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

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

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

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

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

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

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

In summary:

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

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

Picture by Jens Karlsson

The welcome rise of alternative providers

Two weeks ago an 80-year-old waited without food or drink for 14 hours in a Dublin city emergency department having fallen in her local supermarket. She was black and blue from head to toe a response to the call of gravity when she was launched off a faulty escalator. She was ‘triaged’ and seated next to drunken revelers who also managed to injure themselves on that fateful evening. She was seen for all of 10 minutes by a medical student and then briefly by a doctor who recorded that her visual acuity couldn’t be assessed because she didn’t have her glasses. With that, she was sent home with her granddaughter and asked to return a couple of days later when she again waited another 9 hours for a five-minute consultation presumably so that the doctor could make sure she hadn’t really injured herself and wasn’t going to sue the hospital as well as the supermarket.  I know this person and read the discharge summary even though her daughter and I live on the other side of the world. As far as we know the provider believes we should be thankful because they are very busy and at least ‘someone’ saw her.

What’s it like to be your patient?

  1. How long do your patients wait?
  2. How are they greeted on arrival and how do they feel about waiting?
  3. What do they do while they wait?
  4. How long do they see you on average?
  5. What do they expect from the visit?
  6. Why do you order tests? What difference do these tests make to the outcome?
  7. Why do you prescribe those drugs? How many people take them as prescribed?
  8. Why do you ask them to return for a review appointment?
  9. Why do your refer them to someone else?
  10. What do they tell their family about your service?

No business would survive without a handle on this information. Arguably some sectors of the business of healthcare only survive because of a monopoly.

A newer take on the organizational environment is the “Red Queen” theory, which highlights the relative nature of progress. The theory is borrowed from ecology’s Red Queen hypothesis that successful adaptation in one species is tantamount to a worsening environment for others, which must adapt in turn to cope with the new conditions. The theory’s name is inspired by the character in Lewis Carroll’s Through the Looking Glass who seems to be running but is staying on the same spot. In a 1996 paper, William Barnett describes Red Queen competition among organizations as a process of mutual learning. A company is forced by direct competition to improve its performance, in turn increasing the pressure on its rivals, thus creating a virtuous circle of learning and competition. Stanford Business

Certainly, the 80-year-old had no option but to go to a state hospital emergency department because there was a very real possibility that she had fractured something coming off that escalator. The hospital manager might say in her defense that they have no option but to offer the service as described, but where is the data to demonstrate that it is the lack of options rather than a lack of interest or talent in managing one of the most important services the state is charged by taxpayers to provide? The monopoly may be around a little longer when it comes to life-saving treatments but what about primary care? If this 80-year-old can wait 14 hours to be seen by a medical student there may be real scope for the service to be provided by someone who is qualified, will see her much sooner and offer her a cup of tea while she waits for the X-rays to be reported. What about the scope to provide better than what you offer?

Picture by Toms Baugis

No plan, no progress it’s a simple equation in healthcare

Every business manager can lay her hands on plans and policies and can probably recite the ‘vision statement’. I like the one for Lexmark printers because I think it works for healthcare clinics:

Customers for life. To earn our customers’ loyalty we must listen to them, anticipate their needs and act to create value in their eyes.

The manager’s shelves might house annual accounts, a policy for Human Resources,  a policy for health and safety, a policy for recruitment. The practice may have a chartered accountant, a registered financial advisor, a recruiter and an HR manager. Rarely if ever does a clinic have an appropriately qualified research consultant or a five year R&D plan or policy.

Therefore the manager relies on anecdotes and other people’s data to decide if the practice is delivering accessible and effective services. The practice relies on others to advocate for them and to defend the charges that are levied on their behalf. It’s all left to persons unknown in a far away bureaucracy.

The consumer relationship starts with the brand. Before you even meet the consumer, you must fully understand your brand. If you don’t know who you are as a brand, and what makes you different, better, and special, how do you expect a consumer to? You must clearly define a brand’s product benefits to set up more intimate, emotional bonds. It is these emotional bonds that will form the basis of a lasting consumer relationship. HBR

If you are a clinician in a practice what aspects of the practices’ vision are non-negotiable and how will you know if something is undermining that vision? How reliable and valid is your understanding of the following:

  1. What is the context in which the practice is located? What drives morbidity locally?
  2. How are people greeted at the practice? What do they notice about your premises?
  3. What is the commonest reason for attendance?
  4. How long is the average consultation?
  5. What is the outcome?
  6. How many people receive less than evidence based care? Why? What are the consequences?
  7. How many people take your advice? How many go elsewhere after coming to you?
  8. Which innovation is going to be introduced and tested in your practice in the next five years?
  9. What information will guide investment decisions in the practice?
  10. Are you participating in externally funded research? Why those projects and not others?

