Tag Archives: connection

Staff needs should drive improvements

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I sometimes go to the bank on a Saturday. It’s the only day when I can afford to take the time to pack a picnic and wait in the long queue with everyone else who can’t make it there during the week. This week I sold some unwanted furniture and decided I didn’t want to leave the money in cash. So I made my way to the shopping centre and then to the back of the queue and waited with parents who were trying, feebly I thought, to keep their bored kids taking all the leaflets out of their holders. The attraction I’m sure wasn’t the apparently lowest ever interest rates.

Then, and I could have sworn she simply apparated Harry Potter style, a teller sidled up and asked what business I had at the bank. I explained my need to deposit money so she led me quietly outside to the ATM. As if talking to someone very old and deaf she explained that I did not need to queue to deposit money. It can all be done via an ATM. She talked me through the process, waited till I collected my receipt and then smiling kindly waived me off to my next destination. This got me wondering how many patients feel the same way about taking the time to visit a clinic. Waiting in line even when their need is not urgent and when it may be possible for them to get what they need without the inconvenience of attending in person.

The secret to dealing with the problem is to reframe it as staff’s problem. I hope the bank teller is rewarded for assisting me, for taking the time to make some Saturday excursions to the bank unnecessary, perhaps even getting a high-five from her manager. She certainly needs to make a habit of what she just did. I bet even bank tellers prefer to have their exploits celebrated by bloggers than deal with grumpy people who have waited an hour on a hot Saturday morning.

The issue of improving customer service can be reframed as something to be tackled in response to staff needs. Only then will it be a sufficient priority for front line staff to act in response to a trigger- such as ‘there are now more than five people queuing at the counter’. It’s time for someone to see if we can send some people on their way sooner rather than later.

That was quite different from my experience with Rain man’s favorite airline. My flight to Sydney was diverted to Melbourne three months ago. The ground staff gave me a note to send to their customer service people to refund me for the flight to Sydney early the next morning. Three months later and despite following instructions the money wasn’t credited to my account. Eventually I found the number for customer service and after waiting what seemed a very long time spoke to a human being. She assured me I was given the wrong information.

You must claim the money from your insurer.

Nope. No can do. Your staff told me to send you the invoice and I will call you every hour until you credit my account. What your staff are telling your customers in these circumstances is not my issue.

That’s all it took. I got the money refunded before the second call. No good will generated despite, eventually, doing the right thing. It was much easier to hide behind the anonymity at a call centre. Little motivation, despite the ability, so not triggered to act to when the customer calls. How often does this happen in medicine? How often are front line staff put in the position of fending off demands from the customers even when the customer is acting in accordance with information received? This does untold damage to the brand. Our time is at least as important as those who provide services. We scarcely put up with shoddy service in other aspects of life. Why should medicine be a special case?

Picture by A. Currell

What motivates evidence based practice?

Doctor greating patientIt is assumed that doctors will always provide evidence based advice. Evidence based advice will be offered when three factors are aligned- Motivation, Ability and Trigger (BJ Fogg). Looking at the picture, assuming whatever is required is relatively easy to do and there is no problem with the doctors ability, what factors will impact on motivation to provide evidence based advice?

Doctor’s experience of an adverse event- complaint or bad outcome in relation to similar problems.
An overwhelming majority of respondents (91.0%) reported believing that physicians order more tests and procedures than needed to protect themselves from malpractice suits. These views were consistent across a range of physician characteristics, most notably across specialty groups, where 91.2% of generalists, 88.6% of medical specialists, 92.5% of surgeons, and 93.8% of other specialists agreed with the statement (P = .35). No significant differences were seen by geographic location, type of practice, or professional society affiliation. Bishop et al.
Doctor’s experience or training.

