Wednesday, 8 June 2016

Focus Group Ground Rules:Should They Apply When You Consult Patients?

When you are asked questions before you start a survey, or before you are invited to a focus group for market research you might notice that you are almost always asked a few questions before you can start the survey or be invited to a focus group.

Imagine the topic is banking. You'd be asked:

Do you or does anyone in your family work now or in the past in market research, advertising or media?
Do you now or did you ever work for a financial services provider?

If you said yes to either you would not be invited.

These are the basic questions and they're designed for two things. Sometime to keep the client's competition from learning about the client's plans or to ensure that the other focus group participants are comfortable voicing their opinions.

Focus Group

In the 20 years I spent organizing focus groups this never changed. We often asked our clients for clarification, or a bit of stretching the boundaries to make our job easier but not an area where there was flexibility.

When we asked for exceptions the answer we got was this:
As we go around the table and give each person a chance to speak and give their opinion, the dynamics of the discussion change dramatically after someone who is considered an expert gives an opinion on the topic of the group

No one wants to be at odds with the person who is seen to know more than the others because of experience. The person who 'knows the topic' has an overweight influence on the discussion whether they mean to or not.

I heard this point of view from another perspective at the HCSMCA Unconference in Vancouver. In a conversation with Dr. Paul Dempsey he talked about setting up a Moms group on his website so parents could support one another. He found that a lot of the wisdom of  'Dr. Mom' flowed among the participants - until he stepped in. The conversation stopped when he (the expert) stepped in.

This can make a difference when organizations, government or groups try to hear from patients. 

Everyone's opinions are valid, but I would suggest that when there is a broad range of experience among patients, especially when some of the patients are or were health care professionals or health care workers, that holding separate focus groups would produce a better range of opinions and include more voices.

Sunday, 24 April 2016

Patient Groups - Hard Work and Lots of Questions

Last week I attended the CADTH symposium in Ottawa as a member of the Sjogren's Society of Canada.

You might wonder exactly what CADTH is and why I would want to attend. The Canadian Agency for Drugs and Technologies in Health (CADTH) is an independent, not-for-profit organization that provides public healthcare decision-makers with evidence about the appropriate use of drugs and medical devices. Patient input is used in deliberations and decisions.

It is becoming much more important in health care to have the patient, caregiver and public point of view and we see organizations making changes because of this.  Sarah Berglas of CADTH pointed out that 5 yrs ago they asked clinical experts what was important to patients. Now they are asking patients for this information.

To make it easier for patient groups to take part CADTH provides templates and sample submissions on their website to help them.

One of CADTH's aims is meaningful involvement of patients and patient groups in the drug review process.

I heard two important comments about patient submissions:

"Patient experience brings the disease to life" -- Fiona Miller
“The review team has often never met a patient with the disease” -- Frank Gavin

At one of the panels at CADTH, Zal Press of Patient Commando suggested that out of 1682 patient groups, only about 18 have the capacity to make submissions to CADTH to be considered by the Common Drug Review.

Questions that came up: 

How much thought is being given to the cost in terms of time and energy that it takes the patient group to do this?

How can patient groups running on a shoestring with few resources do a drug submission effectively?

Is this small number of groups who make submissions a good representation of the voice of patients and the public generally?

What about the idea of independent financial support for patient groups?
Are we asking too much of patient groups? We invest in clinical evidence, why not patient evidence?

Just the facts? 

Dr Ahmed Bayoumi, who is a member of the Common Drug Expert Committee, asked in the panel whether patient groups have the agency to speak for their patients. 

Dr Bayoumi said with patient submissions the decisions made are better decisions - that statement left patients in the room with questions. How do we know that our submissions really have an impact and can possibly change a decision?

Barry Stein of the Colorectal Cancer Association of Canada said he is disappointed that patient experience is most often used to enrich, rather than change, reimbursement and coverage decisions.

Are patient groups working so hard on submissions for drug after drug, just so that the decisions made in meeting can be “better”?

What about the reality that qualitative research and experiential results are heavily discounted in favour of ‘real' evidence from trials and quantitative research?

How often do we call patient experience evidence? Why do we not call it patient evidence? -- Frank Gavin

What terms do we use to describe patient input? Information is a neutral term, but patient information is not seen as data -- Frank Gavin

The panel talked about evidence vs advocacy. We are dichotomizing this form of evidence. How do we incorporate it?

Gail Attara said that understanding the patient perspective is important. "Is a fifth medication for a condition needed?" She answered Yes, if you are a patient for whom the first four didn't work. Also that the patient's individual goals and decisions may not always follow evidence.

Sarah Berglas: Need to work with patients to capture big ideas on acceptability of treatment, "how life is lived, not just survival"

Those of us attending the panel discussion got concrete advice on making our submissions  to the Common Drug Review have more impact and be more useful.

1.     Discussing unmet needs and quality of life is very relevant
2.      Be very specific about therapy, side effects and challenges e.g. efficacy decreases over time.
3.      Include numbers if we have them
4.      Include strong quotes that "hook into people's brains" and illustrate the authentic voice of the patient.

