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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

 

Healthy living is a hard sell- time to redesign the shop


Doctors set difficult challenges:

  • Eat a lot less
  • Exercise a lot more
  • Stop smoking
  • Drink less
  • Take tablets twice a day
  • Reduce salt

This takes effort and the reason you need to do any of it is because your bad habits have consequences. What is worse is that you may not recognise that you have a problem. You might say to yourself:

It’s not THAT bad.

Everyone in my family /neighbourhood looks like this.

I drink less than my mates.

I like salt, it makes my food taste better.

I won’t remember to take the tablets every day

It’s not like retail- you see something, you like it, the assistant treats you like royalty in a very pleasant environment,  you take out your credit card- that’s it. And there’s also the pay nothing-till- February deal. To please the doctor your habits must change. These habits are reinforced by cued-up behaviour on happy-making dopaminergic pathways. Research has repeatedly reproduced these results:

A sample of Norwegian adults (N=1579) responded to a self-administered questionnaire about seafood consumption habits, past frequency of seafood consumption, and attitude towards and intention to eat seafood. Structural equation modelling revealed that past behaviour and habit, rather than attitudes, were found to explain differences in intention, indicating that forming intention does not necessarily have to be reasoned. The results also indicated that when a strong habit is present, the expression of an intention might be guided by the salience of past behaviour rather than by attitudes. Honkanen et al

You might not see that doctor any time soon. The triggers to the behaviours that you need to change act when you least want them. What’s worse is that some of these triggers may not be obvious to you. You might find yourself chomping on sweets while you watch television. You might crave biscuits with your hourly cup of tea. You might watch television or stop for cups of tea because you are bored or stressed. The problem may not be the sugary snack but the boredom or the way you perceive your current life situation. Recognising that and dealing with is the real challenge. The boredom may be related to the mind numbing job that pays the bills in these ‘hard times’.

Doctors cannot possibly achieve behaviour change simply by pointing out that we are fat or drink too much.

If we conceive of a significant value of  primary care as something that promotes health doctors need to be able to sell the benefits of healthy living so that the patient considers them a priority. Something they wish to do even though it may hurt. It means creating an experience that will impact on the patient’s deepest psychological self. Can we do it from the current base?

  • An office style centre with boring notices and last year’s magazines.
  • Short consultations (ultra short in areas of greatest need).
  • Ineffective communication in uninspiring surroundings.

What can doctors do to change this experience so that the patient is tempted to act? Can what they promote, not to say sell, be made more appealing? According to psychologist we ‘buy’ things because:

  • We think it will make us secure
  • We think it will make us happy
  • We are more susceptible to advertising than we believe
  • We are hoping to impress other people
  • We are jealous of people who own more
  • We are trying to compensate for our deficiencies
  • We are more selfish than we like to admit

Therefore how can health promotion be designed with such an audience in mind? We need to consider every aspect of the experience doctors now provide. It’s not like selling gym membership or  widescreen television. It is about persuading people to make a persistent effort, to forge new habits and to invest in all sort of ways for a future they can’t immediately experience. We know from retailing that:

The …emotional responses induced by the store environment can affect the time and money that consumers spend in the store. Donovan et al

People can be triggered to make instant decisions. But what about decisions that involve a real commitment to change? Small change perhaps but change nonetheless which may lead to smoking cessation. If we look to the future of health innovation then we might learn from experts who have already managed to change our response to the world we inhabit by working out the art and science of triggering.

Picture by Gerard Stolk

Spend a few dollars to enhance the experience at your clinic

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Do you associate a smell with your doctor’s clinic? If you do it’s unlikely to be anything pleasant. I remember my GP’s waiting room when I was a child. He consulted, as did most doctors at that time, from his home and the patients waited in his converted garage. It was always cold and smelled-‘damp’. Not a nice place to be when you had a fever or anticipated an injection. The smell evoked the impression of being somewhere like the picture above which apparently is an abandoned hospital near Berlin. Research suggests this is not surprising:

Subjects then rated their memories as to how happy or unhappy the events recalled were at the time they occurred. Subjects in the pleasant odor condition produced a significantly greater percentage of happy memories than did subjects in the unpleasant odor condition. When subjects who did not find the odors at least moderately pleasant or unpleasant were removed from the analysis, more pronounced effects on memory were found. J of personality and social psychology

So the unpleasant memories of being ill and anticipating pain were reinforced by the musty smell of that waiting room.