Widely used Continuing Medical Education (CME) delivery methods such as conferences have little direct impact on improving professional practice. More effective methods such as systematic practice-based interventions and outreach visits are seldom used by CME providers. Davis et al

The perception that the patient is ‘demanding’ a specific treatment, even if the indications are absent or equivocal.
A total of 4845 discrete items were mentioned as being capable of influencing Family Physicians’ (FPs’) decisions about referral for consultation. Aggregation of related items resulted in a list of 35 nonmedical factors, of which 11 were identified by at least half the respondents and 14 by less than half but more than 10. These 25 factors fell into three categories: patient and family factors (e.g., patient’s wishes), FP and consultant factors (e.g., FP’s capabilities), and other influences (e.g., style of practice). On the basis of both frequency of identification and priority scores “patient’s wishes” emerged as the most important factor.Langley et al.
Payment structures.
The use of financial incentives to reward Primary Care Practitioners for improving the quality of primary healthcare services is growing. However, there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care. Scott et al
Doctors mood.
 82 doctors reported recent incidents where they considered that symptoms of stress had negatively affected their patient care. The qualitative accounts they gave were coded for the attribution (type of stress symptom) made, and the effect it had. Half of these effects concerned lowered standards of care; 40% were the expression of irritability or anger; 7% were serious mistakes which still avoided directly leading to death; and two resulted in patient death. The attributions given for these were largely to do with tiredness (57%) and the pressure of overwork (28%), followed by depression or anxiety (8%), and the effects of alcohol (5%). Firth-Cozens and Greenhalgh.
Time of day.
The researchers looked at the billing and electronic health record (EHR) data for patient visits to 23 different primary care practices over the course of 17 months. Then identified visit diagnoses using billing codes and, using EHRs, identified visit times, antibiotic prescriptions and chronic illnesses. They analyzed over 21-thousand Acute Respiratory Infections visits by adults, which occurred during two four-hour sessions, 8 a.m. to noon and 1 p.m. to 5 p.m. The researchers found that antibiotic prescribing increased throughout the morning and afternoon clinic sessions. Linder et al
Multiple problems presented at the same consultation.
In many health care systems, providers see patients during brief office visits and are overwhelmed by the number of health maintenance activities recommended by guidelines and quality monitoring agencies. When diabetic patients have multiple chronic conditions, screening, counseling, and treatment needs far exceed the time available for patient-provider visits. Piette and Kerr
Cultural factors.
Most clinicians lack the information to understand how culture influences the clinical encounter and the skills to effectively bridge potential differences. New strategies are required to expand medical training to adequately address culturally discordant encounters among the physicians, their patients, and the families, for all three may have different concepts regarding the nature of the disease, expectations about treatment, and modes of appropriate communication beyond language. Kagawa-Singer and Kassim-Lakha
Distractions in the consultation.
The presence of the computer has changed the beginning of the consultation. Where once only two actors needed to perform their roles, now three interact in differing ways. Information comes from many sources, and behaviour responds accordingly. Future studies of the consultation need to take into account the impact of the computer in shaping how the consultation flows and the information needs of all participants. Pearce at al.
Influence of pharmaceutical companies
With rare exceptions, studies of exposure to information provided directly by pharmaceutical companies have found associations with higher prescribing frequency, higher costs, or lower prescribing quality or have not found significant associations. We did not find evidence of net improvements in prescribing, but the available literature does not exclude the possibility that prescribing may sometimes be improved. Spurling et al
All these could be summarised under three headings:
  • What the doctor believes
  • What the doctor hears (or fails to hear)
  • How the doctor feels

Many of these are difficult to influence and therefore innovations that have the greatest effect rarely focus on increasing motivation.

Picture by Vic

How are you today?

4704953402_631194c066_zAustralians do a lot of flying. That’s what comes of  living mainly in coastal cities on the edge of a huge land mass. So we spend a lot of time watching cabin crew run through safety procedures. I’m wondering if that’s something we should do before we consult our patients or clients. Here are three things you might ask yourself during consultations this week:

1. Am I fully with this person in the room just now?

2. What do I know about this person and the impact of their problem?

3. What happens if whatever it is that’s bothering them doesn’t improve or gets worse?

I sometimes wonder if I could be replaced by someone who hasn’t spent 6 years at medical school, four years training and then more years than I care to count ‘practicing’. The answer depends on the extent to which I am able to reach beyond myself on the day the question is posed. On the best days I can pick up on subtle cues. When it’s not so good it’s because I’m not all there.

