Tag Archives: doctor patient relationship

Nurture the most potent pro-innovation quality

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What we value most in any work place are problem solvers. Such people are the engine of the business. They increase productivity and efficiency, reduce costs and complaints. Creative, intuitive, energetic, generous, observant, empathetic, compassionate, committed people who consistently give their best. People who deploy their skills to produce value rather than to maintain employment through crisis and catastrophe. The healthcare industry and medicine in particular has fostered an environment where problem-solving capacity is limited.

Extensive literature suggests that contributors include excessive workload, loss of autonomy, inefficiency due to excessive administrative burdens, a decline in the sense of meaning that physicians derive from work, and difficulty integrating personal and professional life. Shanafelt et al

We sometimes take the brightest and best train them at great expense and place them in circumstances in which survival is the best on offer. The consequences are that those who have the greatest potential to improve outcomes for patients, themselves succumb to ill health.

If we accept, as many do, that the cost and demand for health care is rising exponentially then we need to generate ideas on how to face the future.

Total global health spending was expected to rise by 2.6 percent in 2013 before accelerating to an average of 5.3 percent a year over the next four years (2014-2017). This growth will place enormous pressure on governments, health care delivery systems, insurers, and consumers in both developed and emerging markets to deal with issues such as an aging population, the rising prevalence of numerous chronic diseases, soaring costs, uneven quality, imbalanced access to care due to workforce shortages, infrastructure limitations and patient locations, and disruptive technologies. Deloitte

We need to harness the insights of those who apportion scarce resources on a daily basis. Those who know from personal observation when resources are not being put to the best use. These individuals, like those of the many who work at the coalface in other industries, will only rise to the challenge when they are resilient.

Psychological resilience is defined as an individual’s ability to properly adapt to stress and adversity. Stress and adversity can come in the shape of family or relationship problems, health problems, or workplace and financial worries, among others. American Psychological Association.

Four personality traits in particular have been identified as having a strong influence on one’s capacity for resilience: self directedness, cooperativeness, harm avoidance, and persistence.

  • Self directedness: people who are conscientious, resourceful and goal oriented
  • Cooperativeness: Resilient people don’t lose sight of their own principles but work out solutions to achieve the best outcome for everyone. They are empathetic and excellent communicators.
  • Harm Avoidance: Their ability to accept uncertainty and a degree of risk generates confidence for decision-making in medical dilemmas and emergencies.
  • Persistence: They have a bias towards maintaining behaviour with stamina despite frustration, fatigue, or discouragement.

How do you support your team to foster these qualities? One-way is to encourage reflection and reflective writing in particular. Help the individual to assess if their expectations of themselves and others are realistic. To become aware of their unhelpful reactions or attitudes to the behaviour of others. And to have a sense of their own standards and expectations. There is some evidence that the habit of reflection has a therapeutic value. Empirical evidence for benefit of resilience to productivity comes from elsewhere but finds great resonance in health care:

Teachers working in inner city high schools in the United States face enormous challenges. Their students, most of whom come from economically disadvantaged minority families and often do not speak English as a first language, present a daunting array of educational needs for teachers and schools. Resources and school structures are seldom sufficient for the task. Despite such conditions, some urban high school teachers persist for many years in the classroom and experience success and satisfaction in their work. Through a survey and extended interviews, this study identifies three broad factors that motivated a group of these teachers to remain in inner city classrooms for more than 12 years: (1) the students, (2) professional and personal satisfaction, and (3) support from administrators, colleagues and the organisation of the school. The study discusses how the teachers’ resilience enabled them to overcome difficult challenges and recurring setbacks and to persist vigorously in their work. Gerard Brunetti

Picture by Gabriel S. Delgado C.

In a call to action timing is everything

Nebulizer Baby

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

Health professionals frequently impart information as a call to action:

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

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

  • Clinical visits for health promotion and acute illness

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

  • Notification of abnormal test results

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

  • Pregnancy

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

  • Hospitalisation and disease diagnosis

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

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

Picture by Kristy Faith

Turning up can be the most effective innovation

doctor consultation

What do the following having in common?

