Tag Archives: communication

We have to be part of the solution because we are part of the problem

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She blinked at me expectantly. Her companion sat in the corner of the room, arms folded staring at the floor. She glanced at him side ways and then said in a loud whisper

We are here about that business last week. You know.

I didn’t know. So I frantically searched through the notes. The man in question had been seen here several times recently for various dressings. Nothing to say how he had been injured or the nature of the wound. At that point she lost it.

I don’t like talking about it in front of him! Because of his you know……well I told the doctor everything a couple of weeks ago. We need a report for the police and a referral for counselling.

I was mystified. The cryptic notes mentioned an injury to the arm and the application of various dressings but nothing about a bashing. She would have to see ‘the other doctor’ for the report. He was on holiday and not expected back for 10 days. Neither of us was satisfied. The next patient didn’t help matters. She had been pushed to the ground at the railway station and injured her wrist. She had been to the Emergency Department a couple of days ago and had been sent to the practice for an X-ray report. I assumed that someone had seen the X-rays and that she hadn’t been discharged with a bony injury. But there was no note from the Emergency doctor, hand written or otherwise and I now had to spend the next 20 minutes listening to musak while the ward clerk searched for a copy of the report and faxed it to me. In any other industry this waste of time would be tweeted as an example of bad service.

Meanwhile we are spending millions of dollars in search of electronic records that will somehow transform continuity of care. The assumption is that given such a record a doctor will document the circumstances in which she has come to reviewing a patient repeatedly or that the emergency department will reliably record why a patient was fit to be discharged. All of this is possible now if only doctors will plan for when the patient turns up when they are on a day off or choose to go to another provider. Hours can be saved each day, millions of dollars can be redeployed to make a system that already serves us well even better.

Assuming the technical challenge of a personal electronic record can be overcome the question is whether such a record will deliver its promise given that not all who work in healthcare are committed to treating the patient as they would wish to be treated themselves. There is no doubt that the free flow of information will help improve healthcare provision however the most valuable data that helps us serve people (history and examination) have to be documented by a human rather than a machine. Innovation should start with a change in the mindset of those who work in an industry. Are you confident that no one you served today would have to have their problems reassessed if you didn’t show up for work tomorrow? If so then we will be on the way to better outcomes overnight.

It’s also hoped the new system will reduce the high rate of medical errors (18%) that occur from inadequate patient information, reduce unnecessary hospital admissions, and save doctors from collecting a full medical history each time they see a new patient. The conversation

Picture by Ben Hussman

 

Your idea could save lives

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You don’t have to see the same doctor twice. In fact you don’t even have to go to the same practice. Come to think of it you don’t even have to go to a practice. In many countries including where I work you can dial-a-doc. He or she will turn up Uber taxi style. All you have to do is make the call. There is a cost of course. That’s the whole point. But is medicine a special case? Choice is a good thing but is there a down side to the commercialisation of health care?

Suppose you experience some worrisome condition. Something that isn’t painful but shouldn’t be ignored. Let’s say you notice blood in your pee. You might go to a doctor eventually because you, quite rightly, decide you need to find out what’s causing it. You go to the first doctor who can see you. It might not be the one you’ve seen before and if you are worried enough you might even go across town to someone who can ‘fit you in today’. The doctor might order a test or two. Possibly ask you to provide  sample of your urine, perhaps organise some blood tests and may be recommend a scan. The next day the blood is not so obvious and you think there is no need for all this fuss. Either that or you have the tests and they come back negative or you decide that there is no need to make another appointment with the doctor when the blood seems to have disappeared. You breathe a sigh of relief and leave it there. No need to worry. But of course there is. Painless frank haematuria warrants thorough investigation.

Understand, however, that hematuria may be intermittent in patients with significant urologic disease and a repeat urinalysis should be obtained if the clinical suspicion is present. American Urological Association.

If you are a doctor reading this:

  • How does your practice deal with the possibility that people may fail to follow up positive test results?
  • What is your policy for people who have negative test results in the context of significant clinical signs or symptoms?
  • How do you take into account the possibility that a patient may fail to attend for investigations for reasons various?

