The future of healthcareLearn More

Much of what’s wrong with healthcare is in the consulting room

It’s not that complicated. Not really. So where do you look for pathology? Inspection, palpation, percussion and auscultation. How does it look, how does it feel, how does it sound and what do you hear when you know where to listen closely. I’m talking about healthcare. Take a helicopter ride through your business.

Access

What is the route to your service? Where is the delay? How long do people wait in the waiting room? How do you know? What do you know about the people who use your service even before they are seated in your waiting room?

Greeting

What happens when people call or arrive in person? What message is conveyed?

Welcome we’ll do our best to help you today OR you are lucky we are ‘fitting you in’.

Just stand there- I’m dealing with someone on the phone.

We have no time- go complain to the manager/politician/ bureaucrat-consider yourself drafted to the cause.

Hold the line. We are dealing with something far more important but your call is really important to us so just listen to how good we are as conveyed by our prerecorded message.

Associated with that is what is perceived about your attitude that is not verbalised?

Look at ALL these posters and the many ways you can be helping yourself instead of wasting our time.

People vomit and pee while they wait so the seats have to be cleaned with detergent. Plastic is the best option.

If you want a drink go buy one at a cafe.

We rely on donations for our toys and magazines- we don’t have to provide anything OK? Now if you don’t like the stuff just watch Dr. Phil.

What do you mean you have been waiting a couple of hours? This isn’t McDonalds now take a ticket, sit down, shut up and wait. And turn off your phone so you can hear the old lady at the desk who has an embarrassing problem.

Communication

How long is the meeting with the provider? How does that meeting unfold? What is conveyed during the meeting?

Welcome- I’m so sorry you are not well. Tell me what happened? OR I haven’t got long what do you want exactly, spit it out be quick about it I need to get on with the next guy. Didn’t you see the queue out there?

I’m the important one around here- you are lucky I’ve chosen to be here today. Let me tell you about my holiday, my kids, my new car. It’s fascinating really!

Room 5. Quickly. Never mind my name.

Test/ Referral and Prescription

What action is taken at the consult and are you confident that is the best possible action?

I don’t have time for talk- have this test and take another day off to see me next week.

I don’t have time for you to take off your umpteen layers- go have a scan.

The rep told me this works- I only have to write a script.

If you want to get better take my medicine/advice/ referral or get lost.

What medicine do you want? How do you spell that? Tell me slowly I’m writing it down on your script.

Outcome

What proportion of people takes your advice/medicine/test? How many people stopped smoking? How many were triggered to lose weight? How many are addicted to prescribed medicines? How many were prescribed treatment or tests that were not indicated? Where’s your data? What are your plans for dealing with this?

Team

To what extent can you say that when people transition to another healthcare professional either on site or elsewhere that the relevant information follows them? Is everyone on the same page with the same patient?

All of this matters. All of it. Some of you can fix tomorrow. No need to wait for another round of healthcare reform. No one said it was easy. And whatever their business the best don’t compromise.  A lot of what can be fixed in healthcare takes place behind the closed doors of the consulting room.

Picture by Daniele Oberti

Create your own working conditions or deal with the headaches

It was Friday morning. S/he looked well so I was surprised when s/he said:

I woke up with a headache this morning. I’ve taken paracetamol. I feel a bit better but I couldn’t go to work this morning.

What do you do for a living? I asked. Insert into his /her response:

Teacher/nurse/social worker/call centre operator/forklift driver

Is it busy just now? I asked. Wondering how his/ her boss would take the news of this absence. The smile slipped.

It’s been terrible this year. Lots of demanding (patients/ clients/ kids/shifts).

Then- tears.

I’ve got to hold it together. I’m only six months away from ( holiday/ long service leave/ wedding/ boss leaving)

Is this sustainable? Really?