There are lots of reasons why that might happen. Maslow’s hierarchy of needs explains it succinctly. Hunger, fatigue or boredom are not conducive to caring. Yet we have, and in some cases still expect, our health care staff to function despite those feelings. Roger Neighbour developed a wonderful model for the consultation in primary care. This remains the only guide that specifically includes ‘housekeeping’ as an essential step:

Neighbour acknowledges the need for the practitioner to take care of their own feelings, particularly those brought about by a consultation. If not, the emotions, possibly negative, engendered by one consultation, may spill over into the next.

Perhaps we could take it one step further and determine if someone is fit to work as a health professional on a specific day and especially if they are far too grumpy to care. Many have witnessed objectionable, rude and insensitive behaviour from those who should know better. It was once accepted as the senior doctor’s right to be ill tempered. It may still be. If it is then it should be no longer because anger clouds effective communication. And effective communication is vital to the art of medicine. We aren’t always at our best. Being aware when we aren’t is a first step to ‘safety netting’ as Neighbour put it.

Cancelling the flight because the pilot has a cold isn’t always an option. However replacing the pilot may be wise if she has lost interest in flying the plane. It matters how we look as health practitioners but perhaps it matters even more what we are thinking, and therefore feeling, as the patient enters the room. For those with an interest in innovation, here is the first and perhaps vital focus for improving the quality of the experience for the consumer.

Picture by Ryan Hyde

The power of the pregnant pause

313238312_3c0b16565f_zJohn made an appointment recently. Never seen him before. He shook my hand enthusiastically as he strode into the room. A forced smile. Lots of eye contact. A need to look brave. I remember noticing his hand was a bit wet and his deodorant was working hard. He had flu like symptoms, runny nose, dry cough, sore throat. He had taken a few days off and needed a certificate for this employer. That didn’t explain his anxiety.  He seemed to have come to the right conclusion about his symptoms. I examined his throat, listened to his chest, took his temperature and agreed it was probably ‘a virus’ and that he should be fit for work before the end of the week. Then he hesitated. A pregnant pause. Seemed a bit unsure and blurted out those immortal words

There is just one other thing.

I was expecting it. I’ve seen this before. Adult males who exhibit signs of anxiety in a seemingly ‘routine’ consultation. If I’d looked closely I’d have noticed the dilated pupils and slightly rapid pulse. Sometimes ‘John’ comes with a request for a ‘full body check up’. Nonchalantly declaring that he’s getting older. Occasionally he brings his wife or partner, or perhaps they bring him. But when he comes alone the potential agenda is quite short- an embarrassing problem- impotence or sexual indiscretion and a need to be screened for ‘those other infections’, prostatism or something like what brought John in.

I have a very itchy sore bottom.

A life long problem it seems. Been using creams for years. Not helping. Bleeding a bit too. He knew what was coming. Hence the anxiety. The erythema and excoriations around his perineum verified the history. He left with a prescription for a steroid cream and a request to make a review appointment. It wasn’t as difficult as he had imagined. I clearly had heard all this before and he was pleased to be congratulated for being brave enough to ‘do the right thing’. The smile was now genuine. The prescription tucked away into his top pocket. It doesn’t take a lot to work out that there is more to the patient’s need for medical attention then meets the eye. The ‘Flu thing’ is what he tells people why he needs to see a doctor. In reality it’s a lot more serious- not the eczema that remains undiagnosed but the fear that the ‘itch’ is never going to go away and can’t be brought up in polite conversation despite ruining his life. It’s worth offering every man the pregnant pause. They might spit it out, if you’ve done your job right till that point.

Traditional masculine traits intersect with other physiological, sociological and cultural aspects of men’s lives when deciding to seek help. Andrology Australia

Often the patient wears the hidden agenda on their sleeve. No data or app necessary, just be interested enough to notice.