These questions are of great interest to the better companies. Companies that are ‘lovemarks’:

Lovemarks reach your heart as well as your mind, creating an intimate, emotional connection that you just can’t live without. Ever. Lovemarks

Never let innovation for a brand be something that happens randomly. It should fit strategically under the brand. At Beloved Brands, we believe the best brands build everything that touches the brand around a Big Idea, that guides the 5 magic moments to create a beloved brand, including the brand promise, brand story, innovation, purchase moment and the brand experience. beloved brands

If these issues are of interest to you I invite you to contact me to develop a plan for your practice.

Picture by UCL Mathematical and Physical Sciences

The country needs general practice to be the provider of choice

Ever since I came to Australia as a foreign graduate I have been obliged to work in a so-called ‘area of need’. Directly opposite one practice in such a location, there is a large shopping centre. I sometimes go across the road to get my lunch. I noticed several very busy outlets full to the brim with customers. Here is a price list of some of what they offer:

  1. Reflexology Foot care (20 mins) $40
  2. Deep tissue and relaxation oil massage 30 mins: $50
  3. Headache treatment (30 mins) $30
  4. Sciatica relief $45

The practice across the road is a ‘bulk billing practice’ (i.e. they do not charge more than the government subsidy). The practice feels that people ‘can’t afford to pay’. I often see the same people queueing up for the treatments mentioned above. Today ( Sunday 26th February) there is a full page add in local newspaper headed:

Hope has arrived for men over 40 with low testosterone. Now, as part of our national health drive , a limited number of Australian Men can get free assessment before 5/03/17.

A box on the page asks:

Do these symptoms sound familiar?

  • Sleep problems
  • Increased need for sleep/ feeling tired
  • Physical exhaustion /lacking vitality
  • Deceased muscular strength
  • Irritability
  • Nervousness
  • Depressive symptoms
  • Raised cholesterol
  • Erectile dysfunction
  • Lowered libido
  • Prostate symptoms

The advertisement claimed that:

Studies show that only 10% of men are receiving treatment for low testosterone.

Citing as evidence one academic paper. The other citations are to reports on a news channel. The conclusions of the academic paper are based on a survey of 2165 men attending a primary care clinic in the United States regardless of the reason for attendance. Hypogonadism was defined as follows:

Given the lack of a widely accepted single threshold value of TT to define hypogonadism, <300 ng/dl, which has been used in clinical studies of hypogonadal men, seemed a reasonable choice. (Mulligan et al)

On this basis man with testosterone, levels below 300ng/dl were classified as hypogonadal and their symptoms were attributed to that condition. The team concluded:

The difference in the occurrence of four of the six common symptoms of hypogonadism (decrease in ability to perform sexually, decrease in sexual desire or libido, physical exhaustion or lacking vitality, and decline in general feeling of well-being) was greater in hypogonadal vs. eugonadal patients (p < 0.05).

None of the men were examined for other causes of their symptoms or problems. And on the basis of this research, a clinic operating in Australia is marketing therapy that:

….stimulates natural testosterone production

There is no mention of the cost of this treatment anywhere on the advertisement. The only protection that we offer people in the face of this very questionable marketing are the services of a trained general practitioner able to help people navigate this minefield of nonsense designed to part people from their hard-earned money. However, we need to create an experience that competes effectively with the powerful commercial offerings that are triggering people to spend their money so that they are then considered ‘unable to afford to pay’ for better advice.

Picture by Angie Muldowney

It’s time to consider what we want beyond access to general practitioners

Ever since Adam was a boy the thing that has driven policymakers into a frenzy is ‘access’ to a GP. That’s good because they recognise that the work done by a general practitioner is very important. However, it sometimes feels like ‘access’ is the only thing that really matters in healthcare policy. Politicians and bureaucrats can’t look beyond the quantum of people being seen because that’s how they think their performance will be judged by the voter/shareholder.

Of course, it is important that the public is able to access a doctor trained to deal appropriately, effectively and efficiently with all that can happen in life. However, an ‘open’ sign doesn’t mean people will get that beyond those portals. To get what we imagine lies beyond the door we need to consider how those doctors communicate because the formula is: thoughts -> feeling and feelings ->action. Action is what is needed when someone is overweight, smoking, abusing, bleeding or worrying. The person who needs to take action or consent to treatment is the person now striding through the door.