How much time do you spend on things that are either distractions (not-urgent or important) or someone else’s emergency (urgent /not important)? How much time do you spend on the most valuable quadrant not urgent and important? Why are you always fire fighting (urgent and important) ? Icon made by Ocha from www.flaticon.com

What are you doing during the most productive time of the day? What do you focus on first in the morning? When you are fresh and rested? What are you leaving till later when you should be heading home? Icon made by Freepik from www.flaticon.com

 

It’s your responsibility to set limits to your accessibility. If your boss wants you to do this then s/he doesn’t expect you to do the other.  Are you sure you clarified the situation? YOU have created these unreasonable expectations because the word ‘no’ isn’t in your vocabulary. Icon made by Freepik from www.flaticon.com

 

Finally how much energy, stamina, good will or creativity is left in the tank? There is a limit- even for you. Icon made by Freepik from www.flaticon.com

You are not exempt even if you are a doctor. If you don’t create the life you want then one will be created for you. And it might just give you a headache. You have some thinking to do while you nurse that headache.

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The chasm between patient experience and clinical practice

Can you guess what this abstract relates to without clicking on the link:

ABC is advisable if the patient does not show sustained improvement after a year of active treatment by other indicated means. The operation often represents the turning point in effective treatment. After the first year of ineffective treatment valuable time is being lost, with danger of fixation and deterioration. Then it is safer to operate than to wait. Calif Med. 1958 Jun; 88(6): 429–434.

That operation was last carried out in the 1960s. 40-50,000 were performed in the USA alone. This is what was reported about one person post op:

The reason for Dully’s lobotomy? His stepmother, Lou, said Dully was defiant, daydreamed and even objected to going to bed. If this sounds like a typical 12-year-old boy, that’s because he was.

What is being described below in 2011?

Remission of diabetes mellitus occurs in approximately 80 percent of patients after XYZ. Other obesity-related comorbidities are greatly reduced, and health-related quality of life improves. Complications and adverse effects are lowest with laparoscopic surgery, and vary by procedure and presurgical risk. Am Fam Physician. 2011 Oct 1;84(7):805-814.

In the same abstract the authors, Schroeder et al say:

The family physician is well positioned to care for obese patients by discussing surgery as an option for long-term weight loss…. Patient selection, pre surgical risk reduction, and postsurgical medical management, with nutrition and exercise support, are valuable roles for the family physician.

What do we know about this surgery?

According to the Schroeder:

Complications and adverse effects are lowest with laparoscopic surgery, and vary by procedure and presurgical risk…. Overall, these procedures have a mortality risk of less than 0.5 percent.

Here are some videos of what we are talking about. So what’s the patient experience?

Immediately post op:

Days 7-10: Now, at this stage, I shall only eat 4-6 Tablespoons of food each “meal” and I should have 5-6 meals a day. I can add mashed potatoes, custard, and pudding, but I must be VERY careful to keep it really low sugar and really low fat. Otherwise, my tiny pouch will rebel and make me regret it. Big Fat Blog

After a couple of years:

I had a lap-band. Then I had it removed after 2 years. The restrictions on drinking meant that exercise was difficult. And while I’ve felt emotionally broken for years, those two years were the only time I’ve felt physically broken. The experience was miserable. Big Fat Blog

Years later:

….almost 12 years later, there are still foods I have trouble eating. It still takes me 30 to 45 minutes to eat a meal, even if it’s just a sandwich and some chips. I have to stay away from anything that has a lot of sugar or a lot of grease in it (explosive diarrhea is not something you want to deal with in a public space, take it from me, been there done that). Big Fat Blog

Here are reflections from another blogger:

  • A few months after my surgery I started to have significant hair loss.
  •  It is important to take your vitamins.
  • There have been times that I have forgotten and do drink after I have eaten and when I do this I become quite uncomfortable and this is the occasions I may feel the need to vomit.
  • My taste buds have changed.
  • After I eat most of my meals or have a drink I get a little burppy. Not sure if it’s because I have eaten my meal too quickly (which I do), but it’s a side effect that hasn’t gone away.
  • This is really hard, everybody knows I have had the surgery but what they don’t understand is how little I can eat. I have to remember to ask for a small plate of food and I feel awful when I can’t eat all they gave me.
  • I hit a dark place about 2 weeks in, as I could only drink soups, watered down gatorade, sorbet etc. I really struggled with people eating around me being that I couldn’t eat.
  • I have tuckshop arms, which only recently have started to bother me like this morning when I saw them wobbling when I was drying my hair. It also does get me down a little when I lift my arm up and I notice people noticing my arms. I have an apron fold on my stomach from my pregnancy with the twins. When I have lost all my weight I would like to get the excess skin on my stomach removed. I will only do this when I have lost all my weight though. The organised housewife 

Experience of referral:

A few years later I moved and had to find a new primary care physician. She suggested Weight Loss Surgery… I asked her if she was familiar with WLS research regarding success (lack thereof), mortality rate, etc. After she answered, no, I asked her how she could recommend such a surgery when she was ignorant of its effects. She had no answer. Big Fat blog

So back to the literature (note the dates):

Undergoing laparoscopic sleeve gastrectomy induced efficient weight loss and a major improvement in obesity-related comorbidities, with mostly no correlation to percentage of excess weight loss. There was a significant weight regain and a decrease in remission rates of diabetes and, to a lesser extent, other comorbidities over time. JAMA Surg 2015

And

Not all bariatric patients, however, experience mental health gains from weight loss surgery, which is likely attributable to patients’ reactions to common undesired physical outcomes postsurgery: lack of weight loss, weight regain, and undesirable skin changes. Patients’ expectations that bariatric surgery will undoubtedly change their life may also set them up for psychological failure if expectations are not met. Journal of Obesity 2013

Finally we might reflect on the lobotomy as per Gregory Myers:

  1. The surgeon who introduced the world to the lobotomy was awarded the Nobel prize
  2. Some thought it was better than the alternative
  3. There was poor patient follow up
  4. It had significant adverse effects
  5. There was inadequate patient information and consent
  6. It destroyed people’s lives
  7. It was often a rushed procedure
  8. The indications for this invasive surgery were not limited to severe illness
  9. It was replaced by drug treatment

Is history repeating itself? It may by relevant that the global bariatric surgery market size was valued to be over USD 1,300 million in 2014.

Picture by rossodilbolgheri

Are we allowing technology to hamper healing?

13866052723_2020820f89_zYou’ve heard it before

I’m at that age doctor when I should have a full body scan. Like it’s being offered here.

or at the very least

Can I have a scan doctor?

When offered radiological tests immediately the public is led to believe that such investigations are necessary. In Australia between 1996 and 2010, total CT scan numbers have increased almost 3 fold. (Medicare Australia, Group Statistics Reports 2010, Report No. 2. Available from here). The number of CT scans is reportedly growing at about 9% each year in Australia. In the USA there are estimated to be 62 million scans per year as compared with about 3 million in 1980 with growing concern about the wisdom of exposing people to increasing levels of radiation.

At the same time the value of most tests carried out is also in doubt. In a study of an academic medical department it was concluded that:

…almost 68% of the laboratory tests commonly ordered…. could have been avoided, without any adverse effect on patient management; this figure corresponds to 2.01 unnecessary tests ordered/patient during each day of their hospitalisation. Miyakis et al

In the context of hospital medicine inappropriate test ordering adds to the cost of healthcare. In primary care there is the additional concern that tests fail to achieve any useful outcome. The patient may experience considerable dissatisfaction with the failure of diagnostic tests to explain their pain and may feel they they are being labelled a malingerer.

Therefore one might pause to reflect before requesting yet another investigation. Physical examination, which arguably obviates the need for many tests has an enormous value to the patient even in the context of advanced cancer.