Picture by Drew Leavy

Minor illness a cash cow?

179335018_d96941d1af_oThis week the New York Times reported that Walmart intends to set up primary care clinics in their stores. According to the closing paragraph of the article:

“To make it profitable, you need to make it have more than just a clinical encounter,” said Dr. Glenn Hammack, the founding president and chief executive of NuPhysicia, which closed the six clinics it briefly ran in Walmart stores. “You also need to sell them prescriptions, a bag of chips, maybe a magazine while they’re waiting.”

The news was met with concern on this side of the world. Australians are all too aware that what starts in the US is a sign of things to come. There was talk of:

Dumbing down of general practice

Others thought that:

This change is coming. Patients want it. Government want it. Patients vote.

While the debate continues I was reminded of Joanne (not real name, nor actual details) who presented with her three little boys a few years ago. She looked exhausted and said she needed something to help her sleep. Before long I had to rescue one of the boys who had lodged himself under my desk. Meanwhile his brother, with Down’s syndrome, was climbing onto my desk to get at my key board and the youngest had crawled into the bin. Joanne was weary. I noted that she had been seen three times already in the last month and had been started on an antidepressant. There followed a long discussion about her migraine headaches. Her love of chocolate, her recent pregnancy, her need for better contraception given that she could no longer take the oral contraceptive. Then a discussion about life as a single mum. In time she become a bit more comfortable that I hadn’t yet reached for my prescription pad or interrupted her. She said something that didn’t fit the story of a single, stressed struggling mother- she told me:

And I get breathless on the slightest exertion and have lost quite a bit of weight.

Something wasn’t right. This did not fit the story. Anyone could see how she might be worn out by her situation, but this was something else. Her resting pulse was 120. She had lost several kilograms in the past few months and was not dieting. Despite the cold she was wearing a loosely fitting dress and sweating. A couple of urgent blood tests later we established the diagnosis. She saw an endocrinologist and when we met again she was feeling a bit better- except that she continued as the mother of three demanding young boys.

Joanne, and the many other Joannes, that attend general practitioners every day have no idea what’s wrong- only that there is something wrong. They want the time and space to tell their story to someone they trust. This isn’t going to happen at a supermarket fast-diagnosis clinic where the goal is to issue a prescription and making a sale. There is no such thing as a ‘quick consultation’ in the context of ‘minor illness’. Joanne would have left the surgery with a script for a hypnotic- she needs to sleep but what she needed more than that is to be seen and heard. The crunch often comes- as it did in this case when the patient is about to leave the room- the  ‘while I’m here doctor’ moment.  Perhaps someone with asthma might know they need an inhaler- but can we assume that someone with relatively minor symptoms would recognise that their tolerance to those symptoms was reduced by some other physical or psychological problem (pneumonia, exam stress, divorce, bullying) that warrants more than a quick trip to the pharmacy? It is assumed by some policy makers that doctors respond to disordered machines (mechanics), rather than to distress. It has long been established that:

 The overall prevalence of symptoms in the community is not closely related to general practice consultation rates, and the consulting population is a selected population of those who are in need of medical care. The literature review suggests that poor health status, social disadvantage, poor social support and inadequate coping strategies are associated with higher consultation rates. Some population sub groups may experience particular barriers to seeking care Campbell and Roland.

Does Australia have anything to fear from commercial organisations seeking to cash in on minor illness? Is it likely that it will reduce the demand for traditional GP appointments? I suspect not, if only because of Joanne. What we have learned about why people make appointments to see doctors is that they are far more discerning than we give them credit for. What for-profits will achieve is to rekindle the debate about whether people would be sufficiently enamored with a watered down version of a consultation with a general practitioner to walk away from the queue. Experiments in offering people alternatives to general practice in the UK were not successful. Renewed attempts to test the ‘market’ again will only delay a commitment to the only service that keeps the cost of health care under some sort of control- general practice.