  • The doctor you remember fondly
  • The best teacher who ever taught you
  • The professional who helped you when you were feeling vulnerable

They showed up from the moment you needed them. ‘Elegant Andrew’ was our first obstetrician’s nick name. He was also my boss.  He was called ‘Elegant’ because he was always formally dressed, even in the middle of the night when he was hauled out to get a baby out of trouble. He organised a scan, almost as soon as he knew we were going to be parents so that we could say  ‘There beats the heart of a Jiwa’.  He was excited for us. He did not have to be there for the delivery because he trusted the midwives on his team and they were clearly at ease with him. But we knew that Andrew could get a baby out within 20 minutes of being called if there was a problem. I saw him do that for a woman who bled unexpectedly during labor.  He was there minutes after we entered the labor ward and then again as soon as our baby was born. We have the pictures to prove it. His smiling face beaming down at the newborn in his arms as if he were family.

We also remember the solicitor who facilitated the purchase of our first home. We were new to Scotland and were hardly familiar with the laws around buying and selling property. From the moment we entered his rooms we felt a sense of calm even though we knew that one of his juniors was handling the actual transaction. He walked us through the process, connected us with his team and telephoned in person to tell us we were homeowners as soon as it was official. We sought his help again until we moved out of the country and he informed us with great regret that he could not help us in another jurisdiction.

The point is that these individuals built the relationship with their clients before there was a problem. They showed up. They engendered a sense of personal involvement and excitement or concern and whether it was good news or bad they would be there in person. Some things can’t be delegated. Establishing and maintaining a relationship with your clients or patients is one of these. The enormous social capital that can be banked simply by being there at the key touch points in the relationship is crucial. It doesn’t mean that you have to do everything that is required in a complex case where team work is necessary. However there are critical points in the journey where you have to show up. The outcome, good or bad will be recalled in the light of your first encounter with people. There are many factors that impact on outcomes for people who seek professional advice. There is much that can assist to improve the outcomes; technology, drugs, procedures and luck. However one key factor remains through all such events in our lives, the human factor. People have an innate desire for human contact when they are feeling challenged. Be there if that is the nature of  your business.

Friendships born on the field of athletic strife are the real gold of competition. Awards become corroded, friends gather no dust. Jesse Owens

Picture by ILO in Asia and the Pacific

A test has most value when the prevalence is high

4647883696_c564082a24_zA perennial problem in primary care is whether to schedule laboratory tests. This is an issue that is often very perplexing early in clinical careers because there is often a lot of pressure or perceived pressure not to miss the rarest of rare conditions. The secret, if there is one, is to know the prevalence of the condition before testing for it. Supposing a condition has a prevalence of 20% (1 in 5) in a population, this would be considered very high. What if the recommended test detects 95% of cases (sensitivity) and identifies 80% of people who did not have the condition (specificity). If the test were applied to 200 people:

  • 70 would be identified as positive and of these 38 would be ‘true positives’. Therefore 32 people would be told they might be sick when they were not (positive predictive value = 54.29%).
  • On the other hand 130 would be told they were not sick when two of them were ‘false negatives’.

If the same test were applied to the same population but the prevalence was 2% (1 in 50), in other words pathology is unlikely, then:

  • 43 people would be identified as abnormal and of these 39 people would NOT have the condition (positive predictive value = 9.3%).
  • On the other hand 157 would be reported well, which was everyone with a negative test.

The impact of a test is not only on those who are found to have pathology but also on those who are told they might have pathology and need more, often invasive tests, for a very unlikely condition. Prostate cancer testing has been studied in this respect.

In primary care tests for life limiting illness in particular can be calibrated with a high sensitivity (more true positives), so that pathology is not missed and a modest specificity (more false positives) which means that more people might be subjected to further investigations because their symptoms need explanation and they may need more investigations. However a false positive result has a significant impact on the patient’s life. The numbers above illustrate the impact of prevalence on the proportion of people without pathology who would be subject to further tests. The higher the prevalence, the more worthwhile the test and the better the positive predictive value of a test. You can play with these numbers using this on line calculator.

A question to ask whenever requesting a test is how common is this condition in people like the person to be tested?  If it isn’t very common what harm could be caused by multiple tests to ‘prove’ this person doesn’t have this condition? In the business of healthcare no patient, client or customer should be subjected to tests without the practitioner having a firm grasp on how the test will help to manage the case. By corollary there is no short cut to taking a detailed history and examining the patient in order to make a diagnosis. Tests can never compensate for poor practice, nor should they be used to try to impress a patient that ‘everything is being done’, often what is being done is iatrogenic harm.

Picture by National Library of Medicine.

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.