Kindness and positive deviance

Kindness is a characteristic that has in the past (but hopefully not now) been poorly modelled in our healthcare institutions and training grounds. It is what separates good from great health care.

Last year at the College conference in Auckland Dr Lucy O’Hagan earned a standing ovation for the Eric Elder lecture she delivered. In this issue we are privileged to publish the full text of that lecture. In Narrating Our Selves¹ Lucy urges kindness – to ourselves as much as to others. To ourselves first, even. For if doctors are not kind to themselves how can they practice authentic kindness towards patients? Last year, much of Lucy’s lecture was delivered with humour yet the core of her message was challenging then, and is even more so now, in writing. Implicitly, she explains the unkindnesses of medical school, of social pressures, of medical practice, and she also models hope for change.

All our papers in this issue are about change in some way. ‘Change’ is one of the five habits Atul Gawande advocates so that doctors (and others) become ‘positive deviants’, making life better for their patients in valuable but unexpected ways.² Changing the way health systems do things is necessary to accommodate the rapidly changing population profiles of different parts of the world, physical environments, and evolving social contexts. Arroll and Wallace provide evidence to support changing to chlorthalidone as a first choice of diuretic for treating hypertension.³ Ranta’s team found that changing general practitioner access to hospital based imaging resulted only in more appropriate (and not excessive) imaging, in the context of a randomised controlled trial of a decision support tool.⁴ Research such as that of McKinlay et al. are changing the way we see patients:⁵ first patients were simply anatomy, then whole people, and now there is a growing body of research developing greater understanding of the role of patients’ social contexts in supporting health.

As well, some of our research reports explore current situations to identify where changes are needed and what such changes might be. Keys and her team in Central Otago have used their routine clinical records to show that they cannot follow clinical guidelines for head injury patients without better access to imaging.⁶ Also from rural New Zealand, Johnson et al. report on a local solution to constrained access to health services (in this case, breastfeeding support).⁷

Whether and how to notify partners of people identified as having a sexually transmitted infection is often a complex decision that for many doctors and nurses arises only seldom, but for others occurs all the time. Rose et al. found that among the latter group their partner notification practices might be helped by more readily available patient resources, better training for practice team, more guidance on how to communicate, and access to advice when they needed it.⁸

Bose et al. target a similarly challenging topic: the diagnosis of transient ischaemic attacks (TIAs).⁹ Unlike a lot of other problems patients present with in primary care, diagnosing TIAs is quite important because early treatment reduces subsequent strokes. However, the condition presents in a variety of ways and is reasonably rare so many doctors may not see it often enough to confidently make a diagnosis. This systematic review develops estimates of diagnostic precision and investigates ways this may be improved (referring to Ranta’s research (above), among others).

We draw readers’ attention to the scientific approaches in some of this issue’s papers. Professor Felicity Goodyear-Smith, the previous Editor-in-Chief of this Journal, comments on the role of this Journal in distilling and disseminating research to our readership, referring in particular to the two systematic reviews in this issue.¹⁰ Systematic reviews are a good way to gain a rapid overview about a topic and are valuable in practice if they answer a relevant question of to their practice, and have been rigorously conducted. We think both these reviews meet those criteria for usefulness.

Feasibility studies help researchers decide whether than can actually complete the research they dream of doing and in the process of doing them the dreams are usually modified to make the research possible. They are a type of project this Journal is pleased to publish for the research lessons our readers may draw from them, rather than for their actual results. Wallis and Tucky report the results of their feasibility study.¹¹ They recognise that medicines used by elderly people can harm, rather than help, and they want to test whether they can study an intervention that they hope will reduce medicines harm in this group of patients.

The research report by Ohigashi’s team models a type of research that could not have even been dreamed of a couple of decades ago.¹² These researchers systematically dip their minds into social media to find out what people want to know about breast cancer – a necessary precursor to providing relevant information.

Rounding out this issue we have our three columns providing up-to-date information about probiotics, pregnancy, and … chocolate.

The Cochrane Corner suggests the kindness of chocolate: it is good for us.