Tag Archives: communication

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

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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

Work with employers to improve health

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Annual profits confirm whether the staff of a company performed well. Profit margins, and the rate of innovation, closely reflect the health of the people who deliver that success. Employers are, and perhaps always have been, a key partner in the drive to improve the health of the nation. What has become a greater imperative to forge a partnership is the threat to profit margins from the looming spectre of chronic illness in epidemic proportions. Work is a vitally important aspect in most of our lives:

The average working American spends the majority of his or her waking hours on the job. Some of us live and breathe our work. Others of us work to pay our mortgages. Either way, the workplace has become an important source of social capital for millions of Americans – a center of meaning, membership, and mutual support. More than ever, we find our close friends and life partners on the job, we serve our communities through work-organized programs, and we use the office as a forum for democratic deliberation with people different from ourselves. Countless studies show that a workplace with strong social capital enhances workers’ lives and improves the employer’s bottom line.The workplace and social capital.

Similarly in Australia people spend most of their waking time at work. On average 34 hours a week . Sixteen percent of us work more than 50 hours per week. In contrast we spend 6-9 hours  per week doing house work and 6 hours and twenty seven minutes per day asleep. The impact of the working environment on health ranges from physical to psychological and can be both harmful and beneficial. Employers in most developed countries are therefore legally obliged to provide:

  • safe premises
  • safe machinery and materials
  • safe systems of work
  • information, instruction, training and supervision
  • a suitable working environment and facilities.

However there is much more that can be done to optimise the health of employees. The economic argument for this is clear and closely related to the rising incidence of chronic and complex illness among the working population. In 2002 approximately 59 per cent of global death was attributable to chronic, non-communicable diseases and the toll is projected to increase to 66 per cent by 2030.  The other outcomes that should worry employers is the prospect of premature retirement from the workforce.

It was found that individuals who had retired early due to other reasons were significantly less likely to be in income poverty than those retired due to ill health (OR 0.43 95% CI 0.33 to 0.51), and there was no significant difference in the likelihood of being in income poverty between these individuals and those unemployed. Being in the same family as someone who is retired due to illness also significantly increases an individual’s chance of being in income poverty. Schofield et al

A report by the Australian Institute of Health and Welfare in 2009 outlined the consequences of chronic illness and early retirement on the entire Australian economy. It concludes that:

  • People with chronic disease had, on average, 0.48 days off work in the previous fortnight due to their own illness, compared with 0.25 days for those without chronic disease.
  • The annual loss in workforce participation from chronic disease in Australia was around 537,000 person-years of participation in full-time employment, and approximately 47,000 person years of part-time employment.
  • For people participating full-time in the labour force, there was a loss of approximately 367,000 person-years associated with chronic disease, approximately 57,000 person-years in absenteeism associated with chronic disease and 113,000 person-years were lost due to death from chronic disease.
  •  Estimates of loss do not take into account lower performance while at work. Similarly, the effect of loss from participation in the unpaid labour force (carers, parents and volunteers) has not been accounted for. The estimates, therefore, underestimate the loss in workforce participation associated with chronic disease.

Therefore employers who wish to retain an effective workforce, and by corollary their profitability, need to invest in the well being of their workers. This responsibility extends beyond ensuring the physical safety of their workforce. A workforce that is under threat from an ageing population and an alarming incidence of retirement through ill health. If employees spend most of their waking hours at work then the following might concern the employer (click the links for the literature):

I believe health innovators who address these issues in their dealings with industry will discover an open door with massive potential for mutual benefit.

Picture by Vase Petrovski

The bean counters of BoGIn

5085594028_fc5d378a40_zThe bean counters at BoGIn (Bank of Good Intentions) noticed that some people came to the bank to get mortgage advice and others for personal loans. In fact there was a lot of money to be made by persuading people to borrow money. So they decided to make some reforms. A memo was circulated informing staff that customers will only be able to deposit money in the afternoons- it was to be called the ‘deposition clinic’. Similarly customers would only be able to make withdrawals on Wednesday mornings. Additionally this service would be manned by the most junior clerks who must have all their work checked by the bank manager who would also spend the day at meetings reporting his branch’s performance on key performance indicators.

Customers who withdraw their money are not good for business.

Bank tellers were ordered to ask every customer to fill out a form documenting how much they owe other banks. Customers must always do this before tellers can attend to any other reason the customer came to the bank. Forms must be completed with a black pen and the signatures witnessed by two independent adults. Bank tellers would earn a bonus every time a customer takes out a loan and would accrue points towards promotion if the customer takes out a mortgage at 5% above the cheapest rate on the market.

The bank managers and their staff were shocked. How was this to be achieved? However the bean counters pointed out that the shareholders required the staff to be accountable and there was a need to increase profits by at least 25% this year. A percentage agreed by the committee of bean counters advising the shareholders.

