Sir Bradley Wiggins is a truly extraordinary athlete, but I am sure he would be the first to admit that his achievements in recent years are in large part due to the inspirational leadership of his fellow recently appointed Knight of the Realm, Sir David Brailsford. Sir David, in large part, puts his own success down to the holistic approach he has taken to improving performance – the concept of Marginal Gains. He explained the idea to the BBC during the high point of this summer of success:
“The whole principle came from the idea that if you broke down everything you could think of that goes into riding a bike, and then improved it by 1%, you will get a significant increase when you put them all together.”
Since the Olympics, people have begun to realise that there is no requirement within the concept of Marginal Gains to have spokes, wheels or a crash helmet, and disciplines unrelated to sport are using it to develop their thinking. Teachers are leading the way in the classroom and business bloggers have also latched on to the concept. Increasingly I have found myself talking about it in the consulting room, and wondering how doctors and their patients could learn from Sir David’s idea.
Health problems often leave people facing huge, seemingly insurmountable challenges. How can I get a good night’s sleep? What can I do about my weight? How do I stop my teenager shouting all the time? The success of medical treatments for simple, single cause health problems can often lead to both doctors and patients searching by default for that elusive single solution when faced with more complex issues – which leads to frustration and demoralisation when the problem remains unmoved by this approach.
Sleep difficulties are a good example. Losing sleep night after night can be so debilitating that the prospect of a single, simple solution is understandably very attractive – which must explain why the idea of a sleeping tablet is so seductive for both patients and doctors. The patient’s motivation to reach for a quick fix that might guarantee a full night’s sleep is perhaps more noble than the doctor’s temptation to resort to a tablet in order to bring a rapid conclusion to the consultation, but both are equally understandable when other solutions seem to offer less hope of a cure. The siren call of a sleeping tablet, however, is often less effective even in the short-term than we might expect, and brings with it the very real dangers of tolerance and dependence.
I might suggest that an insomniac tries a warm bath before going to bed, or keeps the room well ventilated at night, to which I will often receive the ‘done that, been there’ response, or the raised eyebrows of someone who really can’t see how that would help, and thinks I am trying to fob them off. The problem is that we often evaluate health solutions in a linear fashion – an approach that goes: ‘If this doesn’t work, try that’ as we work through one solution after another until we hit the jackpot. There are merits to this when it comes to some aspects of medicine – like using medication or arranging investigations where to try several things at once could be hazardous, but there are many health issues that could benefit from a more holistic way of thinking, both by doctors and patients.
There is nothing new to the concept of holistic health care, but this is often in the context of teaching doctors how to think holistically about their patients, as is enshrined in the GP curriculum for trainee GPs. What we may have neglected to do, however, is to find ways of helping patients how to think holistically about themselves. I wonder if there is an opportunity within health to use the concept of Marginal Gains, and its current high profile in the public consciousness due to the success of the British Cycling team, in order to encourage a different approach to solving health problems.
If having a hot bath before bed only gives a 1% extra chance of sleeping well, what would that mean if it was combined with a 1% improvement by having the right pillow? A similar gain might be achieved by a cup of hot chocolate, a well-ventilated bedroom, a ‘stimulation curfew’ after a certain time in the evening or going caffeine free. How many more marginal gains could we think of? Relaxation tapes, getting enough exercise, and eating earlier in the evening could all make their contribution. If they added together they could really start to make a difference – and even one good night’s sleep could reduce the dread of going to bed by a further 1%, bringing its own marginal gain in a virtuous cycle of improvement. Where we apply marginal gains we need to expect only marginal improvements – which will mean we will be less inclined to lose heart and give up when we don’t see instant results.
We could apply the same principles to many other health problems – where are the marginal gains for improving your relationship with your teenage children for instance? What small changes could start to add together in your life-long battle with your weight? What minor adjustments could you start to make to reduce the risk of burnout at work? It’s not glamorous, sexy medicine, but all too often the glamour in medicine turns out to be a mirage that lacks substance, or even does harm. In the gritty reality of the lives of real people maybe the hard, but achievable, graft of looking for marginal gains is a more honest and worthwhile approach to making a difference in health problems. And best of all, not only do you not need to become an Olympic athlete like Sir Bradley to apply start to think this way – you don’t even have to grow sideburns!
I’m sure I have more thinking to do on this one – more working it out in practice with my patients…expect more blogs to follow!