We all know that smell can affect our feelings, whether it’s a loved one’s favourite perfume or the smell of a pastry in our favourite bakery. Humans are able to recall smells with an impressive 65% accuracy a year after smelling them, compared to just 50% of visuals after only three months, making it all the more important to use this additional sensory tool when trying to engage with customers. Engage Customer

Of all the things we consider about the experience we offer our patients smell is the least of them and yet potentially the most powerful. We carefully pick the colour scheme, the toys and magazines, may be even the floor coverings and the video entertainment but rarely if ever the smell. Perhaps it is because until relatively recently it was thought that humans had a poor sense of smell. However research has debunked that myth:

These results indicate that humans are not poor smellers (a condition technically called microsmats), but rather are relatively good, perhaps even excellent, smellers (macrosmats). This may come as a surprise to many people, though not to those who make their living by their noses, such as oenologists, perfumers, and food scientists. Anyone who has taken part in a wine tasting, or observed professional testing of food flavors or perfumes, knows that the human sense of smell has extraordinary capacities for discrimination. Gordon Shepherd, PLOS Biology

Here’s Engage Customer again:

Scent and sensory marketing have the potential to increase sales, boost brand loyalty, spur brand advocacy and create a strong lasting emotional connection with customers. Customer experience goes far beyond simply what meets the eye, or the ear, so try and create a lasting impression for your customers which appeals to all their senses.

Researchers shown consistently that scent has an important impact on satisfaction but also on the quality of the interactions between people in a public space. This has implications for the value of one of the ‘props’ in your practice i.e. the smell.

whats-it-aboutListen to Fred Lee  vice president at two major medical centers and a cast member at Walt Disney World in Orlando, Florida. He suggests in this TEDx talk that we should be focusing on ‘patient experience’ rather than ‘patient satisfaction’. More than 137,000 people have listened already.

We need to move away from the limitations of ‘patient satisfaction’ which is characterised by the cheesy phrase:

What else can I do for you today?

To patient experience which is all about engaging with the patient in all five senses. Some service providers are already on to this:

Airlines Infuse Planes With Smells To Calm You Down (And Make You Love Them). The Huffington post

Picture by Stefano Corso

It is time to redesign the consulting room

Those who talk about the future of healthcare often describe the world as if the patient were a robot. They speak of devices and computers that will tell us what nature has already equipped us to know:

I haven’t slept well, I didn’t do much exercise today, I ate too much and I drank too much.

Many futurists appear to believe that providing information on a small screen will be enough to make all the difference to our behaviour. Doctors know this is a fantasy driven by commercial interests because they also know by virtue of their experience that so much of what we choose is contingent on more than just information. Some of these ‘innovations’ are losing market share faster than the receding snow cap of Kilimanjaro.

The overwhelming evidence is that if I decide to stop smoking it isn’t just because of the information that tobacco causes cancer. If  I commit to jogging four days a week it isn’t only because of information on how little I’ve moved today. These decisions are driven by much deeper psychological factors. We are ready to act on this ‘information’ only when the compulsion to make new commitments is greater than the urge to maintain the status quo. This happens in teachable moments. These are unique to each of us. When there is motivation and ability but we are also triggered to act then as BJ Fogg proposes we will do something different. Noting that we will sustain the effort only as long as it is a new habit. Therefore the task in the consultation is to gauge the motivation, enhance the ability, trigger the action and help to generate the habit.

The future of healthcare isn’t simply about access to information, whether on a wrist band or on a video screen. It isn’t only about access to the doctor or some pale imitation of the real thing.  The world of healthcare cannot exclude the physical presence of the practitioner as the one who can address all four aspects noted above by engaging people at the deepest human level. However as a starting point to designing the future we note that doctors are often at odds with the patient in the consultation:

There is evidence of a discrepancy between the numbers of problems noted by the patients and their doctors. It is possible that this is because doctors give priorities to certain diagnoses while ignoring others. Doctors may also focus on a known pre-existing condition of a particular patient rather than attending to the actual reason for the encounter. Thorsen et al

The authors further conclude:

The vast body of literature covering consultation patterns focuses on patients’ reasons for deciding to consult. Little research has focused on what patients have on their minds while in the waiting room regarding the forthcoming consultation.