But we are doing so well. The bank makes a hefty profit and our customers are among the most satisfied in any industry. We offer a service. We listen to our customers. We try to help our customers achieve great things that keep our economy afloat.

The bean counters were not impressed and threatened to force managers to be recertified every year or lose their right to bonus payments. Many managers have since found alternative employment. Recently the CEO of BoGIn attended her branch to deposit a cheque. She queued for hours before she was first asked to complete a form documenting her debts and given a brochure on mortgages. Then she was informed she could only make deposits in the afternoon so she had to return the next day. The bean counters have been sacked and were last seen at the department of health next door.

Picture by DaMong Man

How to communicate risk and benefit

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The average Australian spends $6 per week on lottery tickets even though the chances of winning the jackpot are 1 in 45million.

For every dollar you spend, you can expect to recover somewhere between 15 and 60 cents, depending on the game and the draw.  The rate of return is essentially the same irrespective of how many times you enter and irrespective of whether you buy a Standard or System ticket, but one thing you can be sure of is that the more you spend, the more you can expect to lose. David Wharton

On the other hand the lifetime risk of developing colorectal cancer is 1:21. Consuming vegetables is known to reduce the risk whereas drinking alcohol is known to increase the risk. On average Australians households spend less than $14 on vegetables but on average more than twice that amount on alcohol. What’s more the uptake of colorectal cancer screening is low.

In healthcare people may not act on risk even when it is appreciable and often overestimate benefit even when it is negligible. In the commercial world advertisers roll up their message in stories in which people imagine winning the lottery (” It could be you”), driving the car (Zoom, Zoom), buying the house (from the people ‘who give a little extra’). And so people spend money when they have no chance of benefit and households are said to be

Awash with debt.

When an adverse event is projected to be years in the future (a stroke or a heart attack) and is described by using the example of what happened to ‘other people’ it does not make an impression. If on top of that what is required to avoid that ‘catastrophe’ is going to take sustained effort (30 minutes of exercise most days of the week), then behaviour change is unlikely. On the other hand you might quickly part with the few coins in your wallet today if it could put millions of dollars in your pocket after the big draw tonight. Four things matter:

1. Are you talking about me? Does that fit with what I already think? Do I see myself clearly in this story?

2. What is this going to cost? And will I notice it straight away?

3. Do I have to keep on paying?

4. When will I get the reward?

The recipe for triggering behaviour change is already been used to great effect. That’s why households are ‘awash with debt’. The call to action is to communicate so that people are more likely to make choices from which they will benefit. Convenience, the hidden cost of ‘benefit now’ is another weakness. People will pay 100s of dollars in extra bank charges to be able to draw their money out of any convenient ATM machine, they will take on huge mortgages over lengthy periods if the monthly repayments seem modest. We already trade our privacy for free access to social media. If in the future it becomes possible to avert a major illness by simply swallowing a pill containing technology that also does things from which someone might profit then we might also relent.

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Effective communication speaks to something people already believe

131417495_81e95b261d_z A doctor who urges a patient to quit smoking ‘to reduce the risk of lung cancer’ may well hear the retort

My grandma smoked until she was 96 and she barely even caught a cold until the day she died in her sleep.

Obstetricians advise women to stop smoking ‘to avoid harming their baby’ may face the rebuttal

My sister is a chain smoker and she gave birth to 3.8kg baby!

General practitioners advise a parent about the dangers of passive smoking may be dismissed with

I never smoke in doors.

Increasing motivation in the hope of changing behaviour is a very hard to achieve. Everyday dozens of men and women will get behind the wheel of a car intoxicated despite dire warnings. Hundreds of informed pregnant women will continue to smoke cigarettes and intelligent teenagers will expose themselves to the sun until their skin peels.

The most effective call to action relates to something people already want. They offer something affordable and speak to something the person already believes. A seductive:

Why have cotton when you can have silk?

In reality not every life time cigarette smoker will develop lung cancer, in fact most won’t.  Not every woman who smokes will have a ‘small for dates’ baby. Not every sun burnt teenager faces the prospect of a malignant melanoma. Unfortunately when people want something, a sun tan, to ride home in their own car after party or to continue a bad habit they chose to believe the facts that support their view. The job of the innovator is to make the messages about less risky life style choices personalised, offer something that seems easily attained and resonate with what that person believes. Each person with whom we wish to communicate speaks a different language and has different ideas, concerns and expectations. We also do well to remember that the choice is theirs to make. We sincerely hope that they are not among the unfortunate few who might suffer the bad outcome that we seek for them to avoid. Just because some smokers don’t develop lung cancer it doesn’t mean that none do.