The ability to help means being able to put the needs of the other first. It doesn’t happen quite so well, or in any sustained way when the person trying to help is troubled, anxious, tired or working in a hovel. There are two parties in the mix- the one who is dealing with the crisis and the one who is trying to help. The needs of both will impact on the outcome.

An older couple I know walk miles and wait hours to see their doctor. This doctor has been looking after them for years. Her clinic is open for long hours and everyone gets seen ‘eventually’ and on the same day. I know these people well and I know they are not taking the statins, the NSAIDS, the antibiotics and list of other things that are prescribed and that the innumerable scans and X-rays ordered every year are futile. What they crave most is to be heard, for someone to acknowledge that things don’t work as they used to, or help prepare to visit their beloved daughter overseas. That takes time, it takes a willingness to see people in context but for longer than 10 minutes at a time. It takes planning for what people will think after their visit because thoughts determine feelings and feelings drive actions.  Good feelings are engendered only when the doctor can invest- not just in what happens when she is face to face with her patients but at every touch point with her practice. Then she can communicate that she cares and that she can be trusted when she says that that ache or pain isn’t something that needs yet more tests or another prescription. What the practice needs is not just another doctor to churn through the waiting list but for those doctors to work their magic. For now, she is open for business- the question is what business and who really benefits from her efforts?

In 1999 Mainous and colleagues published a paper in the American Journal of Public Health which reported data suggesting that access though necessary was not sufficient to make a real difference to patients in primary care:

OBJECTIVES: This study examined a private-sector, statewide program (Kentucky Physicians Care) of care for uninsured indigent persons regarding provision of preventive services. METHODS: A survey was conducted of a stratified random sample of 2509 Kentucky adults (811 with private insurance, 849 Medicaid recipients, 849 Kentucky Physicians Care recipients). RESULTS: The Kentucky Physicians Care group had significantly lower rates of receipt of preventive services. Of the individuals in this group, 52% cited cost as the primary reason for not receiving mammography, and 38% had not filled prescribed medicines in the previous year. CONCLUSIONS: Providing free access to physicians fills important needs but is not sufficient for many uninsured patients to receive necessary preventive services.

Picture by dmon_21

 

General practice can evolve- it just has!

 

It’s Thursday night- I don’t blog on a Thursday night. But this isn’t any ordinary Thursday. Today I believe I walked in on the future of general practice in bricks and mortar– designed and run by a couple whose combined age is not much more than mine. I’m not quite sure what I was expecting when I made the appointment to visit. I suspect I was just being nosy- could a practice really do business without a big reception counter? I was prepared to be disappointed. To see the waiting room damaged and tired after more than a year in business. To see little more in the way of big ideas than the loss of that big ugly barrier. What I wasn’t expecting was to meet a couple whose energy and passion for general practice could easily power a small city and to leave feeling overawed by what they have created.

I saw attention to detail in everything that makes for an extraordinary patient experience. From the music in the waiting room, sounds that could be controlled from smartphones with a different selection possible in each room. Removal of the desk in the consulting room, replaced by a tablet computer fully loaded with the latest clinical software. It is a place I want to be- as a doctor, as a patient, as a visitor or in any capacity they will have me. I can’t begin to describe the impact of each room with windows designed to maximise the natural light even deep in the heart of the building, the removal of clutter (no posters anywhere), the exquisite choice of everything on display with an emphasis on less rather than more. Even the treatment room stocked in a way that makes a Toyota factory the most efficient place on earth.

I heard patients being welcomed, smiling faces everywhere, staff who said they were never happier at work. Doctors who clearly enjoyed what they were doing and a sense of purposeful calm in all that was being done.

This is what can be achieved without relying on any external agent even in a so-called area of need. It has been created by people who care enough to work very hard and want nothing less than they expect for themselves. People who want to create an experience that makes it more likely that people will value what’s on offer. Today I believe I was given a rare glimpse into what it will be like in medicine when these ideas are universally adopted because nothing less than the feelings that this place engenders is good enough.