Policy change that aims to turn back the clock so that people are forced to visit the same doctor who will do the same old thing….sound uninspired. If we consider the consultation as theatre then there are aspects that cannot be changed. Neither the actors nor the the plot (healthcare) can be changed. Patients will attend doctors who are trained to take a history, examine the patient and prescribe treatment. However the props and the script can be used to greater effect. These components impact on what the patient can see, smell, taste, hear and feel. The impact of these on the outcome of the consultation is the same as the impact on the person’s decision to buy anything.

whats-it-about

The economic reality is that people will be reticent to pay for something that is cheaper or readily available free elsewhere. However they are willing to pay for services that offer an experience. What is becoming a driver for innovation in primary care is the need to offer patients not only what they need but also what they want in terms of engagement with the practitioner. It is about changing how people feel in that space that we call an ‘office’ but could be redesigned as a ‘health pod’ in which the choreography aims to make it easier to identify teachable moments and trigger better outcomes.  An office is for bureaucrats, accountants and lawyers. We need to create a new environment that is conducive to selling health and healthy living.

If you are a doctor try this you might be surprised by the result:

seatHow else can you make the patient feel more valued in the encounter?

Picture by Jeff Warren

Why primary care must evolve to become more effective

In the past patients accessed the same doctor from cradle to grave. By making appointments and queuing. They had brief consultations lasting 10 minutes and left with a piece of paper with the doctor’s signature. In the 1970s and 80s we had much less access to sources of information other than professional advice. We were used to queuing, snail mail and waiting lists. It’s how things were done whether you wanted books, airline tickets, a taxi or a prescription.picture1

More recently patients have been able to access medical advice from multiple sources. It’s faster cheaper and convenient. Drugs and procedures that were only available when sanctioned by doctors are now more freely available. During the past decade this includes ranitidine, salbutamol, contraceptives, various drops, lotions and creams. People have to come to expect this service to be cheap. We expect to be able to get what we want at the click of a mouse be that a product or a service. There is no going back to the ‘good old days’- expectations have far exceeded what it is possible to deliver. It is simply not possible to see the same doctor from birth to death, 365 days a year, 24 hours a day. This ‘McDoctor model’ is driven by commercial interests with the aim of delivering product or procedure rather than any specific outcome.In primary healthcare the notable exception is dentistry where you have to attend in person and expect to spend time on the premises. It is not possible to teleport your mouth to be dealt with by someone on another continent. What is interesting is that we pay for dentistry, in the way that we pay for haircuts, massages and manicures. Meanwhile the technical fix-it solutions that includes pills are not delivering all that we would like in stemming the chronic disease tsunami that has begun to engulf so many economies. Technical fix-its are themselves now a questionable expense. We recognise that over servicing is an avoidable expense.

In much of the world medicine and for many conditions healthcare is now about persuading people to make different choices. To prevent rather than cure. To give up habits that drive chronic illness. Habits that are challenging-exercise, eating vegetables, ensuring restful sleep and maintaining satisfactory relationships.  At the heart of the healthcare experience will be the connection between doctor and patient aiming for improved and measureable outcomes in terms of better lifestyle choices, more engaged patients and much better results following the interaction with the practitioner. To achieve this we need to be able to ‘sell’ new habits. To trigger action on advice that does not come with cast iron guarantees.

How do you know this will work? How do you know these tablets are or are not required? Why do you think this test is not needed?

Serving those who live with deprivation and scarcity. Those whose bandwidth is challenged and who need to muster every bit of capacity to reduce risks for conditions that may not manifest for decades. To engage the person most able to change the outcome- the patient herself. To do this we need to design healthcare with reference to the patient experience. We need to trigger change in behaviour in a timely and efficient manner. However in order to be sustainable the challenge is to design something that is valued to the extent that those who practice medicine are rewarded appropriately by whatever funder we choose to impress.

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What is beyond doubt is the growth of complementary and alternative practitioners notwithstanding, in many cases the lack of an evidence base. What is it that the people who turn to such practitioners seek? What can healthcare learn from the practitioners of complementary and alternative health that could be integrated into the experience of visiting the doctor? How can doctors trigger similar change in attitude and action?

Health care services may undergo fundamental changes in the future, as prevailing conventions are questioned and challenged by informed health consumers. Both academic researchers and politicians and professionals within the health care services need more data from the client’s perspective in order to capture the ongoing nature of outcomes and ‘effects’. How do clients gain access to experts within Western medicine as well as within the CAM ‘movement’? What kinds of services have been beneficial and from which institutions do the clients prefer to receive these services? It is likely that a more dynamic relationship will eventually develop between Western medicine and the CAM movement. Sociology of Health and Illness

Picture by Andrea NIgels

 

Perspective is crucial when considering changes in healthcare policy

It was summer of 2010 in Australia. I had been working hard in the garden one Sunday afternoon. Feeling the need for a little mindless entertainment I suggested to our then 14 year old that we might rent a sci-fi movie. It was around 7pm and  getting dark. My son jumped into the car beside me and we took off toward the video shop. That’s when I noticed that the car headlights were far too dim. I turned on full beam- but it didn’t help. I ranted for a good five minutes about how difficult it was going to be to get a mechanic to look at the car so close to Christmas. I was also a bit put out that our teenager was showing no concern for my predicament. At this point he quietly reached across and took my sunglasses off my face.

