Tag Archives: doctor patient relationship

I am terrified of needles

imageLike every other organisation that requires you to sign up there is a ritual when patients aka customers visit their doctor’s practice for the first time. In most places where I’ve worked people are sent away from the counter with a clipboard and a bic biro. The data collected is mostly for administrative and billing purposes. This information is later entered onto the computer database by a receptionist, oddly enough minus a lot of the information that the doctor might find useful, such as  the patient’s allergies, their height and weight and their family history.  But far more important are other omissions: Why this practice? Why now? What are the person’s hopes and expectations? The practice’s are always clearly articulated on every sign post:

There is a charge for non-attenders. The doctor reserves the right to cancel your appointment if you are more than 20 minutes late. Payment must be made in full after the consultation. This practice charges a ‘gap’ payment of $50 per consultation. Abusive language and behaviour will not be tolerated. We aren’t open on bank holidays etc.

Nowhere is it apparent that the practice is interested in the patient’s ideas and concerns. We are left to discover these in time. Sometimes we do, but only if we are moved to seek that information:

I hear you are good with young children. My parents are your patients. Your practice is close to my office. I need regular prescriptions for opiates. I prefer a male doctor. You seem to have a nice office. Your receptionist is my neighbour. I am terrified of needles etc.

And what of the hopes and expectations:

I need you to believe I am in pain.I want you to help us cope with mum’s dementia. I need to be reassured about my symptoms. I am a hypochondriac but want you to be interested in me anyway. I want a scan of my abdomen. I have been injured at work and want compensation to help pay my debts. etc

It might be so much easier to make progress in the subsequent consultations if we sought this information, acknowledged receipt and made this a backdrop to the subsequent meetings. It is so rare, and so gratifying when the organisation, institution, company, supplier or practice appears to care from the moment you enter their portals.

Picture by Cavale Doom

Prepare to say no

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For 10 years I have ridden my 50cc scooter on the streets of Perth, Western Australia. I now want to take my scooter to other parts of Australia- but alas the laws in some states won’t allow it. In WA you can ride a scooter on a WA car license, elsewhere, mostly you need to do a motorcycle test.  Nonetheless I decided to speak to the people at the licensing offices. May be someone would find a way around this. Several people in officialdom seemed irritated that I was making life difficult on the 2nd of January with an office packed full of teenagers doing their test. They vaguely looked at their computer and told me to speak to the licensing offices in the other states. I already had. No one had a definitive answer. Eventually I was ushered in to do a theory test- despite the fact that I had a valid license that allows me to ride my scooter in this state. Having passed the test in about 5 minutes I was ushered to counter 18 to speak with Jayne ( not her real name). She said what I was thinking:

This is ridiculous. Did anyone speak to a supervisor?

I didn’t think so. I didn’t want a motorcycle license. I just want to ride my Vespa moped in other places in the country. My existing license needs to indicate the inclusion of the class ‘RN’. A class that is already incorporated in my ‘LR’ designated license. She looked concerned:

If I can sort this out today, I will refund the money you have just paid for that test.

She spoke to her supervisor, I saw it happen. Then she went to the ‘big boss’ in the office next door. Through the glass window I saw her pleading my case. She eventually told me what I had already guessed- I would need to do the test although I was apparently already qualified. The authorities could then indicate that I had formally been tested and could add ‘RN’ to my license. I’m dubious but that’s the best that was on offer.  Throughout her dealings with me Jayne was empathic and supportive.

If you have any problems on the day of your practical test please don’t hesitate to ask for me at this office.

This was an object lesson in how to enforce the rules even when saying no. We decline requests in healthcare often:

Patients often arrived at the office armed with complex and marginal information from the Internet that was inconsistent with standards of care. Sometimes, if the patient’s spouse was enrolled in a separate insurance plan, the patient moved to a second “primary” provider through that plan to obtain the desired referral. Even if I work with a different kind of patient population in my new practice, I would like to know how to handle patients who insist on having unnecessary and expensive diagnostic studies performed or request treatments of dubious benefit. Victoria Maizes

We need Jayne’s skill in handling these situations. In soccer terms this is a set piece play.

Be Prepared: know exactly WHAT your responsibility is;
Be Organized: know exactly WHERE on the pitch you should be;
Be Aware: know exactly WHO is where at all times;
Be Active: know WHEN to move and HOW to get where you need to go — Get to the ball!

