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Healthcare will do better when Joe accepts that he is in trouble

There is nothing especially remarkable about Joe. At 49 he works as an administrator for a company in the city. He walks to work from the station having taken a train from the suburbs. He weighs 78Kgs and is 170cm tall (BMI 27). To stay that way he needs to consume no more than 1900 calories per day. He has a bowl of cereal for breakfast, a  panini sandwich for lunch and a home cooked dinner with a glass of wine. That’s about 1900 calories. Joe isn’t inspired at work but he earns a reasonable living. They bought a new car last year and Joe is tied to a hefty car loan, his wife Bridgette gave up her job as a nurse when they had their children ten years ago. They now have three children under 10. The youngest has asthma but he seems so much better since he was put on a steroid inhaler. Joe and Bridgette have had their ups and downs. They worry about money.  Mostly they work hard and are doing their best to raise their boys. At the weekend Joe goes to a football match but since his mid-twenties doesn’t play any sport. With the kids doing sport and music lessons there isn’t time. Joe has never smoked a cigarette.

During the week Joe goes for coffee with his colleagues at 10.30 every morning. He also enjoys a small muffin. Then he has a banana at 2 pm and a couple of small biscuits while he is watching television in the evening. He doesn’t think too much about it. He is consuming 500 calories more than he needs per day and in 6 months when Joe is 50 his BMI will put him over the line into obesity.

Joe rarely sees his doctor. In winter he occasionally gets a chesty cough and makes an emergency appointment with any doctor who is available because Bridgette says he might need an antibiotic. Once or twice since his thirties, a doctor checked his blood pressure and it is always normal. He had a medical as part of his mortgage application when he was 35 and everything was ‘normal’. Most of Joe’s friends are heavier than Joe and he still thinks of himself as ‘healthy’.  After all, he walks to work, has a healthy banana as a snack in the afternoon and he makes sure his evening meal is a healthy one.

Joe doesn’t see any problem. There is really time to talk to the doctor about why he likes that large cup of coffee and the muffin or to say that he is stuck in a dead-end job with a mortgage to pay and children to raise. Joe doesn’t admit that he is bored. The coffee break is the highlight of an otherwise long day of drudgery.  Joe’s trousers are getting a little bit tighter. Bridgette has noticed but his friends are all so much bigger and Joe doesn’t think she’s worried about it. She herself has gone up three dress sizes since the children were born so she doesn’t tease him too much. Besides, he just got a bigger size recently and he still thinks he looks good.

Joe is at risk of becoming a statistic in the epidemic of Globesity. All that stands in the way is the ingenuity and interest of those who care to find a way to help Joe turn things around.

Picture by Khuroshvili Ilya

Deploy rituals and be present in practice

Your next patient or client will want you to:

  • Smile (23.2%);
  • Be friendly, personable, polite, respectful (19.2%);
  • Be attentive and calm, make the patient feel like a priority (16.4%);
  • and make eye contact (13.0%).

(An Evidence-Based Perspective on Greetings in Medical Encounters- Arch Intern Med)

Showing up this way for every patient has to be a habit. Essentially you need to be “present or “mindful”. The issue of mindful practice has also been the focus of academic interest:

In 2008, the authors conducted in-depth, semistructured interviews with primary care physicians .. mindfulness skills improved the participants’ ability to be attentive and listen deeply to patients’ concerns, respond to patients more effectively, and develop adaptive reserve. Academic Medicine.

To make a habit of showing up in this way it may be worth considering deploying a ritual.

Hurdler Michelle Jenneke has her famous warm-up dance, long-jumper Fabrice Lapierre competes with a gold chain in his mouth, Usain Bolt points to the sky before breaking yet another world record, while Michael Phelps blasts Eminem to fire him up before hitting the pool. My body+soul

Consider the distinction between a habit and a ritual:

Habit

An acquired behavior pattern regularly followed until it has become almost involuntary: the habit of looking both ways before crossing the street.

Ritual

An act or series of acts regularly repeated in a set precise manner.

Rituals support habit and focus. Rituals support you to repeat habits and create new behaviour patterns over time. Daily rituals can support you to make new habits stick. You can move from doing something that might take a lot of effort, to it becoming almost automatic or done unconsciously. Mary- Ann Webb

Establishing a ritual can be the prelude to a habit.

The term ritual refers to a type of expressive, symbolic activity constructed of multiple behaviors that occur in a fixed, episodic sequence, and that tend to be repeated over time. Ritual behavior is dramatically scripted and acted out and is performed with formality, seriousness, and inner intensity. Rook, Dennis W. (1985), “The Ritual Dimension of Consumer Behavior,” Journal of Consumer Research, 12 (December), 251-264.