Picture by Anne.

Sharing information with patients

Worldwide the incidence and prevalence of chronic and complex health conditions (diabetes, heart disease, cancer, dementia) are rising. Therefore more conversations between doctors and patients will focus on the need for long term medication. Anyone who has been practicing medicine for two decades or longer has noticed a change in patient expectations. Here’s someone who suffered a myocardial infarction(heart attack) five years ago:

I just don’t want to take statins at this dose for ever. The cardiologist isn’t happy. My cholesterol is 3.6mmol/l and he thinks it should be less than 2. He has prescribed the maximum dose of a statin and insists that if it damages my liver there are drugs they can give me to counteract that. Are you prepared to guarantee that I won’t suffer another heart attack? And what is the risk that I will suffer side effects from these drugs? Why don’t you give me the numbers and let me decide? It’s my body!

On the one hand:

5 years of [name] statin would prevent about 70-100 people per 1000 from suffering at least one of major vascular events (and longer treatment should produce further benefit). The size of the 5-year benefit depends chiefly on such individuals’ overall risk of major vascular events, rather than on their blood lipid concentrations alone. Heart Protection Study Collaborative Group.

The Number Needed to Treat (NNT) with any statin to prevent one case of cardiovascular disease over 5 years was 37 (95% CI 27 to 64) for women and and  33 (24 to 57)  for men. Joanne Foody

On the other hand:

Treatment of 255 patients with statins for 4 years resulted in one extra case of diabetes. Sattar et al.

In women, the Number Needed to Harm (NNH) for an additional case of acute renal failure over 5 years was 434 (284 to 783), of moderate or severe myopathy was 259 (186 to 375), of moderate or severe liver dysfunction was 136 (109 to 175) and of cataract was 33 (28 to 38). Overall, the NNHs and NNTs for men were similar to those for women except for myopathy where the NNH was 91 (74 to 112). Joanne Foody

The world it not black and white, drug treatment may be beneficial but not risk free. The patient reporting to me was unhappy that his cardiologist had dismissed his concerns as trivial. Of every 100 people at high risk of cardiovascular disease treated with statins over five years 2-3 might benefit, 97 may not and 2-3 will suffer harm. At the time of prescribing it is not possible (yet) to identify who will experience adverse effects. All that can be said is that the bigger the dose, the longer the duration the greater the risk of harm. For my patient the impact of a second myocardial infarction may be catastrophic, the side effects of statins are mostly reversible. As an alternative to drugs he could have considered lifestyle modification. He may benefit although he may also be aware that there is only equivocal evidence for modest reduction in risk of a subsequent myocardial infarction. Incidentally effectively promoting lifestyle change brings into play a host of other considerations:

Support from family and friends, transport and other costs, and beliefs about the causes of illness and lifestyle change. Depression and anxiety also appear to influence uptake as well as completion. Murray et al 

As health professionals we are obliged to find ways to relay information in digestible format and support people whatever they choose. In most cases the choices also have a downside. Much of what we can achieve to improve health is predicated on our ability to communicate effectively. That is not possible if we do not address the perspective of the person who has sought our advice. After all it is they who must pay for the drugs or it is they who have to change their eating habits. Meanwhile the next patient I saw was a young man with moderate acne. He had been started on oral Minocycline by another GP. He opened with:

I don’t like the idea of taking these drugs for months.

Denying people the feeling that someone cares

The conversation I overheard in my practice many years ago went something like this:

Jean, I’m sorry there are no appointments available until Friday. Has he got a fever? Try him with some paracetamol today and I’ll book him in for Friday afternoon. There’s a lot of this flu like thing going around school. Ok, see you Friday.

A receptionist was triaging my patients! Medical qualifications = nil. She looked up with a pained expression, she was carrying more responsibility than I paid her for. And yet it has long been recognised that:

Little difference was observed between the symptoms reported by patients to the physicians as compared to those received by the receptionist staff. Physicians are more likely to use the telephone contact to treat the patient’s complaint with home care advice or a prescription. Receptionists are more likely to use the telephone contact for scheduling an office visit. Fischer and Smith.

