Tag Archives: connection

Managing demand for primary care

Why do people consult doctors? At first glance because they feel unwell. However research suggests that the reasons are far more complex than that. Innovators also know that the answer to this question is vital for those seeking an agile, intuitive, creative and cheap solution to the demand for their services. Theories predict the consultation habits of many patients. I especially like this summary:

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 reviewed suggests that poor health status, social disadvantage poor social support and inadequate coping strategies are associated with higher consultation rates. Some populations subgroups may experience particular barriers to seeking care. Campbell and Roland

Innovators might also ask why are those patients sitting in my waiting room? I remember a hoary old tale of a doctor who was feeling especially grumpy one day and stormed through the waiting room announcing that anyone who thought they had a ‘real’ problem should stay everyone else should go home- half the waiting room emptied.

It seems quite a few people who go to doctors will have symptoms- however a proportion will be back there by invitation. How big a proportion and why have they been invited back? There are many reasons to schedule a repeat appointment. It conveys the notion that the patient will be harmed if they don’t see a doctor on a given day for one or more of these reasons:

1. Their response to treatment is unpredictable and the dose or drug may need to be revised

2. They have a condition that can’t be diagnosed or may progress or need additional measures by a specified date

However other reasons for requesting a review include:

1. The doctor isn’t confident that the diagnosis is correct and wants a chance to review the advice issued.

2. The patient is required by someone (e.g. an employer) to produce evidence of a visit to a doctor

3. A full waiting room ensures the doctor looks busy for whatever other reason.

4. The doctor needs to reinforce the impression that the condition has been taken seriously.

The time cost for doing everything that could possibly be recommended for patients with chronic conditions  has been shown to be untenable. Either the guidelines are wrong or a different solution needs to be found for at least some of these people. What is the evidence for asking a patient to return within a week or two with a specific new condition and within a month with a longstanding condition?

There is a need to be proactive in some cases. However is it possible that we encourage people to attend for review appointments when there is a low probability that they will benefit? Are there other reasons to fill the waiting room?

The most successful health innovation ever

What medical innovation is:

1. Available worldwide
2. More likely to yield a diagnosis than an X-ray
3. Cheaper than the cheapest stethoscope
4. Requires less training to operate than a tendon hammer?

Answer: A tongue depressor

Why? Because when deployed within the context of a medical consultation- when the practitioner gives the patient their undivided attention, the tongue depressor forges a relationship that may lead the patient to express their deepest concerns. In what other social context can you shove a piece of wood into someones open mouth and get them to say ahhh? A few years ago I consulted a fifty year old mother of five, working as a supermarket check out assistant complaining of a sore throat. We talked about how awful she felt and how she was struggling to cope with her job, how she gets frequent bouts of tonsillitis and how she was afraid her boss would sack her. She had a mildly red throat and I thought I could feel a couple of tender lymphnodes in her neck but her temperature was normal and I remember thinking I’d seen worse earlier that day. Then as I turned around to write a prescription she burst into tears and said-

‘There’s something else I need to tell you doctor. I’m now working as a prostitute because for the first time in ten years I haven’t been able to afford my kids school books.’

That was not what I expected to hear, or anything they told me at medical school could result from examining a throat. That consultation took a very different direction, she was screened for other infections and was fortunately negative. We then talked about her dilemma and she decided there may be better ways to furnish her kids with what they needed for school.

There is very little evidence that the appearance of the throat aids the diagnosis in most cases- even a viral sore throat can mimic a bacterial infection. In any case in developed economies penicillin does not help the patients recover much quicker. However, anyone with a sore throat who consults a doctor expects to be examined. Besides why do people seek medical advice about pharyngitis? It is common knowledge that in most cases a couple of paracetamol, fluids and rest is the only effective treatment. In many cases people are expressing concern about some other aspect of their life when they present with minor self limiting illness. What people say, if you are receptive is

‘I’m unhappy, I’m worried, I’m bored, I’m feeling guilty, I’m tired or I’m not coping and this discomfort is the last straw.’

That’s one of the myriad of reasons that general practice is the most challenging medical specialty, nothing is necessarily what it seems at first glance.

Innovations don’t need to be high tech or expensive- a tongue depressor costs 13 cents. That doesn’t mean that in the right hands such simple equipment is not extraordinarily powerful. There are tools we seldom do without- a stethoscope is vital and not only because of what we can hear when we put it to the chest.

Instruments of measurement vs. instruments of connection

9597562683_0f1bb9156a_zMany health innovators argue that future advances in health care will come from technological solutions. Things we can measure and quantify. Governments and health care providers are holding their breaths for a magic bullet that can easily, measure and thus fix everything.

People who advocate for technological health solutions think that it’s possible for doctors to routinely consult patients without touching them, or even looking them in the eye.

Stakeholders imagine that that health practitioners spend time with their patients simply to gather and process data. We imagine a future when a patient’s wearable device will be handed over to the doctor, who will have everything he needs to know and more, in order to treat any ill.

That is not to say that we should not innovate, or that technology will not enhance the encounter between patient and healer. However we do need to think about how those innovations will become part of that powerful ritual known as the medical consultation. Technology, high tech or low tech, needs to be incorporated in a way that responds to the person in distress. It should be seen as a means to an end, and not an end in itself. If information was all that was required to get people to adopt healthy choices then why do we make so many decisions that defy logic?

Science has identified that people act on impulse, are moved by emotion, or commit themselves to decisions because it makes them feel good even if they know it’s doing them harm.

The reality is that not everything that matters can be measured. Patients don’t just come to doctors to be fixed. As health care practitioners we mustn’t lose sight of the fact that what patients need as much, (if not more) than, instruments of measurement are instruments of connection.

Picture by Alberto Varela