The pathway goes from behaviour, to ritual and then to habit. Charles Duhigg  spoke of the ‘habit loop’.This loop has three components:

  • The Cue: This is the trigger that tells your brain to go into automatic mode and which habit to use.
  • The Routine: This is the behaviour itself. This can be an emotional, mental or physical behaviour.
  • The Reward: This is the reason you’re motivated to do the behaviour and a way your brain can encode the behaviour in your neurology, if it’s a repeated behaviour.

All habitual cues fit into one of five categories: location, time, emotional state, other people, and immediately preceding action. An immediately preceding action is the most stable cue because it’s triggered by an existing habit. So to build a new habit match it with an old habitual cue.

B.J. Fogg, asks:

“What does this behaviour most naturally follow?”

To implement this technique, decide on an existing habit and complete the following sentence:

“After I [EXISTING HABIT] I will immediately [NEW HABIT]”.

Therefore to make a habit of being present for the next patient the “cue” is when you terminate the previous consultation.

The “routine” or ritual: At the end of one consult you might close the notes, tidy your desk and wash your hands. Metaphorically you also wash the previous consult out of your mind. This has physical and psychological components.

Then when you are happy that the previous consult no longer lingers in your thoughts proceed to the next consult, stand in a specific spot, call the patient, introduce yourself and smile. Shake the patient’s hand. Walk with them to the consulting room. Don’t start the consult until you make eye contact. How the patient responds to such a greeting is the “reward“.

Picture by Rob Bertholf

She’s furious but what does your reaction say about you?

Where there is anger there is fear. Health issues are frightening. They pose a real and sometimes imminent threat to our basic needs. Sometimes even a threat to life itself.

There is a strong relationship between anger and fear. Anger is the fight part of the age-old fight-or-flight response to threat. Most animals respond to threat by either fighting or fleeing. But, we don’t always have the option to fight what threatens us. Instead, we have anger. Psychology 

Anger is an emotion that doctors encounter often. Unfortunately they may also find themselves getting annoyed at that angry patient who has been kept waiting, that angry mother who thinks her child’s test results should be available today, that angry young man who says he will be fired unless he gets a backdated certificate, that angry Boomer who is convinced her cancer can be cured if only this doctor arranges an appointment for coffee enemas.

Doctors can choose how to respond. How to interpret that emotion. Doctors too can be angry. Angry about having to work in a healthcare system where one sector doesn’t coordinate with another, a payment schedule that doesn’t reward for time spent waiting on the phone, a system where people come with undifferentiated problems and can’t give a clear history of their symptoms. They can choose whether or not to express this emotion during a heated conversation.

At the end of the day, doctors can go home- for the mother of the child with cystic fibrosis, the young man with the heartless employer, the old lady with bowel cancer there is no such escape. A response that may help is to acknowledge the anger but address the fear. It may even reduce the frequency with which people might see the doctor standing in the way of something they think will immediately reduce the threat. It may also help when doctors are angry that those who are the target of that anger confront the issues rather engage in recrimination.

Picture by Petras Gaglias 

Can the patient relay what was done for them?

A perennial source of dissatisfaction in healthcare (as documented here and here) is the poor flow of information from one sector to another. ‘Joe’ (speaking here– video from BMJ open) couldn’t tell me, his doctor, anything helpful about what had been done while he had been in hospital. That means we have to schedule several appointments to try to unpack it all. He was an in-patient for two weeks and someone had decided one Thursday morning that it was time for him to go home. It wasn’t really clear to Joe or to me why that particular morning or what was to happen when he got home other than that he should contact his ‘local GP’. A letter would follow some time in the future. There may have been good or bad reasons for sending him home. We could only guess what was in the mind of the person who made the decision:

We needed the bed. Joe was fine. His observations were normal, he was ambulant his wife was happy to take him home.

But of course Joe comes home with lots of questions, which I now struggle to answer without making phone calls to track down the busy medical team. The problem is articulated by several ‘stakeholders’ members of the ‘multidisciplinary team’ on the ward none of whom feel they own the problem of telling this man what he needs to know. There is only one constant in this story- Joe. If Joe can collect the information we need during the course of his hospital stay we might begin to improve the outcome:

In addition to increasing the burden on GPs, it engenders a need for a subsequent GP appointment; it limits GP capacity to respond to patient concerns and queries, at least on one occasion; it may result in a re-referral to the specialist; and it increases GP dissatisfaction with the care provided to the patient by the hospital. BMJ