Picture by Kelly Sue DeConnick

In a call to action timing is everything

Nebulizer Baby

I recall with shame that I had failed to protect our little boy when he scalded his hand while I was running his bath. At that moment the advice to keep toddlers out of the bathroom while a hot tap is running was hardly necessary. Similarly the dentist who advised us that dried fruit can cause dental caries rammed home the message when he announced that our five year old needed fillings.

Health professionals frequently impart information as a call to action:

You are drinking too much. You need to stop smoking. You need to take more exercise. You need a holiday. You are damaging your hearing. You are putting yourself at risk of skin cancer. You need to take the test.

The problem is that the advice is rarely followed. A wonderful paper by McBride, Emmons and Lipkus cited 487 times offers a heuristic model for ‘Teachable Moments’. Events such as: clinic visits, notification of abnormal test results, pregnancy, hospitalization and disease diagnosis. In many cases the impact of a health promotion message delivered in this context is substantial, and far better than any other intervention.

  • Clinical visits for health promotion and acute illness

It is more likely that a parent will stop smoking if their child is attending a clinic for a condition that is exacerbated by passive smoking. Similarly dentists are much more likely to promote successful quit attempts when they advise smokers attending with dental problems.

  • Notification of abnormal test results

It is more likely that people with abnormal spirometry results will quit smoking if advised at the time of receiving their results.

  • Pregnancy

Studies have reported that among those smoked prior to pregnancy 39% quit after becoming pregnant, a rate 8 times that reported among smokers in the general population.

  • Hospitalisation and disease diagnosis

The 12-month follow-up quit rates among hospitalised smokers who received no formal intervention ranges from 15-78%. Reason for hospitalisation has been suggested as an important co-factor in cessation rates. Long-term abstinence rates are higher among cardiac patients and those receiving care for cancers.

The evidence from research is that pregnancy and hospitalisation have the greatest potential as a ‘Teachable Moment’. It seems that the triggering effect of a health promotion message is much more effective given the heightened emotional state and the increased perception of risk and benefit from the suggested action. In addition ‘individuals see greater personal relevance in events that threaten or increase their self-esteem, undermine or enhance feelings of personal control and endanger positive expectations of the future‘. In these circumstances people will invest greater emotional and cognitive effort in achieving the necessary outcome.  It’s not just the message that needs to be considered but the ‘Teachable Moment’ and how that message is to be imparted. The most effective health professionals know how to do this without making a bad situation worse.

Picture by Kristy Faith

See demand in context and respond creatively

9645066390_babd98c3f1_zHello Jill, Oh, I’m sorry I have no appointments to offer you today. the doctors are all fully booked. If your son has a fever try him with some paracetamol and call back on Friday when I might be able to squeeze him in with Dr. Jones. Ok, bye.

Many years ago I overheard this conversation in my reception. Our receptionist giving medical advice without any qualifications. The surgery was over booked. She was harassed, doctors were grumpy and the patients were being turned away without being assessed by anyone.

We noticed that there was a seasonal pattern to this demand for appointments. Most doctors were aware of this trend because there were specific weeks of the year when they avoided taking holidays. Our reception staff kept meticulous colour coded records of such ‘same day’ appointments. When we entered this data on a statistical database there could be no doubt of a seasonal pattern with definite peaks and troughs. What’s more, we could predict the demand for ‘same day urgent appointments’ with reasonable confidence. At this point, it may be important to stress that doctors in the UK are paid a ‘capitation fee’ for serving patients. That means they are paid an annual fee no matter how many times they see the patient.

Understanding that people have a fundamental desire to talk to the decision maker, we settled on the notion of putting the doctor in charge of making the appointment. Patients who requested a ‘same day’ appointment were offered a telephone consultation with a general practitioner initially. Not with a nurse, as happened in some practices, but with their doctor. We believed patients wanted to speak with a medical practitioner, not because the advice they received was necessarily better than that given by another member of the team, but because people in distress want a doctor. Whatever the reason it worked. Important policy makers noticed. Doctors could deal with most requests within a couple of minutes, offer a ‘same day’ slot or something else without the need for a face-to-face appointment. We calculated a 40% reduction in demand for such appointments. Patients loved it, reception staff loved it too (no more arguments about lack of appointments with irate patients) and doctors found themselves in control of their workload. What’s more, we could prove that this simple intervention worked from the impact on longitudinal seasonal trend.

By allowing patients to speak to their doctor when they felt they couldn’t wait our practice chose to treat this small minority of patients differently to those who were happy to make a routine appointment. We acknowledged that these patients had a need that warranted a creative solution. Perhaps you have a group of patients who would benefit from being treated differently too? What is the context in which they seek help? The tired mother with a fevered child does not have the same needs as the young professional who requires a convenient appointment to obtain a prescription for the contraceptive pill. Both might seek an urgent appointment.

Picture by Marjan Lazerveski