In some countries it is easier to track people who fail to turn up or return after tests. In other countries it is up to the practice to have a fail-safe mechanism. In healthcare, occasionally, the ‘customer’ falls between the cracks and the consequences can be a delayed diagnosis or worse. First and foremost  it requires the service provider to know the circumstances in which it is prudent to go the extra mile. If you work in a place where it may be possible that people might be harmed by the way they use healthcare services what are the circumstances in which you take more precautions? What do those precautions look like? It might be that your approach could scale to protect more people who wish to exercise choice.

Picture by Mark Wilkie

Are doctors OK with being fallible?

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Every doctor’s nightmare

  • Patient presents to doctor looking reasonably well one day.
  • Doctor fails to make the correct diagnosis of some dreadful disease.
  • Bad outcome the following day.

It starts in medical school. Student’s, especially those who are used to giving the right answer, may feel unworthy if they didn’t ask the right question, didn’t examine under the drapes or didn’t order the right test. How mentors handle receiving the ‘wrong’ answer will make a huge impact on whether the student will cope with mistakes in future.

In reality patients rarely present as described in textbooks. Biology is not a mathematical science. People may not be good witnesses to their own illness. There are four presentations that are troublesome in relation to people with significant pathology:

In these circumstances misdiagnoses are possible and, in theory, could result in legal action. Bad outcomes however are rare. So could a doctor survive a lifetime in clinical practice worrying about their fallibility?

How doctors handle a case of someone in each of these four scenarios will depend on the context. Their response might vary depending on:

  • What they know about this person before they presented
  • Who was expressing concern
  • What they say that doesn’t fit with what appears to be wrong
  • How the patient describes what’s happening to them and not just what they say

But more than that it depends on how they practice:

  • Are they able to review the patient soon afterwards?
  • Is there anyone else who can corroborate the patient’s story?
  • If they take shortcuts on the way to making a diagnosis (too little time listening, no examination or too many distractions) .

The consequences of the bad outcome will also vary. They are most likely if the patient or their family don’t believe the doctor cares.

Four things might help:

  1. If the description of the symptoms doesn’t fit with what the doctor can confirm on physical examination, the doctor should think again before dismissing it as benign.
  2. Doctors must have excellent communication skills to practice medicine even if their patients are going to be a sleep most of the time they have contact with them.
  3. Doctors should anticipate being wrong at some point in their career and have a strategy for how to handle that scenario.
  4. Clinicians must be aware of the circumstances in which they are more likely to get it wrong and have contingencies in place.

The other lesson that is seldom taught is the harm that is done because of an injudicious use of tests in search of the needle in the haystack. But that’s another story.

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In healthcare better right than fast

365651675_f53581b7f6_zIt may be tempting to dream about being presented with a list of options, preferably as colour pictures. Standing in a very short queue or better still ordering by text and minutes later collecting the order (or have it delivered) complete with a discount coupon for the next visit. You’ve heard the words:

Have a nice day

This MO has been highly successful for selling things that we have now come to realise are harmful. The young lady at the fast food counter doesn’t have to care:

  • If you’ve been there before.
  • What you expect from the product (other than not to be poisoned any time in the next 24 hours).
  • If you can afford it (as long as you pay up today).
  • If you know and understand what you are about to eat.
  • Even if you enjoy the product as long as it complies with the description on the menu.

She is paid a wage and all she wants is to get through her shift and go home.

Joe (not his real name, nor any of the details below), whom I had never seen before, turned up one day and before he sat down starting fumbling through his wallet.

Won’t keep you long doctor. My own doctor is off sick, so I thought I’d pop in here.

He produced a business card from an alternative health practitioner. I noticed that he struggled to take the card out of his wallet.

I just need a letter of referral to this place

Apparently ‘this place’ won’t see patients without a ‘referral’ from a doctor. It could all have been over in less than five minutes. The letter might have said:

Thank you for seeing this man who has asked to be referred to your clinic.

