Picture by JD Lasica
Picture by JD Lasica
In the wake of her book launch I had the honour to interview Dr. Halee Fischer-Wright President and CEO of MGMA. In her book: ‘Back to balance:The art, science and business of medicine’ the author asserts:
We have lost our focus on strengthening the one thing that has always produced healthier patients, happier doctors, and better results: namely, strong relationships between patients and physicians, informed by smart science and enabled by good business.
In a separate blog post Larry Alton, business consultant addressing the business community says:
In 2017, you’ll find it difficult – if not impossible – to be successful without strategizing around customer communications. Customers have become conditioned to expect interaction and service. Provide both and you’ll be delighted with the results.
Most people will interact only with primary care when they need healthcare. The average consultation in primary care is less than 15 minutes. Therefore efficient communication is a priority. Larry Alton goes on to advise:
Communication is at the heart of engaging and delighting customers. The problem is that, even with all of the new advancements in communication technology, very few businesses are taking this all-important responsibility seriously. This results in poor relationships and a bad brand image.
His four key action points are:
One area that seems to receive scant attention in medical practice is explaining technical concepts. And yet technical concepts are integral to medical practice:
Ours is a technologically proficient but emotionally deficient and inconsistent medical system that is best at treating acute, not chronic, problems: for every instance of expert treatment, skilled surgery, or innovative problem-solving, there are countless cases of substandard care, overlooked diagnoses, bureaucratic bungling, and even outright antagonism between doctor and patient. For a system that invokes “patient-centered care” as a mantra, modern medicine is startlingly inattentive—at times actively indifferent—to patients’ needs. Meghan O’Rourke
When explaining complex ideas there is a checklist:
Adapted from a post by Thorin Klosowski
Perhaps the neatest medium to communicate some aspects of a complex idea is the infographic. According to experts:
In the past 5 years, the term “infographic” has seen an impeccable rise in trend.In fact, the popularity of infographics is expected to see an increase of almost 5% by next year, meaning that anyone who isn’t yet riding the infographic bandwagon is bound to fall behind. The Daily Egg
Here are the data:
The Journal of Health Design has recently introduced the Infographic as a submission type. Communicating using this medium could reduce the time required to assimilate the information needed to make a decision.
Much of what we do in healthcare is communicate ideas. That is far more common than ‘doing’. Executive control over decisions are the purview of the patient. It is a basic tenant of medicine that the patient has autonomy.
Often armed with little more than a stethoscope doctors must communicate to the patient that:
When communication about the evidence base is effective the patient, the practitioner and ultimately the economy benefit. How we communicate such ideas is where innovation has the brightest future. It gives us hope that we can improve outcomes in health without recourse to major policy change or curbing freedom of choice.
We communicate in words, pictures, video, audio and using models. Yet so much of how that is done in the doctor’s office hasn’t changed over the decades. ‘It’s just a virus’ doesn’t cut it any more.
We experience the power of effective communication everyday and in every other area of our lives. Look at your credit card statement this month- does it all make sense? What pressed your ‘purchase‘ button?
What if this extraordinary power deployed so effectively in commerce was unleashed in the clinic?
Picture by Dan Moyle
Despite billions of dollars of investment in technology the results in healthcare are disappointing.