There. Problem solved dad.

I learned something that day not least what it would cost me if that story was not be retold to his brothers.

I love the work of Deana McDonagh and Joyce Thomas, especially their thinking on empathic design. Deana and Joyce begin their sessions on empathic design by inviting participants to try on their designer glasses- the ones that demonstrate what it must feel like to have tunnel vision. They’ve written about it in the Australasian Medical Journal. I keep those glasses in my office to remind myself and visitors of the valuable insights they offer but also as a treasured momento of a fun workshop generously organised by a brilliant team.

Their work came to mind later when we were investigating the attitude to self-management of a condition that is progressive and for which there is no cure. Patients and doctors in an Asian setting were interviewed. We recorded poignant stories about the impact of this condition on people’s lives- resulting in social isolation, self loathing and a need to feel supported by a health practitioner:

Both patients and doctors were against the adoption of self-management strategies. This is contrary to recommendations for the management of COPD by many studies and guidelines. However, another study has similarly shown that self-management skills were not rated as important by patients. Furthermore, the psychosocial impact of their disease such as fear limited their ability to manage their own symptoms. A lack of knowledge may also contribute to their dependence on doctors and health care providers.

We concluded:

In reality, patients have to conduct self-management daily and it is not feasible for physicians to provide all of the management needs that patients have during their day-to-day lives. Therefore, self-management remains an aspect of overall COPD care. However, it should not be the only focus and future interventions should also examine ways to improve access to health care.

On reflection we noted something similar with patients in Australia. Those who had an established medical condition were much more likely to ‘trust’ their doctor than those who were not currently unwell or those from higher socioeconomic groups. Innovating requires the ability to see people as heterogenous having very different perceptions on the need to be in charge of their own health, perceptions that are liable to change with circumstances. I also wonder if policy makers consider what it must be like to implement their big ideas from this perspective:

Picture by Redfishingboat

What can hairdressers teach their doctor?

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I had to try a new salon and it was an incredible experience. A long scalp massage, warm towels for my hands and an aroma-therapy treatment (3 sniffs of an oil??) made me feel ultra-pampered. I marveled at Elysa’s ability to tame my mane. The Power of a Haircut

Every shopping centre in Australia also now appears to have a massage parlour.

Stiff, painful muscles? Treatment: Myotherapy. Cost: From $100. Some companies cover myotherapy treatments under their insurance. My body+soul

Each year Australians spend over $4 billion on complementary and alternative medicine (CAM) and visit CAM practitioners almost as frequently as they do medical practitioners. But the spending doesn’t stop there:

The national survey of Australians (18-64 years)…. found over the past four weeks Australians spent an average of $594 each on clothes, accessories, beauty products and cosmetic services.Victoria, the self-proclaimed fashion capital of Australia, is home to the biggest spenders, who spend 19 per cent more than the national average at $707 a month. New South Wales spent $669 on average, 13 per cent more than average, followed by South Australia ($618) and Western Australia ($616). Suncorp bank

On the other hand a family doctor or GP might charge $50 for a standard consultation. The Medicare rebate for this is $36.30, leaving a gap of $13.70 for Australians to pay out of their own pocket. The average amount an Australian pays out-of-pocket for access to a GP is $29.56 a year (averaged across Australia).

So it seems that we are willing to pay up to $100 for one massage, $90 for one hair cut but pay a third of that sum for the services of a GP over a whole year. (Note: people pay far more for a ‘specialist’). The Value Tunnel explains this because the price is a function of the alternative options and the perceived value of that good or service. On that basis the cost of personal grooming is greater than a visit to a family doctor. It may be perceived that the alternative to visiting the doctor in your neighbourhood is to pick one who doesn’t charge above the Medicare rebate, visit a pharmacy or go to an emergency department. There are fewer viable alternatives to a haircut or massage from ‘that’ salon. There is constant downward pressure in the ‘Value Tunnel’ so that as the market accommodates more competition it drives the price down. That’s why a cup of coffee costs less than $5 and is unlikely to increase.

