Nudge nudge, wink wink

The role of a journal such as Clinical Medicine (ClinMed) is to be a resource for continuing professional development, but also to showcase examples of good practice. We are pleased in this edition to have a paper by Lewis and colleagues showing how clinicians can be ‘nudged’ towards changing practice and making better informed decisions.¹ Richard Thaler is a Nobel laureate economist who developed the ‘Nudge Theory’ to influence behaviour and decision making. The most well known of these nudges is the engraving of images of houseflies on men's urinals in public restrooms. This simple intervention resulted in an 80% reduction in floor soiling. A less male-centric example is the ‘supersize your meal’ phenomenon offered in fast-food retailers, where customers can pay more and increase calorie intake. The nudge approach is especially contemporaneous as the law around organ donation is changing from spring 2020 in England (to match Wales) to an ‘opt out’ system whereby all deceased adults will be considered an organ donor unless they had recorded a decision not to donate or are in one of the excluded groups. The paper in this journal demonstrates how the addition of an educational message about the risks of ionising radiation reduced the rate of request for computed tomography. Do read the paper to see how simple the message was, and to see the extent of reduction of imaging request.

Since 2010, there has been an almost doubling in the number of people sleeping rough. There is an inevitable increased level of hospitalisation for these vulnerable individuals, who often have poor engagement with primary care. The 2017 Homeless Reduction Act puts a burden on hospitals to provide better post-discharge care of these individuals, and Barrow and Medcalf describe the value of appointing dedicated staff to address this issue.² There is a nudge of improving staff attitudes, but more importantly they also show improved patient outcomes.

Physician ‘burnout’ is a topical issue, and a controversial one. One could contend that ‘burnout’ is a form of victim shaming of the unfortunate doctor who is struggling to provide adequate care in an underfunded system. Alternatively, the phenomenon has been ascribed to the stresses of providing increasingly complex healthcare. What is clear is that physician engagement is an important construct which has been shown to be correlated with the success of patient care. A paper from Vancouver, Canada, describes how a ‘charter’ for physician engagement was established there.³ Although the initiative is at an early phase and there is no measure of success, we felt the manuscript worth including to engage the readership with the challenges in this area, and to provoke a conversation about the merits or otherwise of attempting such engagement between physicians and senior management.

The continuing medical education topics in this edition are on the theme of palliative care. Andrew Davies has coordinated a sequence of outstanding contemporary reviews. There are excellent summaries of the data on managing sleep,⁴ thrombo-embolic⁵ and gastrointestinal⁶ symptoms in the terminally ill patient. What may be more novel to the reader is an excellent description of the OncPal guideline to help with deprescribing for patients in a palliative setting, who often face a large list of medications despite being in the final weeks of life.⁷ The potential to reduced tablet burden and drug interactions make this a necessary and practical article. In a similar vein, we include a manuscript on the importance of providing prognostic information.⁸ While it is plainly beneficial to patients and carers, there is also an advantage for clinicians in terms of defining the appropriateness of medical interventions and optimising placement of care. Almost all physicians look after patients who enter a palliative phase of illness, and these articles will prove valuable to many.