Picture by AmadeoDM

Junk used to wallpaper doctors’ offices

Of all the things doctors can do in their practice they can certainly choose what to display on their walls. In 1994 a group of researchers reported:

To determine whether patients read and remembered health promotion messages displayed in waiting rooms, 600 patients in a UK general practice were given a self-complete questionnaire. Two notice-boards carried between 1 to 4 topics over four study periods. Three-hundred and twenty-seven (55%) of subjects responded. Twenty-two per cent recalled at least one topic. Increasing the number of topics did not in crease the overall impact of the notice-boards. The numbers of patients recalling a topic remained constant, but increasing the number of topics reduced the number remembering each individual topic. Patients aged over 60 years were less likely to recall topics, but waiting time, gender and health professional seen had no effect on results. Very few patients (<10%) read or took health promotion leaflets. Wicke et al

It would appear that the notices are basically used as wallpaper. They do not seem to serve any other useful purpose. Researchers suggest that the design of such ‘community communication channels’ requires further thought:

Our results highlight how they are used for content of local and contextual relevance, and how cultures of participation, personalization, location, the tangible character of architecture, access, control and flexibility might affect community members’ level of engagement with them. Fortin et al

Essentially the role of the notice board with its myriad of posters and leaflets is to ‘sell and inform’ not to decorate and distract. They sell ‘health’ or services related to health. Vaccinations, antenatal care, weight loss, smoking cessation, early diagnosis, screening, the list is endless. They might also inform about practice policy. The notice board, or as it often seems almost every available space on the walls is used in a vain attempt to ‘communicate’ with people. But this sort of communication is carefully choreographed in the retail and service industry:

Businesses like gas stations and banks regularly provide information about the availability and price of particular items, such as gas, convenience items, loans, and savings certificates. The display of this information plays a central role in these companies’ business strategies for increasing traffic and sales. Indeed, the value of a corner or other highly-visible location rests largely on the ability to use signs to inform passers-by about the availability of a business’ goods and services. University of Cincinnati Economics Center

The way these notices are displayed can have an impact on the bottom line of the business:

In conclusion, exterior electronic message boards offer business a lift in store sales performance and generate a relatively quick return on investment. While the overall 2.12 percent lift in sales is modest, in a high-volume store with low installation costs, the investment returns to using this technology can be significant. University of Cincinnati Economics Center

Your bank, department store, hairdresser does not stick everything they have on their walls and hope for the best. The walls in a doctors’ premises are high-value real estate, not a back street that can be pasted with whatever junk is sent by whoever wants to get attention until the material becomes dog-eared or torn. The key is to focus on ‘content of local and contextual relevance’. However, in the end, the wall space should prepare the patient for the consultation. It is in the consultation that the advice can be tailored to the patient and as Wicke and colleagues concluded in 1994:

More modern methods of communication such as electronic notice-boards or videos could be used. However, the waiting room might best function not as an area where a captive audience can be bombarded with health promotion messages, but rather as a place for relaxation before consulting a health professional, making patients more receptive to health advice in the consultation. Wicke at al.

Would it really do any harm to jettison this confetti altogether?

Picture by Bala Sivakumar

Start the consultation as you mean to continue

What I consider this week requires no renovations, no insurance rebate or government subsidy. It does require clean hands. Yet the humble handshake has the power to catapult a meeting into an entirely different dimension.

Many of our social interactions may go wrong for a reason or another, and a simple handshake preceding them can give us a boost and attenuate the negative impact of possible misshapenings.  Dolcos

The importance of any act that makes for a more positive interaction is that doctors are more often than not in the ‘sales’ business. They ask us to ‘buy’ all the time:

  • Buy my advice
  • Buy the recommended tests
  • Buy this diagnosis
  • Buy the suggested lifestyle change
  • Buy these pills

On the other hand ( pardon the pun) some researchers have called for a ban on handshakes because they can spread infections. But are you more or less likely to ‘buy’ from someone who does not shake your hand?  The evidence that the simple handshake can make a huge difference to the outcome of a meeting is overwhelming but there is precious little written about it in the medical literature.  As recently as 2012 researchers at the University of Illinois noted that:

Despite its importance for peoplesʼ emotional well-being, the study of interpersonal and emotional effects of handshake has been largely neglected. Dolcos et al

We have all heard that handshakes have an impact on the outcome of job interviews. But perhaps more than any other literature consumer psychology has a lot more to say on the subject:

A successful sale depends on a customer’s perception of the salesperson’s personality, motivations, trustworthiness, and affect. Person perception research has shown that consistent and accurate assessments of these traits can be made based on very brief observations, or “thin slices.” Thus, examining impressions based on thin slices offers an effective approach to study how perceptions of salespeople translate into real-world results, such as sales performance and customer satisfaction….Participants rated 20-sec audio clips extracted from interviews with a sample of sales managers, on variables gauging interpersonal skills, task-related skills, and anxiety. Results supported the hypothesis that observability of the rated variable is a key determinant in the criterion validity of thin-slice judgments. Journal of Consumer Psychology.