It’s highly unlikely that anyone would have cared what it said as long as it was on a doctor’s letterhead. I could have collected my fee and moved to the next patient. But that’s not how I think it works. I coaxed Joe to sit down. He blinked in surprise. Was I really going to waste time when he just wanted a referral? Turns out he was a widower. He lived with his daughter. He moved to Australia 40 years ago. He was a motor mechanic until he retired and now in his late seventies he spent much of the day pottering in the garden.

That’s the problem doctor. I can’t do any weeding. My shoulders are killing me.

He described severe shoulder stiffness in the morning so much so that he occasionally asked his grandson to help him dress. The stiffness improved in the course of the day but his upper arms were still tender. He had lost weight recently but his own doctor didn’t seem too concerned. No headaches and his jaws didn’t hurt when he was eating. I couldn’t find anything wrong on examining him other than tender upper arm muscles. I had a hunch I knew what was wrong with Joe. I sent him for a blood test and arranged to see him the next day. If I was right I could fix this relatively quickly. Joe was nonplussed.

Thank you doctor. I really don’t know what’s wrong with me but my own doctor says it’s a trapped nerve and should get better. I’m in agony and the painkillers aren’t helping. But these guys at this clinic said they needed a letter before I could see them. So that’s what I was after. I will definitely come and see you again.

Joe was a frail old man, impeccably dressed with a politeness that is typical of his generation. He would have accepted anything and been grateful for it. Joe deserves the best and that doesn’t mean getting him in and out the door quickly with an insincere ‘have a nice day’. Why are colleagues encouraged to behave in this way? MacMedicine is not what the taxpayer ordered. Joe didn’t know what he needed other than pain relief. That’s not the same as being hungry and wanting a burger.

Picture by Brian Wallace

Do you know if you stand in the way of your own success?

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Whose is the voice that helps you decide? Whose is the voice you listen to always? For you there is only ever one person in the room even though the room may be packed. In the end it is your own voice that will determine the outcome because without your input a team will only achieve partial victory or worse.

What is your self-talk?

This is dreadful. It’s a catastrophe. A disaster. We’ll never achieve this. It won’t work. It’s all too hard. We don’t have time. We can’t. We won’t. It’s always like this. What does he really want? We are going to fail.

Listen carefully to your prophecy. Because if you think you can or if you think you can’t- you will be right.

Catastrophe, Disaster, Never, won’t, can’t, don’t, always.

To dramatically improve the prospects for success revise this language. That doesn’t mean becoming a Pollyanna. Here’s an alternative dialogue

This is interesting. It’s a challenge. It’s a small hiccup. It’s an opportunity. What can we learn from this? How can I contribute? Can we make this better? Can we help this become a victory for everyone?

If you can’t change what you are saying to yourself at work then you have to ask three questions:

  • Why am I here?
  • Have I said this before?
  • Am I the problem?

If your self-talk is negative then the chances are that you are neither fulfilled nor satisfied with your role on this team. Your duty is to find out why and fix it or find an alternative place to be where your skills will bring you joy. Ultimately you are responsible for you. A free person’s happiness can never depend on the actions of others. If you don’t feel you fit where you work and decide to quit your colleagues may be disappointed. But they will also respect you for your insight.

Tomorrow you should indicate that you are on-board by voicing the alternative dialogue. Because sooner or later someone will over hear your negative self-talk (it’s not as private as you think) and you will find yourself removed from a seat at the table either figuratively or physically. In healthcare there is no room for those who are not fully committed to improving outcomes. The best place to begin to improve outcomes for patients is nurturing a can-do attitude. It costs nothing to make this change if required. Tony Teegarden offers a helpful short presentation on this issue.

Picture by Kevin O’Mara

Lead your team or leave

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It is tempting to think that all solutions to your team’s problems, all efforts to enhance your productivity can be imported from some wise expert. You can’t please everyone. But the chance of pleasing your patients or clients becomes drastically reduced if you can’t work as a team. The insidious and toxic nature of some workplace disagreements can easily overturn any attempt to improve the quality of your services. No amount of innovation or advertising will compensate for the team’s habit of sabotaging it’s own efforts especially when person X in this department does not like person Y in that department.