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What can GPs do to move up the Value Tunnel ? They must increase the perceived value while honing a niche market. While doctors no longer hold the monopoly on a range of things they also do things that others can’t offer. How can family doctors recast their brand in a way that sustains if not enhances the perceived value? Like every other business healthcare is subject to market forces. A recent survey offers businesses the following takeaways;

  • Know your customer and form a genuine relationship. What do the doctors know about their patients?
  • Make it easy for your customers to do business with you. To what extent are patients able to access what they need at the practice?
  • Solve your customer’s problems and go beyond what is expected. To what extent is the practice a one stop shop? What does the practice offer that other providers do not? ( Note: pharmacists and video consultations don’t include physical examination)
  • Look for opportunities to make an impression. Does the practice communicate well at every touchpoint?
  • Invest in your frontline staff; they are of course the face of your company, so it is essential that they happily reflect the core values you wish to promote. What are the reception staff like in the practice? Can patients be expected to be treated the same way by everyone they come across at the practice?

Picture by ndemi

How can doctors remain the health practitioner of choice?

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You work as a checkout assistant at a supermarket. It’s Thursday. You’ve got a sore throat. It started a few days ago. You’re sneezing, you’re tired, you’ve got a headache. You’ve taken paracetamol already today it didn’t take away all the discomfort you still feel dreadful. You have several problems.

You want to feel better. Secretly you may be concerned that this is more than just a cold. You want to reassure the people that you are going to be well again in a few days. You want people to understand and accept that you are not functioning at your best at the moment. You want it all now not next week when you might be better or worse.

You may want information but you probably also want to have your discomfort validated and acknowledged. You’ve got some choices to make. You can try and get a doctor’s appointment. You can Google the symptoms and treatment. You can go to the local pharmacy or to your favourite alternative health practitioner. You can also try the emergency department. What you choose will depend on your previous experience of a similar episode but also on what your friends and or family suggest.

Upper respiratory tract infections are among the commonest reasons that patients seek the services of a general practitioner in Australia. It’s a presenting problem in one in twenty consultations. In the majority of cases these infections are viral and don’t require a prescription from a registered medical practitioner.

On the other hand there may be a financial cost to attending a doctor. You will need to take some or all of the day off and you may be required to queue despite you physical discomfort and it is more than likely that the doctor will tell you what everyone has already suggested that you will probably feel better in a few days. Whether you consider it useful to attend the doctor will depend on whether your needs were met last time. How do you feel at the end of the consultation? Did you feel that your visit was welcomed and that you were treated sympathetically? Did the doctor listen to you? Did they examine you? How did they convey the news that there isn’t any curative treatment available? How did they make you feel about the decision to make an appointment at the practice?

If we consider that such ‘trivial’ problems could be managed by another healthcare practitioner then we are asking for one in twenty encounters in practice to cease. How do we convey this message to our patients.

Colds are generally mild and shortlived, so there’s usually no need to see your GP if you think you have one. You should just rest at home and use painkillers and other remedies to relieve your symptoms until you’re feeling better. NHS Choices

The challenge is that most of what the patient is likely to present with as a new problem is similar: bronchiolitis, gastroenteritis, sprain/ strain, viral disease, contact dermatitis, back pain, bursitis, solar keratosis/ sunburn, tenosynovitis, tonsillitis, vaccination. These conditions or problems form a substantial chunk of the workload.

What can doctors add to these encounters that would make them a worthwhile experience for patients? Not just what might be ‘evidence based’ but also perceived as useful by the patient? Experiences that will retain the doctor and not a pharmacist, nurse, chiropractor, naturopath, homeopath, Dr. Google or ‘McDoctor-dial-a-doc’ as the healthcare practitioner of choice. In Australia doctors have typically 15 minutes. Here are some possible value adds:

  1. Offer advice on weight loss and exercise
  2. Advise on smoking cessation
  3. Review the patient’s medication
  4. Promote cancer screening
  5. Advise on vaccinations
  6. Examine the patient
  7. Document any possible risk factors for chronic illness
  8. All of the above

Back to the checkout assistant who is feeling dreadful, wants more than anything to go home after sitting in your waiting room, nursing a fever and a runny nose. It’s up to you of course but it I know which of the above I would want my doctor to do at that time. Patients tell it as they’ve experienced it and research has suggested what they are willing to pay for.

Picture by Tina Franklin

Continuity of care is a good thing right?