Information Technology (IT) surrounds us every day. IT products and services from smart phones and search engines to online banking and stock trading have been transformative. However, IT has made only modest and less than disruptive inroads into healthcare. Nicolas Terry (2013)
This was predicted in a prophetic article by Gregory Hackett (1990) when he concluded that:
The primary reason is that technology alone does not determine corporate performance and profitability. Employee skills and capabilities play a large role, as do the structures of day-to-day operations and the company’s policies and procedures. In addition the organisation must be flexible enough to respond to an increasingly dynamic environment. And products must meet customer requirements. Investment in Technology-The Service Sector Sinkhole? SMR Forum Service
However, there are still those who seem enamoured of machines:
Rapid growth of robotic industry is leading to novel applications in medical field. Evolution of new terminologies like tele-presence, tele-medicine, tele-consultation, tele-diagnosis, telerounding, tele-health centers, tele-doctors, tele-nurses are overwhelming and required to be readdressed. Iftikhar
That way leads to a nightmarish world in which we push vulnerable people onto an assembly line and healthcare looks like this but also includes the dehumanising impact of machines:
….. hospitalists care for sick inpatients and are charged with rapid throughput by their administrative overlords; nocturnists do this job as well — but at night; intensivists take over when work in a critical care unit is required; transitionalists step in when the patient is ready to be moved on to rehabilitation (physiatrists) or into a skilled nursing facility (SNFists). Almost at the end of the line are the post-acutists in their long-term care facilities and the palliativists — tasked with keeping the patient home and comfortable — while ending the costly cycle of transfers back and forth to the hospital. Finally, as the physician-aid-in-dying movement continues to gain support, there will be suicidalists adept at handling the paperwork, negotiating the legal shoals and mixing the necessary ingredients when the time comes. Jerald Winakur- The Washington Post
Technology now impinges on every interaction- for better and for worse:
There were the many quiet voices who urged circumspection as long ago as 1990:
Diagnosis is a complex process more involved than producing a nosological label for a set of patient descriptors. Efficient and ethical diagnostic evaluation requires a broad knowledge of people and of disease states. The state of the art in computer-based medical diagnosis does not support the optimistic claim that people can now be replaced by more reliable diagnostic programs. Miller
One could not argue against technology as a tool but the art of medicine requires that technology helps the doctor. People are not disordered machines and the promise of better health is not forthcoming as we throw money at machines hoping for greater access, efficiency, and safety. However, there is now mounting evidence that the patient is not responding and it’s time to pause for thought, again.
It’s not that complicated. Healthcare works when the doctor and her patient are on the same page. So to what extent does a gadget or gizmo allow that? Does it help them to:
If it becomes a substitute for the doctor it will disappoint. People respond best to human doctors. No ifs or buts. Medical school 101. Doctors also have choices in how they deploy and interact with technology. Turning to face the computer, ordering a test and recommending an app aren’t always the way to the best outcome.
Picture by Guian Bolisay
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.
Listen 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
The probability that your family doctor will need to make heroic efforts at your next visit is very low. That’s because you are most likely to go with a minor self limiting illness and the best she will be able to do is reassure you that the rash, cough, discharge or fever will resolve in a few days. She might recommend paracetamol, rest or exercise and above all apply judicious tincture of time. You will leave the room feeling better or decide that you have wasted time. Either way it will influence how you feel about going back to see that doctor and inform your opinion about whether it was worth the dollars you, the funder and or the government invested in that visit.
A desk, chair and a couch furnish most consulting rooms. How that furniture is arranged may have an impact on how you feel about being in that space. We know that posture, eye contact and verbal communication matters. However we might also consider that where we sit in a room, and what we sit on also influences the interaction. This is true of boardrooms but it also applies when there are only two at a desk. There are three factors in raising perceived status and power using chairs: the size of the chair and its accessories, the height of the chair from the floor and the location of the chair relative to the other person. Executive chairs, the kind the doctor might sit on are bought because they are perceived to convey authority. ( OK, may be also because they are comfortable). But nonetheless they create an impression:
The height of the back of the chair raises or lowers a person’s status…the senior executive has a high backed leather chair and his visitor’s chair has a lower back.
Therefore from the moment the person enters the room they glean the impression that they are less important than the person in another spot. Unlike the situation where the seating arrangements make the person feel valued.
Picture by Cacau & Xande
First impressions are the love-at-first-sight of the business world.
If you are a doctor have you ever considered letting the patient have the high back leather chair? How doctors position themselves physically relative to the patient matters. There is some evidence in the literature but there’s nothing better than trying it yourself.
Patients commonly perceive that a provider has spent more time at their bedside when the provider sits rather than stands. Swayden et al
The perception that the doctor is spending more time is important because in some cases there isn’t more time available. There is not much doctors can do in the short term about healthcare policy or resourcing. However just by changing the seating arrangements in the consulting room they can convey to patients that they matter. That’s before they even begin the consult. I’ve tried it, I think it works.
Picture by banlon1964
I didn’t think I could have heard her right.
Oh yes doctor $2000. The vet lets me pay it back in instalments. He did the same a couple of years ago. He is very kind.
This old lady had visited me umpteen times. I knew she didn’t have a lot of money and that on occasion she would go without her pills because things were tight. She tried to make ends meet by working as chef at a greasy spoon. Her boss was a bit of a bully and often refused to pay her overtime. I had seen her through oesophagitis, osteoporosis and breast cancer. Each time she couldn’t afford to expedite the investigations and insisted on waiting months to be seen as a ‘public’ patient. But that weekend her dog had been paralysed and the vet had been authorised to carry out emergency surgery. Something she would be paying for months into the future.
