years
People aged ≥18 years with chronic kidney disease
People aged ≥18 years with diabetes
Black and nonblack populations
2017 ACC/AHA Hypertension Guideline
In 2017 the ACC/AHA and 9 other specialty organizations published an updated hypertension guideline which, among many changes, redefined elevated blood pressure to lower BP levels, enlarging the population considered potential candidates for monitoring and treatment. Learn more here.
2018 ESC/ESH Guideline
In 2018 the ESC/ESH published a guideline which retains the 140/90 threshold definition of hypertension, including for patients with chronic kidney disease (CKD), and emphasizes lifestyle interventions as primary treatment, with consideration of antihypertensive drug therapy only in adults at very high risk, eg with established CVD. In many other respects, the 2018 guideline is similar to the 2017 ACC/AHA guideline.
JAMA have produced two Podcasts: Battle of the Heart Societies: Who Is Right–the US or Europe–Regarding How to Manage Hypertension? Part I & Parts II. There can be downloaded free of charge from Appstore or Google Playstore.