Advice to patient groups on submissions: Be specific in what you include and pick powerful direct quotes. Sarah Berglas, Patient Engagement Officer, CADTH

Ducks in a row
Advice for patient groups from Gail Attara from

If patient groups could make submissions in person it would be more satisfying. Why can't patients comment on draft reports like other experts?

Patient group submissions are heavy on quotes, testimony and voice. Patients have the feeling that lived experience can’t compete with clinical data when the end result is up to the funders. Some patient groups wonder how much of  a difference their input makes.
There is a need to develop patient capacity.

I'm always conscious that patients have no strong networks to enable us to stay in touch and connect in between events like CADTH.

HTA provides the facts: ethics judges the facts. All who are affected need to be heard. Are patient values represented in HTA?
There is limited operational (action-oriented) guidance to assist HTA with the evaluation of ethical issues.

Even at the Plenary we heard this question: How do patient groups organize so they can feed into changes within the health care system?

A slide from Dr Ahmed Bayoumi's presentation

Wednesday, 23 March 2016

Arthroplasty of the MCP Joints (New Knuckles)

If you had rheumatoid arthritis (RA) diagnosed in the 80's, or if your RA has been very aggressive, you might know the meaning of the title. Otherwise it sounds like medical jargon that you need to go home and google. As an involved patient I always want to know what medical language means.

The story starts with a surgeon who must have been tired of describing procedures to patients. He put up a hand to stop my questions at the first visit, when he laid out a plan that ultimately involved straightening my fingers. 

However when he said this process would take 3 operations that was the end of the road.  With a full time job I could not afford the time to have that much surgery. His plan was to fuse both wrists and then straighten the fingers - I found out later that this is the best way to proceed. 

Once I retired I was able to deal with surgery. The results of operation #1 were very successful, so after a year I went back to have the second one. With both wrists fused I was ready for the grand finale and just in time, because my fingers were getting worse and using them was getting more difficult. 

How much worse? This much

But - when I went back to the surgeon, he said "Too bad you didn't have this done when I suggested it because I'm retiring." Not the most sympathetic doctor, but also not the only one in the city.

Now it's done and I have new knuckles. Despite telling Debby's story of success with this I had doubts, especially when a trusted friend told me that doctors in her city were no longer willing to do this procedure.

However, with a US friend who has RA finding that three of her fingers were so badly displaced that she has lost hand function I carried on.

This is a picture of what I believe my knuckles look like on X-ray now. I don't have an x-ray of my own since the doctor did not do one. Now I have an implant in all 4 of my knuckles (MCP joints).

Silastic implants

You might wonder whether the operation was a success. It was done ten weeks ago. I started in a cast, then graduated to various splints. Every week the Occupational Therapist would adjust both the night splint and the one for days. I almost had the impression that my hand was being molded into the right shape after the surgeon did his part.

After the cast came off I wore a splint like the one on the right all of the time. As the weeks passed I had an exercise splint like the one on the left that got smaller as the weeks passed. 

I can write and type better now. The occupational therapist who is still helping me advised me to wear a small splint to keep my fingers straight during the day, and a splint from fingertips to forearm at night. 

Here's the finished product - my hand today! Better than before.

Perfection  is impossible, but I expect to be able to use my hand for a lot more years now - in fact maybe people will no longer give me a seat on the subway.

Wednesday, 16 March 2016

HCSMCA in Vancouver

The #hcsmca symposium felt like a family reunion, or a live in person tweetchat, from walking in the door of the room in the morning, right until I left for home.

Feels as though we've known one another for a long time

The atmosphere in the (un)conference room was excited and exciting. Robyn Sussel was an excellent moderator and starting with a prayer for the day from Syexwaliya of the Squamish Nation was an inspiring beginning.

Pat Rich talked to us about only building what you can maintain, and quoted @Berci. "I want every medical professional and empowered patient worldwide to feel connected to many others... when they have questions or just need a good word or support.  Social media has the potential to become this bridge between people"

Colleen Young talked about the strong sense of belonging and the give and take in social media - the way the Twitter welcome wagon is ready for anyone. And one of the biggest achievements of social media is that it helps people to take a step back - it breaks down silos, is a fountain of plain language, and creates circles of trust and real conversations. We need that trust to be able to share

So we all came to Vancouver to do more of that, and to try to make a road map to see HCSMCA into the future.

Larry Chu asked us how we use technology to break through silos and achieve mutual trust and inclusivity.

Lee Aase gave us sharing and learning from the Mayo Clinic and talked about how having a group of co-belligerants helps break through the blocks such as patient privacy.  

His point about healthcare shifting and emphasizing respect over power was chosen as one of the top 10 ideas of the day. Larry Chu added to that with "How might we improve healthcare if we focus on respect instead of power?"

Another idea from Lee Aase "Don't let perfect be the enemy of good." and a top idea from Colin Hung "Change the world locally." That one is worthy of a  shirt.