There’s a wonderful video that illustrates the point I’m making this week. You can see it here.

It is assumed that continuity of care is a good thing. That if you consult the same doctor every time then you will benefit with better health. We all have relatives who insist on seeing the same doctor every time. No one but Dr. X will do. Yet doctor X has all sorts of interesting approaches to their problems and despite knowing Aunt Mildred for years hasn’t twigged that her latest symptoms may be a manifestations of some family drama. She might suddenly be more bothered about her aching hip because Uncle John is making her miserable or making her carry the shopping on their visits to the supermarket.

So, is there strong evidence that people who consult the same doctor at every visit are:

  1. Less likely to be prescribed inappropriate drugs or have unnecessary tests?- Maybe.
  2. More likely to have symptoms of life limiting illness recognised early?- Not really.
  3. More likely to be counselled about poor lifestyle choices addressed?- Maybe.
  4. More likely to be screened for chronic illness? – Maybe
  5. More likely to be immunised?- Maybe.
  6. More likely to have better outcomes from chronic illness?- Maybe

The evidence is equivocal at best. Even the most ardent supporters of continuity conclude that there is ‘lots more research needed’.

So what does that tell us?

Perhaps it suggests that simply because people choose to see different doctors does not necessarily mean they are opting for, or receiving, inferior care.

When it comes to test ordering ‘walk-in’ patients are not necessarily after tests and there is some evidence that those doctors who order tests in the hope of ‘satisfying’ the patient are misguided.

There is lots of evidence that ‘continuity of care’ increases trust in a doctor. As per the example of Aunt Mildred. But there is no evidence that Aunt Mildred will be better off trusting her doctor because ‘trust’ ( which isn’t consistently defined) does not guarantee better outcomes. If Aunt Mildred attends here GP presenting with symptoms of bony metastases and is referred for urgent investigation because her GP recognises the clinical signs then she will have been well served regardless of whether she attends Dr. X, Dr. Y or someone at another practice. The point is one of them should spot the moonwalking bear.

Picture by torbakhopper

Profiting from vanity- they may be targeting someone you love.

Where I live you’d be forgiven for thinking that you will be reported for child abuse if your teenager has less than perfectly straight teeth. Kids are growing up believing they need to be physically perfect.  So when the first crop of zits appears there is a hasty and often expensive trip to the chemist. Treating acne is a $3 billion industry in the United States alone.

..but i just feel so ugly when i see pretty girls with perfect skin around me.. it just makes me feel terribly disgusting, honestly. like i’m less of a person. it’s not fair. at my age there’s so much pressure to look beautiful constantly. even though i know most people don’t care how good you look a lot of them are secretly judging inside… everyone does it, even me..Nyla

Those in the age group 15-24 account for 7.6%  of consultations in general practice. Significant or life limiting pathology is unlikely in this age group but for many these meetings with their doctor will set the tone for a life long relationship with their main healthcare provider. For young people acne and eczema are the reason for almost one in three consultations with a GP. Sadly it has been reported that some teenagers get a very poor deal when they pluck up the courage to see a doctor:

It’s not that he doesn’t listen … sometimes he doesn’t fully comprehend that he’s talking in a way you can’t understand … it would help if they talked to teenagers. ( As reported by Jacobson et al in the BJGP)

This could be a missed opportunity to forge a relationship with the patient. If you are a doctor it may be worthwhile rehearsing a lucid explanation of common problems presented to you, including and especially acne. There is a bewildering array of opinions on this problem. Indeed the conclusion of research on this topic was that the majority of young people are getting information from non physician sources and there may be a need to evaluate the resources they are using to make sure they are receiving appropriate, helpful information. That includes parents who would rather their teenager would learn to live with her spots and expect you to endorse that view.

For those who want a ‘cure’ the opportunity for to profit from their distress makes them vulnerable to the most unscrupulous practices. $3 billion USD represents a substantial market for lotions, potions and diets that don’t work.

Substantial numbers of those surveyed had ideas about cause, treatment, and prognosis that might adversely affect therapy. Rasmussen and Smith

The truth is acne is a manageable condition, it’s just a matter of finding a treatment that works for an individual. For most people, it may take few attempts at find something that works. For some, over-the-counter topical creams are fine, for others, oral antibiotics or hormonal treatments work better, and yet others only respond to drugs prescribed by a dermatologist, with multiple courses required in relatively rare circumstances. The goal of having clear (or at least totally acceptable) skin is not unreasonable. This is a teachable moment in the interaction with young people.

Picture by Caitlin Regan