Circumstances in which we have to say ‘No’, are easy enough to predict in health care. Not all of them are curved balls. Our team needs to be prepared for a situation when the ball is kicked out of play. Jayne was motivated to give me what I wanted but because she was not able to, my request did not trigger the response I desired. She took longer to deal with my problem than she needed to. She demonstrated that she was indeed not able. I was in the office at least 90 minutes. She asked me to wait while she investigated and dealt with other customers.  She went above and beyond the call of duty. She offered to reimburse me if the rules were wrong. She made eye contact. She smiled. She showed empathy. In the end I will do that test and whatever the outcome I will write to the licensing office in praise of Jayne. Her job is to apply the rules, not write them. She need never see her customers again and can remain yet another faceless person there to enforce the rules even when they are daft.  In health care where continuity of care matters, we cannot simply vanish into the ether like yet another public official. Denying someone something that they feel might help them, or that they are entitled to may have greater consequences than the right to have a toy on the street. On the occasion when the patient is unable to trigger the response they wish from us their relationship with us is strained. We need to be prepared to say no but to retain their trust.

Picture by Carlos Fronseca

How to make data more valuable

The 1st of July 2014 will be forever etched in my memory. On that date I woke up and peered across the bed to the window. Realising by the half light it was just past dawn I wondered why there was another body in the bed. It should have been at the gym. So I turned over and put my arm around her. I registered she was looking straight at me. She then uttered the words no man wants to hear who hasn’t planned for it. ‘Happy anniversary darling’. In the micro seconds it took my male brain to weigh up a response, her female intuition had already worked out my dilemma and laid the charge. ‘You’ve forgotten haven’t you?’  Guilty. I had forgotten. The rest of the day was spent demonstrating that 1. I loved her and 2. regretted forgetting our special (and easily remembered) date. It would have been so much easier to focus on one rather than both. A stitch in time and all that.

Later in the week I received what looked like a court summons with an official looking government stamp on the envelop. The letter inside read:

Dear (first name, last name),

Did you know that around 80 Australians die each week from bowel cancer? ..blah, blah , blah,…inviting people turning 50….blah, blah,.. faecal occult blood test kit with instructions…sent to you in the next few weeks…blah blah. If you are already being treated for bowel cancer contact….during business hours.

Yours sincerely,

Scanned signature

Chief Medical Officer.

Not ‘Happy birthday this is a big one mate!’ Not ‘We want you to stay healthy and happy’. No connection with me. Just a cold request to take a government funded test now that I have reached an age when my bowels are more likely to turn on me. Were they concerned about me or the statistics? This lack of connection may be part of the reason most people fail to participate in what is a life saving program.

Still later in the week my reception staff told me that a patient had left something for me in the staff room. Also being an Indian he anticipated my penchant for curries and had prepared a small feast as a thank you. Instant connection. I felt appreciated. I pulled out my pen and drafted him a note. The government invitation on the other hand, though it may save my life didn’t have the same impact. Sure I’ll take the test but only because I know it’s a good idea.

People who chose to share intimacies with us want to know that we really see them and that they matter. Medical practitioners and general practitioners in particular document all sorts of information about their patients; height, weight, gender, waist circumference, family history, alcohol and tobacco consumption, sexual orientation, menstrual history, temperature, blood pressure, pulse, heart sounds, medications, allergies, etc. How about their date of birth? Anniversaries of births, deaths and marriage? Why don’t we collect and use this information to make a connection? What I would have appreciated from my doctor in April this year was a hand written card that said something like:

Happy Birthday Moyez! Thank you for letting us be part of your life. We wish you health and happiness always. Don’t forget your wedding anniversary 01/07/2014! This year you can help keep yourself in good shape by taking the bowel cancer test, someone will write to you about that soon. To mark the very special occasion of your 50th birthday we have donated $20 to Medecins sans frontieres  Australia (http://www.msf.org.au/). Please stay in touch and call us if we can do anything to help you stay in good shape this year.