What we also don’t acknowledge is that receptionists take calls from their friends, neighbours and relatives. The callers may be worried, unwell, confused, frustrated, angry, grieving, embarrassed, lonely, sad, suicidal, dying or just simply unable to cope. We place them in a front line role in a system that is often over subscribed, under staffed and the first port of call for anyone who thinks they need medical attention. Sometimes receptionists undertake tasks that should be the preserve of someone with other qualifications! We expect the receptionist to be polite, courteous, discrete, sensitive, thoughtful, obliging and intuitive. If she, and it’s usually a she, gets it wrong the practice faces complaint or litigation and a very bad press. Employers have recognised the challenge inherent in the role, but in many parts of the world those who under take this work have no formal qualifications or appropriate training. This issue has received research attention but there are challenges to developing innovations to help reception staff to prioritise patients.

Where contamination of the study population is an early complication, no current gold standard exists to define safe triaging, contextual differences between practices lead to inter-practice variation, and proxy outcomes (improvement in receptionist response to written scenarios of varying urgency) are used. Hall et al
Can we really guide someone who isn’t a doctor, or have any medical qualification, to make appropriate decisions based on a telephone conversation about potential medical emergencies?  There was a recent report of a disastrous failure to appropriately sign post the parents of a very sick child which involved ‘suitably qualified’ people working to nationally accredited algorithms. The issue at heart is that there is a greater demand for access to medical practitioners than supply. In response to demand policy makers have promoted ways to limit or control access to that expertise. The temptation is to innovate for alternatives that don’t involve the doctor. Those who advocate for this approach may be failing to recognise that people in distress aren’t simply disordered machinery in need of a technical fix. They can’t be rescheduled like a car service. That doesn’t mean they need to see the doctor straight away but they do need to feel they have had that experience sooner rather later. People are hard wired to feel better after contact with a doctor- it’s fundamental to how medicine works. That was what we decided back then so we relieved our reception staff from having to determine who was ‘not urgent for today’ when our schedules were full- instead we, the doctors, spoke to the patient by telephone and if we were not absolutely sure we had enough information we saw the patient and we still reduced our workload by 40%. Innovating to ration access to the healer is a bad idea if only because we are deny people the feeling that someone cares. The cost of that loss of connection is a failure to fulfill our purpose in people’s lives.

 

Quantified self – the downside

The manufacturers of wearable health tech devices are set to make millions if not billions. Wearables are relatively cheap adjuncts to existing technology. But what difference will they make to the health and well being of the average user?  We have been offered a preview of what these devices can do- monitor your heart rate, blood pressure and blood glucose. Keep track of your respiratory rate, calorie expenditure and sleep patterns. Detect cardiac arrythmias and abnormal brain electrical activity. It sounds good, but so what? If you experience a significant drop or severe rise in blood pressure you are going to notice even before you check the readings- you will feel very unwell. Similarly low blood sugar and dysfunction of the respiratory or cardiac system. Do we really need our smartphone to tell us we aren’t taking enough exercise and eating too much? Or that it’s time to see a doctor urgently? I agree with Jay Parkinson:

The exclusive-to-human part of our brain evolved so we can be creative and manipulate the world around us so we can invent things like the iPhone. And now, the creators of the iPhone want to give us the tools we need to badly do what evolution solved for us hundreds of millions of years ago.

Here’s the problem with this technology in practice:

About 10 percent are “quantified selfers” with an affinity for this kind of feedback; just by looking at the numbers, they are motivated to be more active. An additional 20 percent to 30 percent need some encouragement in addition to tracker data to effectively change their behavior. Kamal Jethwani

Therefore the vast majority of people who buy a wearable device right now will not benefit from that purchase. Those who do, might be amenable to other interventions. Unfortunately much of the data is meaningless or has no impact on long term decisions about health and well being. Sure, a trend in high blood pressure over a few weeks might indicate a need for treatment but a single high reading might be an anomaly or simply confirm that you are excited. Worrying about every little bleep on the chart is not going to add to your quality of life but will detract from it. For a sustained and beneficial change in life style people need more than data. They need motivation and help to workout the benefits of making different choices. They need the undivided attention of a practitioner who understands their needs and assists with a bespoke plan.

