Domhnall MacAuley is a CMAJ Associate Editor and professor of primary care in Northern Ireland, UK
Simon Griffin (Cambridge) was the headliner at the Association of University Departments of General Practice in Ireland (AUDGPI) Conference. Through his keynote address and workshop, he gave a scholarly and comprehensive insight into his team’s work both on promoting physical activity and exploring the evidence on routine health checks. It was clear that to examine a major research question means a long-term commitment, building multiple layers into a study, and testing different hypotheses as the work progresses. Success is incremental rather than through any single dramatic breakthrough. He described the different components of each programme of work and their sequential publication in peer reviewed journals. His views on the difficulty of promoting physical activity and the limitations of routine health checks carry considerable weight, formed on such a robust body of quality evidence.
The simple message portrayed by both government and the health promotion industry — telling people to be more active — makes no difference. Risk information on its own makes little impact, and simply telling people they are inactive is ineffective. Even using multiple methods of feedback —simple feedback, visual (e.g., heart rate) or contextual (“people like you did x”) — had little influence. Using the theory of planned behaviour may influence self-reported activity, but not activity itself. However, although trials showed little difference between groups, often people in both arms changed behaviour. It may be that the measurement itself influenced behaviour (i.e., that wearing an activity monitor or completing a questionnaire encouraged people to be active). Getting people moving is much more complex than simply counselling patients. But, as Simon stated, policy-makers have great difficulty understanding that people don’t immediately change their behaviour just because a doctor mentions it in a consultation.
Simon also took us though the chequered history of health checks in the UK, from the early studies to recent systematic reviews. Without faulting the evidence from current systematic reviews, one limitation is how they are influenced by studies that predate the availability of some of our newer drugs, so that although there may be little difference in the effect of risk assessment and advice, prescribing may have changed; a small difference in prescribing at the national level may make a difference.
There is, of course, a fundamental difference between the societal approach, where a small change in population risk has an impact on mortality versus the impact of individual advice, such as health checks. However, when you talk to people about screening, even at the individual level, it can be difficult to convince them that screening could be waste of time. I loved Simon’s concise message that screening always causes harm and that the key question is whether any benefit outweighs harm at a cost that is affordable.
Our behavioural science colleagues appreciate that habitual behaviour is more influenced by context. If we are to make a difference, we need to understand that behaviour should be seen in a much wider content. This is especially true in diet, smoking and alcohol consumption where legislation, fiscal changes, minimum pricing and nicotine replacement can have a greater impact than doctors. Any media message that makes doctors solely responsible for patients’ lifestyles is unfair. As Simon pointed out, don’t blame the GPs.
Prescribing featured highly in the sessions I attended. Andrew Murphy’s research on prescribing for urinary tract infection illustrated two important features of research. First, unexpected things happen, and interventions designed to improve prescribing, which we generally consider to mean reduced prescribing, may actually increase prescribing. Second, he introduced a novel partner into a genuinely multidisciplinary complex intervention with the inclusion of a social marketing expert in the team (where social marketing means using the principles of marketing for social good). It was fascinating to hear Andrew describe how his social marketing expert could see so many opportunities to change behaviour that we, even as family doctors trying to influence patients, might never have considered.
Prescribing errors happen and although major mistakes make newspaper headlines, have serious outcomes for patients and get doctors into trouble, there are frequent minor errors and multiple near misses. In a world where we increasingly hear about systems failure, many errors are not just a matter of an obvious mistake. Elaine Walsh identified many potential nodes of decision error in prescribing (not just at the interface of primary and secondary care, but across many transitions) through prescription and transcription, throughout the patient pathway. Her work resonates with a current editorial and article in CMAJ that underline the importance of handovers. Patrick Redmond also looked at medication errors and, in the context of increasing technological innovation in medicine, I was struck by one of his qualitative responses “…so why are we still receiving illegible written prescriptions from hospitals?“
In a similar context, Kirsty O’Brien’s work identifying inappropriate prescribing in pregnancy surprised me: almost 50% of mums were taking some medication during pregnancy, excluding folic acid, although this rate is apparently lower than in many other countries. Many of these medications may be harmless over-the-counter preparations, such as clotrimazole and acetaminophen, and many medications were prescribed appropriately (typically antimicrobial agents), but there was a small but significant area of questionable prescribing (e.g., FDA category D and X drugs). Interestingly, a member of the audience pointed out that the average age of pregnant mums in her study was 31 years, and this is now the national average in Ireland, which surprised me too.
Gerry Bury’s typically innovative approach to screening for atrial fibrillation (AF) showed just how important it is to think laterally. His opportunistic use of defibrillator traces engaged the audience who began to suggest other alternatives including their adapted mobile phones. Identifying AF can be critically important; for many people, the first indication that they have AF is when they have a stroke. And, of course, we don’t know how many people have intermittent and paroxysmal atrial fibrillation.
For a refreshingly honest real-life illustration of how difficult research can be, Madeline Brennan’s study on exercise in pregnancy was breathtaking. It was a great idea, well thought-out and driven by a dedicated and committed researcher. But the patients simply evaporated; they were difficult to contact and almost impossible to engage. Seldom do researchers paint such a vivid and honest picture, and rarely do you hear someone admit that, after their pilot study, they need to go and think it out again. Her story would make a great article and compulsory reading for anyone attempting research. But I will not say any more; I have asked Madeline to write a blog, and I hope she will. It’s a fascinating story.
Awards acceptance speeches are usually best avoided, but in receiving the Fiona Bradley award, Sinead Walsh, the Irish Ambassador to Liberia and Sierra Leone, told us of the challenges faced by the Irish and UK voluntary agencies in coping with Ebola ( 24 000 cases and 10 000 deaths) in a country with 42% literacy and a rudimentary health service. Furthermore, how do you break the chain of infection when there is widespread distrust of messages from the outside world, and the local belief is that if don’t wash the deceased’s body, they won’t go to the afterlife. Perhaps the greatest challenges have yet to come in a country where there were already few doctors and 10% have died, together with 500 other health workers. More help is needed.