The problem is Joe often does not know what he needs to know by the end of his hospital stay. It isn’t impossible to work out how to trigger questions for Joe to ask throughout his hospitalisation. What is far more difficult is to motivate every hospital ward and every discipline in a team to address this challenge consistently. It is ‘easier’ to nudge one individual than enlist the cooperation of the dozens of health professionals who will come into contact with Joe. Making people active in healthcare processes has achieved results before:

Influence at Work, a training and consultancy company that Cialdini founded, worked with the United Kingdom’s National Health Service (NHS) in a set of studies aimed at reducing the number of patients who fail to show up for medical appointments. They did this by simply making patients more involved in the appointment-making process, such as asking the patient to write down the details of the appointment themselves rather than simply receiving an appointment card. Sleek

Picture by Michael Coghlan

Doctors need better tools to help people recognise danger

Doctors see it all the time. The fifty-year-old with a BMI of 28, the teenager who is developing a taste for cigarettes, the twenty-year-old who now binge drinks every weekend, the soon-to-be-mum who is ‘eating for two’. Small choices that may become habits and habits that lead to consequences. Where I have worked the average consultation lasts fifteen minutes. In that time we address whatever symptoms or problems have been tabled. The list may be long. Occasionally it’s possible during the conversation to bring up a subject that I’m worried about. The problem is the patient may not be worried about that issue.

Afterall doctor I don’t drink any more than my mates do or I don’t really eat that much.

What’s needed are tools that help frame the issue from the perspective of the patient, not the practitioner. Tools that help us address public health priorities that speak TO that person, not AT everyone. Before making any changes the person needs to agree that their choices might blight their hopes for the future. These are not inconsiderable challenges given the gloomy predictions for the future.

At the other end of the malnutrition scale, obesity is one of today’s most blatantly visible – yet most neglected – public health problems. Paradoxically coexisting with undernutrition, an escalating global epidemic of overweight and obesity – “globesity” – is taking over many parts of the world. If immediate action is not taken, millions will suffer from an array of serious health disorders. The World Health Organisation

Diabetes is likely to cement its place as the fastest growing epidemic in history. The Medical Journal of Australia

In addition, youthful drinking is associated with an increased likelihood of developing alcohol abuse or dependence later in life. Early intervention is essential to prevent the development of serious alcohol problems among youth between the ages of 12 and 20. NIH

Picture by Marcelo Nava

A small act that never goes unnoticed

Much can be said about the way we greet people. However nothing is more telling than the memory of the last time we were greeted when we were in need. Those who have travelled overseas know exactly what it’s like to be in an alien environment, where things are unfamiliar and a little threatening. Like pulling up at an immigration check point, passport in one hand and tired kids at your feet.

The one that sticks in mind was the experience at Italian passport control decades ago when we arrived in Rome with our then very young brood. The smartly dressed official eyed us all in turn from behind the tall counter, then made to count our children, smiled broadly at the parents, nodding as if in approval of the size of the family and waved us through. A charming start to the holiday. That was fifteen years ago and we still  talk about it.

Last week in Bali the receptionists stood up every time a guest passed the desk, bowed with hands clasped to heart smiling brightly. It set the tone for the whole day.

My favourite greeting is Malay.

“The traditional Malay handshake, known as ‘salam’, involves both parties extending their arms and clasping each other’s hand in a brief but firm grip,” advised Lew Wai Gin, the guest liaison manager at Tanjong Jara Resort. “The man can then offer either one or both hands, grasp his friend’s hands, and then bring a hand back to his chest, which means: ‘I greet you from my heart’.” Grantourismo

Having experienced the impact it has when I travel for work in that country it persuaded me that how we greet each other matters more than we might realise. It’s a small choice which costs nothing. In medicine the provider has the opportunity to set the tone for what follows which can be to agree or disagree, to give good or bad news. Whatever follows people remember the way they were made to feel when they were most vulnerable. They might even write about it decades later!

Picture by Ben Smith

Are we are obstructing the doctor with gadgets?

Despite billions of dollars of investment in technology the results in healthcare are disappointing.