Information that we need right now, which our built in human senses may not already have alerted us to is another issue; microscopic haematuria (blood in the urine) proteinuria (protein in the urine), faecal occult bleeding (blood in the faeces), raised intraoccular pressure (high pressure in the eye ball) and changes in moles, breast or testicles will prompt doctors to investigate for sinister causes. Investigations that might lead to the early diagnosis of some costly and treatable or life limiting condition. Acquiring this information doesn’t require you to wear a device continually for a year. The business case for manufacturing devices to do that isn’t as compelling because of a limited market. Enthusiasts for wearables argue that:

Studies are beginning that examine the data from wearables, which is much more granular data about human activity than scientists have been able to access previously. This will answer questions like: how much of an increase in activity, of what type (moderate or cardio-challenging) leads to what degree of health benefit? Todd Hixon

What we may also discover is that there are probably side effects associated with wearable devices. Psychological harm may be associated with prolonged and heightened anxiety and obsession with self. What we won’t discover (and this is a guess) is that there is a short cut to losing weight that doesn’t require any significant effort. We might also discover that there are limited indications for wearable devices and that the market for them is much smaller than we envisage. Parallels exist with some parts of the pharmaceutical industry which has begun to promote ‘illnesses’ that would benefit from it’s offerings. So called disease mongering. We may well find ourselves being circumspect about wearables in the way that we have misgivings about drugs:

…drugs approved for devastating illness, such as clinical depression, are indicated for milder conditions, such as shyness, which is now dubbed ‘social phobia’. Howard Wolinsky

Data is no more the answer to all problems than are drugs. The indications for collecting data have parallels with the indications for prescribing drugs and how and why that data is collected merits thought. Those who promote the use of wearables need to question a trend which isn’t without a downside.

Innovating locally

The foreign-looking chap in the baseball cap, the one wearing a pair of torn jeans and a singlet, the one on the mobile phone, sporting a dragon tatoo on this forearm might be a famous musician and the only son of a bedridden widow. But you’ve decided he is  probably a drug addict and treat him with suspicion and hostility. On the other hand the smartly dressed, attractive white woman carrying the brief case might be a drug dealer and you greet her with a welcoming smile. I was born of an ethnicity that wherever I have lived or worked people I meet for the first time assume things about me that are false, even laughable. Before I open my mouth, my students are invited to guess the nationality on my passport, the city where I was born and my first language. They mostly get it wrong. Therefore I do people the courtesy of not making assumptions. Often in medicine the doctor is the only person who will treat some people with respect in a day when they have to contend with lots of challenging behaviours, whether because of their appearance, their accent, their culture, the clothes they wear, their disability or their needs.

I should not have been surprised by research that suggests that doctors know very little about their patients. And least surprising was the finding:

Physicians were poorer judges of patients’ beliefs when patients were African-American (desire for partnership) (p=0.013), Hispanic (meaning) (p=0.075), or of a different race (sense of control) (p=0.024).

Street and Haidet

Could a doctor pick out a patient’s partner, whom they have never met from a police line up? Would they know what car that person drove? Would they have any idea what their patient had for breakfast? Where that person is planning to go on holiday ? What they wanted to be when they grew up? In many cases it doesn’t matter but as innovators we feel we are able to develop interventions that will make it more likely that those very people will comply with our prescriptions, give up smoking, eat more vegetables, wear a condom and monitor their chronic condition. Not all at once of course!

Technology now allows us to take a bird’s eye view of our practices. We record key parameters for people who attend our clinics- for example blood pressure, cholesterol and glycosylated haemoglobin and can link that to geographical data- demonstrating where our poorly controlled diabetics live. We might like to guess before we are presented with the data- I bet we would be way off the mark.