We now have very sophisticated was to assess the impact of our behaviour on each other. And when functional MRI is deployed the data suggest:

A handshake preceding social interactions positively influenced the way individuals evaluated the social interaction partners and their interest in further interactions, while reversing the impact of negative impressions. Journal of Cognitive Neuroscience

David Haslam (Said by the Health Service Journal to be the 30th most powerful person in the British National Health Service in December 2013) wrote:

Touch matters. Really matters. It is a highly complex act, and touch has become taboo. Touch someone’s hand in error on the bus or train and both parties will recoil with hurried exclamations of ‘sorry’. To touch someone has become an intimate act–generally limited to family, lovers, hairdressers and healthcare professionals. The very word carries significance. We say we are touched by an act when it moves us in a strongly positive emotional way. And all manner of other phrases have connotations that link touch to emotion–giving someone a shoulder to cry on, or saying ‘you can lean on me,’ ‘hold on,’ ‘get a grip,’ ‘a hands on experience,’ ‘keeping in touch,’ ‘out of touch’ and so on. For doctors, touch can be a vitally important part of our therapeutic armamentarium. I’ve lost count of the times that I’ve leant over and held someone’s hand when they started to cry in the consulting room. The healing touch

In a small study now a decade old, Mike Jenkins suggests that a spontaneous handshake proffered by the patient at the end of the consultation is a very good sign:

This small study suggests that most handshakes offered by patients towards the end of consultations reflect patient satisfaction — ‘the happy handshake’. Indeed, many reasons were recorded using superlatives such as ‘very’ and ‘much’ representing a high level of patient satisfaction — ‘the very happy handshake’. Mike Jenkins

It cost nothing- although, in some cultures, it may be taboo to shake hands. In most cases, it can only help to establish trust and improve the outcome of the consultation. Of course, if you care enough to want to engage with the patient you would wash your hands thoroughly before sticking out your hand but failing to make physical contact at the outset comes at an enormous cost of reducing the ability to put the patient at their ease.

Whatever we decide patients notice:

I saw one of your doctors today, she didn’t shake my hand, listen to my heart, do any type of extremities tests to verify my condition. Just referred me to another doctor. Is this the kind of poor medicine I can expect from the rest of your professionals? Mark Roberts, Facebook

Picture by Rachel

The first thing people see is an ugly great barrier

For effective engagement with their quarry, the service provider has to be open. When the first point of contact with that person is a tall desk it sends the wrong message. The reception counter says:

  • You are on that side, we are on this side.
  • We are hiding things from you back here.
  • You are here to ‘get something’ from us, we’re not sure we want you here just now.
  • We are very busy and your needs are one of many things we have to cope with today.

There are many aspects to designing the ‘ideal’ reception counter but first, consider the reason for having one in the first place:

What kind of impression should it make? Should it be warm and inviting, or bold and austere? What kind of reaction do you want to create in the visitor? Is it purely functional or a real ‘statement piece’ aimed at dominating the whole area? Jo Blood

For many practices, it seems that the counter is designed to process a queue much the same as the counter at an airport check-in or a vehicle licensing office. It speaks to what we think of our visitor:

Who will be using it from the visitor side? Will it be treated with respect by all who come into contact with it, or must it be able to withstand some abuse? Maybe a tough, metallic finish plinth would help to prolong the counter’s working life. Jo Blood

When you arrive you must:

  • Check in.
  • Prove that you are entitled to be there ( i.e. you have an appointment)
  • Prove that you can pay or that someone will pay or make a payment.
  • State your business clearly and briefly.

The counter hides PCs, printers, fax machines, security equipment. It’s there to keep people from abusing staff and to keep people out. To complete the ‘look’ the walls may be covered in mismatching posters and the counter stocked with leaflets dispenser full to the brim. Who reads this stuff? There is limited evidence that such communication has any impact. There are suggestions from the retail industry that less is more.

As for the counter, it is generally as tall as it can be.

An able-bodied visitor with a typical minimum height of 1540mm approaching a raised counter tall enough to hide a large monitor on a desktop height of 740mm, would clearly struggle to make eye contact with a seated receptionist. As a rough guide, a counter height of over 1200mm will create a potential ‘blind spot’ resulting in the visitor remaining almost unseen and making the counter simply too high to be practical for signing in.