If a practice manager at an average Australian general practice searches their database for every 49 year old who visits the practice, I guess the list would contain a 100 souls at most. A 50th birthday card would cost the practice less than $25 including the donation. The goodwill that would generate would be priceless and make all of our lives better. As experts have noted:

GPs who initiate discussions about screening with underserved population segments in particular (e.g., those aged between 50 and 55, men, and people from a non-English speaking background) are in a unique position to decrease inequity in health outcomes and improve morbidity and mortality from bowel cancer. Carlene Wilson

 

Testing assumptions before innovating

Successful innovations are based on addressing ‘real’ problems. They are not founded on assumptions that haven’t been tested. All too often we are presented with ideas that don’t really address the problem from the perspective of the end user. Usually these innovations are designed to solve someone else’s problem and then foisted on an unsuspecting end user. The result is the creation of yet another problem and worse of all wasted resources at a time when economies are under strain.  There is another way. In a very generous contribution with a more sensible approach Julius Parrisius offers this brilliant slide deck. It involves actually finding out what the ‘client’ aka end user needs from you to get through their day, what they find challenging about the problem in question and what’s on their wish list.

The issue in healthcare is that many value propositions are hard to pin down, either because the circumstance are relatively uncommon or because people don’t want to talk about them. They include people presenting/ experiencing:

  • Cancer symptoms- especially the kind that involve embarrassing symptoms- diarrhoea or offensive discharging from unmentionable orifices.
  • Psychosexual problems
  • Sexually transmitted disease
  • Substance abuse
  • Death and dying

Sure you can organise focus groups with a handful of ‘representative stakeholders’ but are you really going to get to the truth? The whole truth? There isn’t really a better way then observing the interaction between practitioner and patient. The challenge is that no one wants you or your video camera in the room while they confess their problem and the care professional doesn’t care for this either. Ethics committees tend to agree. What’s more this preliminary, hypotheses generating research is seldom funded by anyone and sounds daunting- much more so than calling up a friendly ‘stakeholder’ from your list and taking it for granted that they know what they are talking about. So you enlist the ‘support’ of your token end user on one of your ‘project steering groups’ and then hope and pray that they haven’t misled you. Unfortunately it can persuade grant committees that you have done your homework. They won’t find out until they read the press following a launch of your baby and discover that other end users don’t agree. Then you…start again, if anyone still trusts you.

The other issue is that you may also uncover evidence that could land the professional end user into some difficulty-failure to provide evidence based practice with actual patients cannot be overlooked if it is likely to put people at risk in the future. You have a responsibility to protect people- notwithstanding your role as innovator. So, where to from here? How do you get behind closed doors without interrupting the business at hand and while also allowing the practitioner to demonstrate their ‘pain’ with this problem/ issue? Our team has done well deploying simulations. It has allows us to generate and even test hypotheses in an environment in which people have not been put at risk and also relatively quickly allowed us to duck blind alleys before we were committed to them. The key is to accept that the rubber always hit the road when the person with the problem seeks help- in our setting that is usually when they present to a general practitioner /primary care physician/ family doctor and therefore the stage, the props and the actors are already defined- all we have to do is produce enough of the script to let the cast develop the plot- the rest is done by the participants and the truth will out.

The importance of touch in the medical consultation. There is no app for that

When people are scared or in trouble what they want most is to be touched. Information alone is never enough to satisfy the deepest human needs that bubble up when our bodies appear to malfunction. This was recognised generations ago and the role of doctor was socially ordained. Doctors are licensed to examine the body intimately. Any doctor who abuses this trust is severely punished. The examination provides the healer with the information required to make a diagnosis, but more importantly it comforts the sufferer through human contact.

When I was a ‘wet behind the ears’ GP trainee, my clinical mentor offered me two pieces of advice in relation to the medical consultation. He told me to always stand up to greet the patient as they walk into the room and to look for an opportunity to lay hands on the patient, even if only to take their pulse.

Innovators may be tempted to think that everything that takes place in the consultation can be distilled down to the exchange of information and advice. However the consultation is designed to promote healing by allowing people to express concern and empathy through verbal and nonverbal behaviour. The former requires excellent communication skills, the latter is conducted as a series of rituals: ‘inspection, palpation, percussion and auscultation‘. And even as the body is examined the patient needs to feel that the examiner is concerned and respectful. If this is done well, healing can begin, sometimes against the odds.

This has important implications for innovation in health care. It’s not possible to interrupt or diminish the direct association between the doctor and the patient with gadgets or gizmos. If we do we may lose more than we gain.