Information Technology (IT) surrounds us every day. IT products and services from smart phones and search engines to online banking and stock trading have been transformative. However, IT has made only modest and less than disruptive inroads into healthcare. Nicolas Terry (2013)

This was predicted in a prophetic article by Gregory Hackett (1990) when he concluded that:

The primary reason is that technology alone does not determine corporate performance and profitability. Employee skills and capabilities play a large role, as do the structures of day-to-day operations and the company’s policies and procedures. In addition the organisation must be flexible enough to respond to an increasingly dynamic environment. And products must meet customer requirements. Investment in Technology-The Service Sector Sinkhole? SMR Forum Service

However, there are still those who seem enamoured of machines:

Rapid growth of robotic industry is leading to novel applications in medical field. Evolution of new terminologies like tele-presence, tele-medicine, tele-consultation, tele-diagnosis, telerounding, tele-health centers, tele-doctors, tele-nurses are overwhelming and required to be readdressed.  Iftikhar

That way leads to a nightmarish world in which we push vulnerable people onto an assembly line and healthcare looks like this but also includes the dehumanising impact of machines:

….. hospitalists care for sick inpatients and are charged with rapid throughput by their administrative overlords; nocturnists do this job as well — but at night; intensivists take over when work in a critical care unit is required; transitionalists step in when the patient is ready to be moved on to rehabilitation (physiatrists) or into a skilled nursing facility (SNFists). Almost at the end of the line are the post-acutists in their long-term care facilities and the palliativists — tasked with keeping the patient home and comfortable — while ending the costly cycle of transfers back and forth to the hospital. Finally, as the physician-aid-in-dying movement continues to gain support, there will be suicidalists adept at handling the paperwork, negotiating the legal shoals and mixing the necessary ingredients when the time comes. Jerald Winakur- The Washington Post

Technology now impinges on every interaction- for better and for worse:

There were the many quiet voices who urged circumspection as long ago as 1990:

Diagnosis is a complex process more involved than producing a nosological label for a set of patient descriptors. Efficient and ethical diagnostic evaluation requires a broad knowledge of people and of disease states. The state of the art in computer-based medical diagnosis does not support the optimistic claim that people can now be replaced by more reliable diagnostic programs. Miller

One could not argue against technology as a tool but the art of medicine requires that technology helps the doctor. People are not disordered machines and the promise of better health is not forthcoming as we throw money at machines hoping for greater access, efficiency, and safety. However, there is now mounting evidence that the patient is not responding and it’s time to pause for thought, again.

It’s not that complicated. Healthcare works when the doctor and her patient are on the same page. So to what extent does a gadget or gizmo allow that? Does it help them to:

  1. Work out what’s wrong together?
  2. Make it easier for them to work together?
  3. Make it easier for them to achieve a goal together?

If it becomes a substitute for the doctor it will disappoint. People respond best to human doctors. No ifs or buts. Medical school 101. Doctors also have choices in how they deploy and interact with technology. Turning to face the computer, ordering a test and recommending an app aren’t always the way to the best outcome.

Picture by Guian Bolisay 

Doctors get to choose so much of what matters

You choose what you wear. They own the building, they chose the furniture, they employed the staff, they chose the wallpaper, they decided the policies, they set the opening hours. But whoever ‘they’ are there are only two people in the consultation. You and the patient.

You choose:

  • Your mood today
  • If you shake the patient’s hand
  • If you introduce yourself
  • Where you sit in the room
  • Where you look
  • When you stop talking
  • Whether you examine the patient
  • What you think
  • What you say and how you say it
  • What you do
  • How you terminate the consultation

And the patient chooses whether they like it.

Guess what? You get to choose so much of what matters to the patient. Choose well. You can make a difference. Create a better future for everyone.

Picture by Gilbert Rodriguez

Much of what’s wrong with healthcare is in the consulting room

It’s not that complicated. Not really. So where do you look for pathology? Inspection, palpation, percussion and auscultation. How does it look, how does it feel, how does it sound and what do you hear when you know where to listen closely. I’m talking about healthcare. Take a helicopter ride through your business.

Access

What is the route to your service? Where is the delay? How long do people wait in the waiting room? How do you know? What do you know about the people who use your service even before they are seated in your waiting room?

Greeting

What happens when people call or arrive in person? What message is conveyed?

Welcome we’ll do our best to help you today OR you are lucky we are ‘fitting you in’.

Just stand there- I’m dealing with someone on the phone.

We have no time- go complain to the manager/politician/ bureaucrat-consider yourself drafted to the cause.

Hold the line. We are dealing with something far more important but your call is really important to us so just listen to how good we are as conveyed by our prerecorded message.

Associated with that is what is perceived about your attitude that is not verbalised?

Look at ALL these posters and the many ways you can be helping yourself instead of wasting our time.

People vomit and pee while they wait so the seats have to be cleaned with detergent. Plastic is the best option.

If you want a drink go buy one at a cafe.

We rely on donations for our toys and magazines- we don’t have to provide anything OK? Now if you don’t like the stuff just watch Dr. Phil.

What do you mean you have been waiting a couple of hours? This isn’t McDonalds now take a ticket, sit down, shut up and wait. And turn off your phone so you can hear the old lady at the desk who has an embarrassing problem.

Communication

How long is the meeting with the provider? How does that meeting unfold? What is conveyed during the meeting?