But what if the reception counter were removed altogether? It’s not unthinkable if hotel chains are beginning to consider it:

Two bloggers walk into a hotel …No, that’s not the opening line to a joke. We’re talking about two travelers who picked the same hotel chain — Andaz, a boutique Hyatt property. One stayed at a Los Angeles Andaz, the other at a New York City Andaz. Neither lobby contained a front desk — a budding hospitality-industry trend that’s equal parts chic and shrewd. Bill Briggs

But of course, doctors clinics are not hotels or airport terminals. But that’s not to say that clinics should not be welcoming, comfortable and inspiring places to be. This issue received some attention in the medical literature last year- with the authors of the paper were cited as concluding:

96 percent of patient complaints are related to customer service, while only 4 percent are about the quality of clinical care or misdiagnoses. Kelly Gooch

There are umpteen ‘reasons’ why it is so. Primarily the process of dealing with payments. However such administrative tasks are also a part of many other industries and they are striving for better solutions rather than risk their customers take their business elsewhere.

The critique of the paper quoted above included an insightful comment from a ‘front of house’ staff member:

Our role has developed from “just scheduling staff” to a more complex, and crucial, role for any healthcare organization. We are the start and end of every patient visit and also the start of the revenue cycle. In order for “customer service” to improve, an organization first recognize the importance of their Patient Access department and understand that their processes are directly related to the culture of the organization. Kelly Gooch

Is it possible that people who perceive that their visits are welcomed are more likely to take the advice on offer? Isn’t that what healthcare is about? We have had evidence for this for decades. This quote from the literature says it all:

…the feeling in the practice when you arrive, busy…exhausted receptionists, people fed up, waiting , a feeling of delapidation and stress…You can hear people being put off on the phone and you can hear ‘no no I can’t put you through to the doctor now’, ‘no no you’ll have to call back’ and that makes you feel worse because you don’t want to call back at an inappropriate time. Gavin  J Andrews

The reception area engenders the circumstances in which the outcomes of care are compromised. There is a better way and at least one Australian practice has redesigned the experience.

Picture by Barnacles budget accommodation

Some things in medicine need to be modernised

Many of our experiences in life have changed beyond recognition. Shopping for example- you can now choose whatever you want and have those goods delivered to your door. When you shop in person you can check out your own purchases and find out the nutritional value of the food you buy by scanning the barcodes on the packets using your phone. You need never visit a book shop or a library ever again and you can get all the music and films you might ever want delivered to your living room. You can even hear what other people think of these things before you buy.

You can hail a taxi, book a flight and find accommodation where ever you are going on holiday without getting off your couch.  You can draft a review of that taxi or accommodation as well as discover what others have thought of the same good or service. With minimum effort you can change the way these things flow into your life so radically that your grandma would hardly recognize it as ‘shopping’. You need never do to a post office again and you can even pay your taxes on line. While the way these things are brought into our lives have changed, we are still buying food, reading books, travelling and watching films as we did decades ago.

Similarly you make an appointment with a doctor from the comfort of your chair. You can even have a video consultation. In some places you can have the order for your medicines delivered to a pharmacist so that you pick it up on the way home or have it delivered to where ever you happen to be. For some conditions you can choose to see someone other than your doctor. Some supermarkets now stock some of the medicines that were only prescribed by doctors. However that experience is not the same as visiting a doctor face to face. That experience is a watered down version of what was available to your grandma. Your grandma’s doctor met her in person, he or she touched her and knew about her life. He might even have visited her at home. In many ways your grandma had it much better than you do even though she had to get herself across town to the clinic. It was even called the drug doctor and it was as potent as anything that has ever been distilled in a lab.

On the other hand the experience when you see a doctor in person is the same as it was decades ago. You still ‘take a ticket’ and wait with everyone else.  The receptionist still treats you like a number.  You still have a very short time with the doctor sitting in the big chair, in the same busy office surrounded by paperwork and dog eared posters. If anything the doctor might even just look at a computer screen throughout your visit. How could the experience be improved? What happens in every other service where you might still need to see someone in person? Your hairdresser, masseuse, your manicurist. How much do you value those experiences? How could seeing a doctor in person be modernized but retain its core value in our lives? How would we convey our gratitude if the experience met with our approval?

Picture by Francisco Osorlo