Most patients (83%) indicated that the overall experience of being examined was highly positive (median score, 4; interquartile range [IQR], 2-5; P ≤ .0001). Patients valued both the pragmatic aspects (median score, 5; IQR, 4-5) and symbolic aspects (median score, 4; IQR, 4-5) of the physical examination. Increasing age was independently associated with a more positive perception of the physical examination (odds ratio, 1.07 per year; 95% confidence interval, 1.02-1.12 per year; P = .01). Kadakia et al

According to Paul Little and colleagues reporting in the BMJ perceived pressure from patients is a strong independent predictor of whether doctors examine, prescribe, refer, or investigate in primary care. It seems, at least in part that we may be responding to such pressures to order necessary tests. On the other hand our perception of the value of examination may be blunted.  As Professor Little wrote:

The doctors thought, however, there was no or only slight medical need among a significant proportion of those examined (89/580, 15%), given a prescription (74/394, 19%), or referred (27/125, 22%) and among almost half of those investigated (99/216, 46%).

One could argue with the doctors’ impressions of the ‘need’ for medical examination. To some extent it is necessary in every case. We may be losing the sight of the therapeutic effect of the examination as part of effective communication in primary care. There is a need to revitalise our ability to heal. At a time of increasing costs in healthcare examining patients is a relatively low cost intervention with significant potential to improve outcomes.

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For best results next year leave the office now

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Let’s agree what success looks like at work. It’s simply ‘better outcomes for those you serve’. It’s about improving on what was done yesterday. Machines can ‘do’ many things but they can’t imagine. People can be made to work like machines but unlike machines their ‘parts’ can’t be replaced easily when things start to fail. However people can be replaced. If you exist to ‘do’ things that could be done more efficiently or more profitably you will be replaced perhaps not today or tomorrow but soon enough. If your boss doesn’t sack you, one day in the foreseeable future you will walk out when it all gets too much to bear.

So your real value in whatever you do is the ability to add value and to do that reliably and sustainably.

Think of a time when you landed that job, made that discovery, found that break through, solved that problem. Could it all have been different? What if you had failed that exam? What if you had succumbed to that virus? What if you hadn’t met that key partner? What if they hadn’t supported you? What if the funds hadn’t been available? What if you hadn’t attended that course or crossed that road? What if Fleming hadn’t gone on holiday or noticed that Petri dish?

Often described as a careless lab technician, Fleming returned from a two-week vacation to find that a mold had developed on an accidentally contaminated staphylococcus culture plate. Upon examination of the mold, he noticed that the culture prevented the growth of staphylococci. Endocrine today.

What if the egg containing your genes hadn’t been fertilised? Your life by statistical computation is a miracle.

If you go back 10 generations (250 years) the chance of you being born at all is at most 1 divided by 6 x 10100 or
1 in 60000000000000000000000000000000000 00000000000000000000000000 000000000000000000000000000000000000.
In gambling, even a chance of 1 to 100 is not worth a gamble. Hooge

You don’t really ‘do’ anything other than join the dots, but first you need to see the dots. There is nothing you have including life that couldn’t be taken from you in an instant.

At this time of year, for many people, there is an opportunity to invigorate that part of the brain that is the crucible of creativity. For best results flood the senses with new experiences; listen to new songs, read, taste different food and let your brain prepare to solve problems by making room for new ideas. De-clutter, let go the oars and do that for the sake of those you serve if not yourself. So say to your boss this is the most important thing you are doing for him this year- sharpening the saw.

Do you believe this sound conducted by Morricone is the product of a mind focused on the banal? You too have done some extraordinary things this year- big things, little things, all of which point to your potential to improve this world. What you believe about where the ideas come from doesn’t matter because they will continue to flow into our experience notwithstanding your convictions. What will matter to your boss in January is that you have an active problem solving capacity. So take a holiday. Enjoy!