If you need a survey to gauge if there are effective working relationship where you work then you have failed and need to spend more time with your people. If, knowing this as a leader you have not tackled this matter head on then you need to consider your own position.

It takes a great deal of courage to stand up to your enemies, but a great deal more to stand up to your friends. Albus Dumbledore

There is no easy way to remedy some situations. Years of resentment can spill over into acts of guerrilla warfare. Everyone will know why and many will chose to ignore the elephant in the room. This one was promoted, that one was not, this one gets to go to conferences, that one does not. The list is endless. The real issue is that their colleagues tolerate this behaviour. Perhaps because they depend on both for something that lets them get on with their day. There lies your real problem. While they may complain about ‘things not being done, or done properly’, they will not see that they are complicit in this dreadful set of circumstances. In this situation neither individual can continue to remain on board. Both have demonstrated that in their opinion their needs must come before the needs of those they serve. Your job as leader is to pave the way for their exit. Here’s Dumbledore again:

We must all face the choice between what is right and what is easy.

Your next task is to work out why your colleagues tolerated the situation and why you didn’t spot this coming until now.

Picture by Craig Sunter

Yet more reasons GPs should not be distracted by pay for performance

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There is no doubt that doctors make mistakes. Mostly people forgive them, the charitable view is that it’s because people recognise that their doctors are human and by and large are trying to do a good job. The issue becomes most problematic when the error might cause a delay in the diagnosis of a condition that is best treated sooner rather than later. And especially when the red flag symptoms of that condition are well documented.

Late in 2014 Devesh Oberoi interviewed men who had presented to a specialist late with symptoms that were later diagnosed as cancer. One of the interviews suggested that the delay might in part be due to a late referral:

I spoke to my GP …that time … and. … I was concerned about the symptoms. I told him that I had seen some blood on my toilet paper and he said … umm … yeah that … since it is fresh blood it could be piles (haemorrhoids) or something. Patient with Rectal carcinoma.

Such delays are widely reported in the literature with some experts calling for better research to establish why the diagnosis of cancer is sometimes late in primary care.

Last week our team published secondary data from an experimental study in which we report that the diagnosis of cancer can be missed even when the presentation is straightforward and there are no distracting issues in the consultation (e.g. co-morbidity, psychiatric illness or social problems). One in eight ‘cases’ presented as short video vignettes to doctors in the study failed to elicit a response that included a referral to a specialist or investigations to establish the diagnosis of cancer. What’s also of concern is that where the management decision was to prescribe something, it was hard to see the benefit. In some cases it might even have resulted in harm. Where the decision was to investigate, the indications for some of the investigations were not immediately apparent. Delays may also have occurred in those investigated if the findings were negative or misleading.

None of this is new. Numerous audits have established similar patterns including one we published in 2004 in which three reasons were given for a failure to recognise patterns of cancer:

  • A failure to consider the diagnosis of cancer. ‘Blinkered’ approach in assessing patient.
  • Inappropriate or incomplete investigation.
  • False-negative investigations.

Despite such findings some policy makers think that it is appropriate to pay GPs to focus more on preventive health; to drive payment structures to reflect this public health agenda and distract doctors at the front line of the health service from their core business, namely giving a patient, who consults very briefly, their undivided attention. Doctors need to reflect when they have failed in someway to deliver a satisfactory outcome especially in cases of life threatening illness. That requires a renewal of the commitment to the process of history taking and examination and to updating the skills to make the diagnosis of conditions that are best treated ASAP. When done properly this is time consuming. When doctors are otherwise incentivised to either collect data or tick boxes the result can be less than satisfactory. That it may be already unsatisfactory even before we are driven to adopt practices for which there is very little proven benefit should lead to a rethink.

In relation to pay for performance the King’s Fund reported in 2010:

What evidence does exist suggests that significant improvements have been made in some areas – particularly for diseases such as diabetes, heart failure and chronic obstructive pulmonary disease –but less progress has been made for depression, dementia and arthritis, and these require a more collaborative care model for a higher quality of care to be achieved.

Alternatively it may be that what we can’t afford is to pay GPs to do better at something at the cost of deskilling them in other aspects of their work.