More advice from Colleen Young "Model the behaviour that you want to see and spend time on the people who do model it."

Then with these two memorable statements -
"Take one bite out of the elephant at a time." Robyn Sussel
"The Law of Two Feet - You can move to another group at any time."

- we were ready for 12 challenges in 50 minutes.

I picked Challenge #7: Using social media to advocate for policy change
Deb Maskens submitted it and led the group. It was a real learning experience for me.

We talked about engaging with policy makers, strategic positioning of advocacy, mutually beneficial partnerships, moving from slacktivism to interactivism, the qualitative shift in how people are engaging now.

Incremental change is a key as we ask why research, evidence and common sense do not carry the day. Question: What is respectful political advocacy?
One obstacle noted is that when patient groups meet with the opposition party they lose credibility with the government.

Another important barrier is the structural exclusion of advocates from decision making.

Our group of Canadians using social media, who have a passion for changing the healthcare system, had a very rich discussion about changing the system - in fact we decided to start using a new hashtag (I just checked and we will be the first) #HCsystemChange. 

We sent ourselves a postcard from the future, and since this very useful conference also gave us the ability to keep in touch with one another, we will be working on making some progress.

All of the challenges had ideas that were usable. I think the largest challenge we are faced with is making use of what we learned, and keeping in touch with our community. The value of community was obvious at the Unconference, and I think we all learned how effective it is to have the whole team working on solutions.

Personally #hcsmca has made a large difference to my life and seeing virtual community change to real life community in BC was a powerful experience.

Meanwhile I look forward to the next Road Trip!!

Andre Picard with delegates from #hcsmca

More ideas:
Proceed until apprehended. Pick a back-burner idea and go for it on Monday.
Involve patients.
Use technology to support patients.
Don't let perfect be the enemy of good.
How do we listen to and use stories and then turn the stories to action?

Wednesday, 17 February 2016

Intimacy, Sexuality and Sjogren's Syndrome. Sjogren's National Conference 2015

In comments and feedback to the Sjogren's Society of Canada members have indicated a wish to hear more about a topic that is usually kept in the closet - intimacy. In 2015 we had a great speaker who gave us useful information about intimacy and sexuality.

Many of us have brought this issue up during doctor visits and have found that many health care providers seem to be uncomfortable with this topic and do not offer much advice. 

Since this is so crucial to maintaining our relationships, we were happy to hear Iris Zink, a Rheumatology Nurse Practitioner and President of the Rheumatology Nurses Society, speak on the topic of "Intimacy, Sexuality and Sjogren's Syndrome." Her advice sounded excellent for people with any chronic disease.

Normally she lectures to audiences of health care professionals across the United States. In her role at the Beals Institute she is known as "the sex lady" and I think we may have been her first audience of patients.

I elect Iris Zink as our most memorable and original speaker ever. 

When I first noticed her in the room on the morning of the Conference I wondered about her red and silver boots but I had no idea that underneath her ordinary white jacket she was wearing a Wonder Woman cape.

  Note the pointer in Iris's right hand

Her no-nonsense talk was straightforward and clear - we can't keep treating Intimacy and sexuality as the elephant in the room. Embarrassment on the part of the patient and healthcare provider results in no discussion.

Elephant in the room

It was too bad her audience wasn't bigger. She got her message across in a very compelling way - so much so that if Iris wrote a book I would give copies away as a public service. Her lecture was helpful for patient and provider communication, as well as for patients and their spouses.

She told us that 66% of patients with hip and back Osteoarthritis, 62% with Rheumatoid Arthritis and 71% with Fibromyalgia have difficulties with sexual problems. 

She stressed that we should accept what we've got, and told us the brain is 90% of sex, the skin only 10%. Her presentation went over well with the mixed audience. 

The main issue is how we start the conversation and how we communicate with each other. For instance: Complete this sentence - "I miss ............." when you and your partner discuss intimacy. Talk, touch and practice. She defined sex as the ultimate union of the body and the mind.

Don't forget your Kegel exercises, men too. She suggested doing Kegels 30 minutes before sex to increase the blood flow to that part of the body. 

Her talk was optimistic and empowering. Most of the people in the room were smiling at the uninhibited style and the anecdotes and cartoons that drew us in. 

We were even given homework to do with our partners:
1. Talk to one another
2. Spend 30 minutes touching each other without intercourse or orgasm
3. If you are interested in steamy sex talk you have to practice.
4. Know your body and what makes you aroused
5. Date!!! Make it a priority!

All who wanted came home with catalogs so that we could have a look at some of the possible intimacy enhancing products.


Iris Zink wrote an article called "A Rheumatologic Perspective on Intimacy and Chronic Illness" for The Rheumatologist - an official publication of the American College of Rheumatology (ACR).

A study by Bitzer and Platano that Iris referenced concluded that "sexual problems are frequent in many clinical conditions, but are not yet a routine part of diagnostic workup and therapeutic planning." She mentioned that 40% of ObGyns don't ask about sexual function.