Picture by Claus Rebler

Ten things you should know about people who changed the face of healthcare

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They noticed things

They wanted to solve a problem

They were charismatic

They were risk takers

They were resourceful

They were tenacious

They were considered crazy

They were great communicators

They weren’t all doctors

Their ideas weren’t instantly adopted

Alexander Fleming noticed that mould had grown on the culture plates in his untidy laboratory, the rest is history. Edward Jenner wanted to rid the world of small pox, and did. Atul Gawande challenges the conventional wisdom and is an excellent communicator. Barry Marshall infected himself with Helicobacter Pylori. Timothy Presto designed child incubators from car parts. Florence Nightingale faced repeated opposition throughout her life. Ignaz Semmelweis was committed to a psychiatric institution because he promoted hand washing by doctors to reduce the risk of infection during childbirth. Anthony Atala gives a TED talk on regenerative medicine. Kiran Mazumdar Shaw, a zoologist, leads the largest biotech company in India, she was consider unfit to study medicine. William Harvey’s ideas on the circulatory system were not widely accepted by the medical profession. Two things are true of such people today, they are determined and they don’t all personally benefit from what they do for us.

Picture by U.S. Department of defence

Work with employers to improve health

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Annual profits confirm whether the staff of a company performed well. Profit margins, and the rate of innovation, closely reflect the health of the people who deliver that success. Employers are, and perhaps always have been, a key partner in the drive to improve the health of the nation. What has become a greater imperative to forge a partnership is the threat to profit margins from the looming spectre of chronic illness in epidemic proportions. Work is a vitally important aspect in most of our lives:

The average working American spends the majority of his or her waking hours on the job. Some of us live and breathe our work. Others of us work to pay our mortgages. Either way, the workplace has become an important source of social capital for millions of Americans – a center of meaning, membership, and mutual support. More than ever, we find our close friends and life partners on the job, we serve our communities through work-organized programs, and we use the office as a forum for democratic deliberation with people different from ourselves. Countless studies show that a workplace with strong social capital enhances workers’ lives and improves the employer’s bottom line.The workplace and social capital.

Similarly in Australia people spend most of their waking time at work. On average 34 hours a week . Sixteen percent of us work more than 50 hours per week. In contrast we spend 6-9 hours  per week doing house work and 6 hours and twenty seven minutes per day asleep. The impact of the working environment on health ranges from physical to psychological and can be both harmful and beneficial. Employers in most developed countries are therefore legally obliged to provide:

  • safe premises
  • safe machinery and materials
  • safe systems of work
  • information, instruction, training and supervision
  • a suitable working environment and facilities.

However there is much more that can be done to optimise the health of employees. The economic argument for this is clear and closely related to the rising incidence of chronic and complex illness among the working population. In 2002 approximately 59 per cent of global death was attributable to chronic, non-communicable diseases and the toll is projected to increase to 66 per cent by 2030.  The other outcomes that should worry employers is the prospect of premature retirement from the workforce.

It was found that individuals who had retired early due to other reasons were significantly less likely to be in income poverty than those retired due to ill health (OR 0.43 95% CI 0.33 to 0.51), and there was no significant difference in the likelihood of being in income poverty between these individuals and those unemployed. Being in the same family as someone who is retired due to illness also significantly increases an individual’s chance of being in income poverty. Schofield et al

A report by the Australian Institute of Health and Welfare in 2009 outlined the consequences of chronic illness and early retirement on the entire Australian economy. It concludes that:

  • People with chronic disease had, on average, 0.48 days off work in the previous fortnight due to their own illness, compared with 0.25 days for those without chronic disease.
  • The annual loss in workforce participation from chronic disease in Australia was around 537,000 person-years of participation in full-time employment, and approximately 47,000 person years of part-time employment.
  • For people participating full-time in the labour force, there was a loss of approximately 367,000 person-years associated with chronic disease, approximately 57,000 person-years in absenteeism associated with chronic disease and 113,000 person-years were lost due to death from chronic disease.
  •  Estimates of loss do not take into account lower performance while at work. Similarly, the effect of loss from participation in the unpaid labour force (carers, parents and volunteers) has not been accounted for. The estimates, therefore, underestimate the loss in workforce participation associated with chronic disease.

