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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

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

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