Then we can see if there is public transport to bring those people to the clinic. Where they buy their food. Whether there are open spaces and leisure centres within reach.  Could those people easily attend an optician or a podiatrist? Only then should we contemplate something locally that will make it more likely to improve outcomes. But only after we check our assumptions with the people for whom the innovation would be designed. This work has a local flavour- ineffective innovations are designed on a ‘one-size fits all’ model as if everyone lives in an affluent middle class neighbourhood and seek care at the convenience of the healthcare provider. To quote Idris Moottee:

The customer is King, Queen and Jack. Any innovation efforts will fail eventually if the end user is not driven to use your new product or service. Most consumers are intelligent and can contribute so much to the process. It is true that people can not always voice their needs and desires in a way that makes sense, but our job is find creative ways to understand their attitudes, values and behaviors and figure out how to include them in your innovation process.

Meanwhile my friend Alan Leeb noticed that people are wedded to their mobile phones and are likely to respond to an SMS from his practice. So now each time his nurse administers a vaccine, the practice sends them an SMS asking if they had any sort of adverse reaction. The practice is now able to monitor reactions to vaccines in real time, that means if there are severe reactions his practice will know within 24-48 hours, probably faster than any other agency. This information might just help to save lives in his practice but perhaps in yours too.

Innovating to save precious time

When I was at medical school Pendleton’s book on the consultation was required reading. Pendleton maintained that one of the tasks in the consultation was to consider ‘at-risk factors’. It’s one item on an otherwise long list of tasks to be completed. Today it is often the case  that a discussion of  those ‘at-risk factors’ take over the focus of the consultation. Doctors are urged, even rewarded for moving the agenda to- diet and exercise, responsible drinking, colorectal, breast and cervical screening, hypertension, safe sex….the list is endless. The impact of having the doctor’s agenda up front and central in the consult is what has been described as

High controlling behaviours.

Ong et al.

The resultant style of consultation is described thus:

It involves… asking many questions and interrupting frequently. This way the doctor keeps tight control over the interaction and does not let the patient speak at any length.

Recently medicolegal defense organisations have taken to issuing advice against this pointing out that when the patient does not feel they have been heard they are more likely to complain. Research has shown that patients don’t ask for much. They won’t take long to spit out the reason for their visit. In one study:

Mean spontaneous talking time was 92 seconds (SD 105 seconds; median 59 seconds;), and 78% (258) of patients had finished their initial statement in two minutes.

Langewitz et al.

Allowing the patient to speak first is a good start. Then how do we support practitioners to earn a living by also attending to those topics for which they must tick a funder’s check box? Tasks introduced by policy makers as if the primary care consultation was replete with redundant time. In some ways it’s like what happens when you buy a new television, it’s not long before the sales assistant wants to sell you insurance and other products- ‘just in case’ but really because their commission depends on it. What we need in medicine is to stop eating into the time it takes to explore a patient’s ideas, concerns and expectations, time needed to examine the patient and express empathy. We need cheap, agile, intuitive and creative solutions that will quickly offer the patient an indication of their risk from whatever the latest public health issue happens to be- smoking, influenza, prostate cancer…but also the benefits and why they might want to consider ‘taking the test’, accepting ‘the jab’, or changing the habit.  My colleague Oksana Burford invested three years testing one such innovation. What Oksana realised is that in the end it’s the patients choice and the key is to introduce the idea of change in a way that speaks to her but only when she is ready to hear the message.

The reasons why primary care is selected to relay public health messages is that people trust their health care provider and are more likely to comply if that practitioner recommends it. However that does not mean that we should assume the patient can only get the necessary information from one source. What the practitioner can do is sign post where that information can be found and effectively convey why the choice being recommended is better than the status quo. I recommend the food swap app– its downloaded free and saves a lot of time which can then be used to deal with the reason the person had come to see me in the first place. There is lots of room for innovation but it should meet the needs of the patient and the practitioner.