Therefore employers who wish to retain an effective workforce, and by corollary their profitability, need to invest in the well being of their workers. This responsibility extends beyond ensuring the physical safety of their workforce. A workforce that is under threat from an ageing population and an alarming incidence of retirement through ill health. If employees spend most of their waking hours at work then the following might concern the employer (click the links for the literature):

I believe health innovators who address these issues in their dealings with industry will discover an open door with massive potential for mutual benefit.

Picture by Vase Petrovski

Managing demand for primary care

Why do people consult doctors? At first glance because they feel unwell. However research suggests that the reasons are far more complex than that. Innovators also know that the answer to this question is vital for those seeking an agile, intuitive, creative and cheap solution to the demand for their services. Theories predict the consultation habits of many patients. I especially like this summary:

The overall prevalence of symptoms in the community is not closely related to general practice consultation rates, and the consulting population is a selected population of those who are in need of medical care. The literature reviewed suggests that poor health status, social disadvantage poor social support and inadequate coping strategies are associated with higher consultation rates. Some populations subgroups may experience particular barriers to seeking care. Campbell and Roland

Innovators might also ask why are those patients sitting in my waiting room? I remember a hoary old tale of a doctor who was feeling especially grumpy one day and stormed through the waiting room announcing that anyone who thought they had a ‘real’ problem should stay everyone else should go home- half the waiting room emptied.

It seems quite a few people who go to doctors will have symptoms- however a proportion will be back there by invitation. How big a proportion and why have they been invited back? There are many reasons to schedule a repeat appointment. It conveys the notion that the patient will be harmed if they don’t see a doctor on a given day for one or more of these reasons:

1. Their response to treatment is unpredictable and the dose or drug may need to be revised

2. They have a condition that can’t be diagnosed or may progress or need additional measures by a specified date

However other reasons for requesting a review include:

1. The doctor isn’t confident that the diagnosis is correct and wants a chance to review the advice issued.

2. The patient is required by someone (e.g. an employer) to produce evidence of a visit to a doctor

3. A full waiting room ensures the doctor looks busy for whatever other reason.

4. The doctor needs to reinforce the impression that the condition has been taken seriously.

The time cost for doing everything that could possibly be recommended for patients with chronic conditions  has been shown to be untenable. Either the guidelines are wrong or a different solution needs to be found for at least some of these people. What is the evidence for asking a patient to return within a week or two with a specific new condition and within a month with a longstanding condition?

There is a need to be proactive in some cases. However is it possible that we encourage people to attend for review appointments when there is a low probability that they will benefit? Are there other reasons to fill the waiting room?

Instruments of measurement vs. instruments of connection

9597562683_0f1bb9156a_zMany health innovators argue that future advances in health care will come from technological solutions. Things we can measure and quantify. Governments and health care providers are holding their breaths for a magic bullet that can easily, measure and thus fix everything.

People who advocate for technological health solutions think that it’s possible for doctors to routinely consult patients without touching them, or even looking them in the eye.

Stakeholders imagine that that health practitioners spend time with their patients simply to gather and process data. We imagine a future when a patient’s wearable device will be handed over to the doctor, who will have everything he needs to know and more, in order to treat any ill.

That is not to say that we should not innovate, or that technology will not enhance the encounter between patient and healer. However we do need to think about how those innovations will become part of that powerful ritual known as the medical consultation. Technology, high tech or low tech, needs to be incorporated in a way that responds to the person in distress. It should be seen as a means to an end, and not an end in itself. If information was all that was required to get people to adopt healthy choices then why do we make so many decisions that defy logic?

Science has identified that people act on impulse, are moved by emotion, or commit themselves to decisions because it makes them feel good even if they know it’s doing them harm.

The reality is that not everything that matters can be measured. Patients don’t just come to doctors to be fixed. As health care practitioners we mustn’t lose sight of the fact that what patients need as much, (if not more) than, instruments of measurement are instruments of connection.

Picture by Alberto Varela