Welcome- I’m so sorry you are not well. Tell me what happened? OR I haven’t got long what do you want exactly, spit it out be quick about it I need to get on with the next guy. Didn’t you see the queue out there?

I’m the important one around here- you are lucky I’ve chosen to be here today. Let me tell you about my holiday, my kids, my new car. It’s fascinating really!

Room 5. Quickly. Never mind my name.

Test/ Referral and Prescription

What action is taken at the consult and are you confident that is the best possible action?

I don’t have time for talk- have this test and take another day off to see me next week.

I don’t have time for you to take off your umpteen layers- go have a scan.

The rep told me this works- I only have to write a script.

If you want to get better take my medicine/advice/ referral or get lost.

What medicine do you want? How do you spell that? Tell me slowly I’m writing it down on your script.

Outcome

What proportion of people takes your advice/medicine/test? How many people stopped smoking? How many were triggered to lose weight? How many are addicted to prescribed medicines? How many were prescribed treatment or tests that were not indicated? Where’s your data? What are your plans for dealing with this?

Team

To what extent can you say that when people transition to another healthcare professional either on site or elsewhere that the relevant information follows them? Is everyone on the same page with the same patient?

All of this matters. All of it. Some of you can fix tomorrow. No need to wait for another round of healthcare reform. No one said it was easy. And whatever their business the best don’t compromise.  A lot of what can be fixed in healthcare takes place behind the closed doors of the consulting room.

Picture by Daniele Oberti

We don’t have to agree but it doesn’t have to end in tears

I told him NO. You don’t need antibiotics you have a virus. Now leave.

This is the rather macho way in which the story of how a patient’s ‘unreasonable’ request was rejected is sometimes recounted. In some cases the law was changed to allow people to access some items much more readily:

In some countries, potent drugs are now losing their efficacy because of unregulated access. The stage is set for disagreement and inevitably it comes when the provider does not have a plan for how to tackle the request that is not in the patient’s best interest or does not address associated risks that patient is taking. Arguments might be even more common were it not for the evidence that healthcare providers sometimes act without assessing the requests fully. This makes matters worse because it raises unreasonable expectations. In one recent study it was reported:

In spite of the requirement that pharmacists sell restricted medicines, shoppers often found it difficult to distinguish pharmacists from other pharmacy staff. Shoppers were able to confirm that a pharmacist was definitely involved in only 46% of visits. In 8.8% of the diclofenac visits, and 10.8% of the visits for vaginal anti-fungals, no counselling was provided. The vaginal anti-fungal visits tended to be more product-focussed than the diclofenac visits. When they purchased diclofenac, most pharmacists asked shoppers if they had, or had had, stomach problems (74.6%) or asthma (65.4%). A minority asked about the symptoms of the vaginal fungal infection which the female shoppers presented with. While most pharmacies recorded patient names, many did so in a way which compromised patient confidentiality. Pharmacy World and Science

Similarly, it has been shown that performance varies in general practice:

In more than one-in-eight cases, the patient was not investigated or referred. Patient management varied significantly by cancer type (p<0.001). For two key reasons, colorectal cancer was the chosen referent category. First, it represents a prevalent type of cancer. Second, in this study, colorectal cancer symptoms were managed in a similar proportion of options—that is, prescription, referral or investigation. Compared with vignettes featuring colorectal cancer participants were less likely to manage breast, bladder, endometrial, and lung cancers with a ‘prescription only’ or ‘referral only’ option. They were less likely to manage prostate cancer with a ‘prescription only’, yet more likely to manage it with a ‘referral with investigation’. With regard to pancreatic and cervical cancers, participants were more likely to manage these with a ‘referral only’ or a ‘referral with investigation’. BMJ open

In summary:

  1. People often present with ideas that are at odds with those of the provider.
  2. The law sometimes enshrines the right to over the counter treatments that may not be indicated or may actually harm people.
  3. Patients are not appropriately assessed in all cases which mean they either acquire things that are not appropriate or denied things that are.

Once the decision is made to say no it isn’t always handled well. This has also been demonstrated in the literature. What has been published suggests that one of the most potent tools in the armory are good consultation skills. The more worrying issue is how this comes as news to some in a profession that pride itself on members’ ability to communicate. The bottom line is that any business that loses the relationship with its clients is heading for the rocks. Every business knows that there are polite ways to reject a customer. Therefore the answer to the question of whether and what to prescribe is a function of the consultation skills taught to every medical graduate. The issue at stake when things go wrong is how well those skills are being exercised. The quote at the top of this post suggests that some doctors need a refresher.

Picture by Jens Karlsson