Picture by David Goehring

Indication of fundamental problems where you work

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Patient feedback surveys are fashionable. Every healthcare organisation feels the need to do them; hardly anyone does anything in response to the feedback unless it comes with the threat of a formal complaint. Yet we spend countless hours designing and administering the surveys so that someone can tick a box to say the job was done as per their Key Performance Indicators (KPI). I have to agree with others who have said similar things.

People who use the health service range from those who work in the service to those who have never been ill before. They may speak perfect English or require a translator. They may have a PhD or never have been to school. They may have come to collect a prescription or require cardiac surgery. They are about as different a group as it is possible to be.

If you really want to know what your patients /clients/ customers think of the service they received. Do one of the following:

  1. Ask the front line staff, not those who might be criticised if the feedback is bad, but the staff that sees that person before and after they have been served. I’ve mentioned them before.
  2. Sit in the waiting room and listen to those waiting talking among themselves.

But before you find out what the people you serve think, consider what they need and how you might respond if that need is not met. Do you have the wherewithal to fix what is most problematic where you work?  Where are the bottlenecks? What is in short supply? What leads to unhappy customers? Do you really want to know or by asking what you already know are you simply adding insult to injury? Why not ask instead how the customer would change the experience? Are you then willing to admit to the shortages in what is available? Are you willing to tell them that one of your staff is not coping with his /her job and letting the side down? Are you willing to say that your organisation is not willing to invest in order to change the experience for that customer? Before you commit to finding out what the patient thinks ask yourself:

  1. What do I already know that isn’t working?
  2. Why haven’t we done something about it yet?

If you want to know what your patients think and anything they say suggests a serious deficit, of which you as a senior stakeholder in that organisation were unaware, then you should be alert to the fact that you have not been keeping your eye on the ball.

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How you might stumble during a marathon medical career

299398986_994a9e9feb_zMedicine is an art. Sure there is science involved but in essence it is an art because science alone does not guarantee good outcomes in healthcare. If you fail to communicate with the patient, no amount of science is going to make a difference if the patient does not choose to act on your advice. That means the neither doctor nor patient can be removed from the outcomes equation. The needs and wants of the physician have as much of a bearing on the outcome as anything else in the mix. How we feel as health practitioners, how we are perceived, our biases and shortcomings are worthy of close attention and may be a great place to focus efforts to innovate in healthcare. Here are ten videos, reports or papers that identify the pitfalls.

Workloads can make it difficult for some doctors to perform optimally.

We may not be communicating effectively.

4 out of 5 doctors don’t get enough exercise.

Nearly 60 per cent of doctors may be overweight or obese.

Some doctors might lose empathy in the course of their training.

Burnout is a real risk in medicine.

While obesity may be increasing some doctors can harbour prejudice.

Dangerous drugs may be over prescribed .

The evidence doctors adopt in a specific case may be flawed.

Some doctors don’t explain risk well

Picture by Giulio Volo

Ten things you should know about people who changed the face of healthcare

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They noticed things

They wanted to solve a problem

They were charismatic

They were risk takers

They were resourceful

They were tenacious

They were considered crazy

They were great communicators

They weren’t all doctors

Their ideas weren’t instantly adopted

Alexander Fleming noticed that mould had grown on the culture plates in his untidy laboratory, the rest is history. Edward Jenner wanted to rid the world of small pox, and did. Atul Gawande challenges the conventional wisdom and is an excellent communicator. Barry Marshall infected himself with Helicobacter Pylori. Timothy Presto designed child incubators from car parts. Florence Nightingale faced repeated opposition throughout her life. Ignaz Semmelweis was committed to a psychiatric institution because he promoted hand washing by doctors to reduce the risk of infection during childbirth. Anthony Atala gives a TED talk on regenerative medicine. Kiran Mazumdar Shaw, a zoologist, leads the largest biotech company in India, she was consider unfit to study medicine. William Harvey’s ideas on the circulatory system were not widely accepted by the medical profession. Two things are true of such people today, they are determined and they don’t all personally benefit from what they do for us.

Picture by U.S. Department of defence