Australia has one of the highest rates of pet ownership in the world. The pet care industry in Australia is estimated to be worth $8.0 billion annually. 39% of households own a dog. In fact 50% of Aussies live in a household with at least one cat and or dog in it, whereas only 35% share their household with at least one child under 16. Companionship is the driving reason behind pet ownership. Australians are showering pets with gourmet food, protecting them with insurance and pampering them with reflexology, acupuncture and hydrotherapy. Pet food has been compared to baby food in terms of resilient market performance. I notice that one of the major supermarket chains has half an isle now stocking chilled pet food.
Most pet owners consider their pets to be members of the family and this has a powerful impact on how and what people buy. Julie Power
This trend has taken medicine by surprise. It may be prudent to enquire if your patient has a pet and if that pet is well. This is especially the case for pensioners whose dog or cat may be the only company they have. The impact of pet ownership on health continues to be debated. On the one hand it is considered to be beneficial, for reasons unknown. On the other hand being responsible for a pet may negate all the benefits. It is stressful worrying about the dog barking and annoying neighbours or damaging property.
Health care practitioners might ponder the impact of these surrogate family members on the lives of people. For pensioners in particular:
High levels of grief may also be experienced in the event of a pet’s death. Other aspects include cost, time, and behavioural problems that may lead to further stress, anxiety and loneliness. Bradley Smith
It is helpful to know if the person who is consulting you smokes tobacco or drinks alcohol. We think nothing of asking other intimate details. However we often fail to ask if the person has a pet. It might explain a lot.
Picture by Malcolm Payne
Australians do a lot of flying. That’s what comes of living mainly in coastal cities on the edge of a huge land mass. So we spend a lot of time watching cabin crew run through safety procedures. I’m wondering if that’s something we should do before we consult our patients or clients. Here are three things you might ask yourself during consultations this week:
1. Am I fully with this person in the room just now?
2. What do I know about this person and the impact of their problem?
3. What happens if whatever it is that’s bothering them doesn’t improve or gets worse?
I sometimes wonder if I could be replaced by someone who hasn’t spent 6 years at medical school, four years training and then more years than I care to count ‘practicing’. The answer depends on the extent to which I am able to reach beyond myself on the day the question is posed. On the best days I can pick up on subtle cues. When it’s not so good it’s because I’m not all there.
There are lots of reasons why that might happen. Maslow’s hierarchy of needs explains it succinctly. Hunger, fatigue or boredom are not conducive to caring. Yet we have, and in some cases still expect, our health care staff to function despite those feelings. Roger Neighbour developed a wonderful model for the consultation in primary care. This remains the only guide that specifically includes ‘housekeeping’ as an essential step:
Neighbour acknowledges the need for the practitioner to take care of their own feelings, particularly those brought about by a consultation. If not, the emotions, possibly negative, engendered by one consultation, may spill over into the next.
Perhaps we could take it one step further and determine if someone is fit to work as a health professional on a specific day and especially if they are far too grumpy to care. Many have witnessed objectionable, rude and insensitive behaviour from those who should know better. It was once accepted as the senior doctor’s right to be ill tempered. It may still be. If it is then it should be no longer because anger clouds effective communication. And effective communication is vital to the art of medicine. We aren’t always at our best. Being aware when we aren’t is a first step to ‘safety netting’ as Neighbour put it.
Cancelling the flight because the pilot has a cold isn’t always an option. However replacing the pilot may be wise if she has lost interest in flying the plane. It matters how we look as health practitioners but perhaps it matters even more what we are thinking, and therefore feeling, as the patient enters the room. For those with an interest in innovation, here is the first and perhaps vital focus for improving the quality of the experience for the consumer.
Picture by Ryan Hyde
Research reveals that a US civilian is expected to spend 72.35 years in the community, 59.5 days in short-stay hospitals, and 2.28 years in nursing homes throughout his or her lifetime. The probability of receiving care from a primary care physician is 100%. It is conceivable that an individual may never need specialist services but it is inconceivable that an individual will never need to attend a primary care practitioner.
It is therefore a priority to ensure that the impact of contact with primary care practitioners is optimised. Two recent studies meet the criteria for lean innovations- low cost, agile, intuitive and creative solutions to common problems. The first of these was published in the British Journal of General Practice . The authors set out to increase the attendance rate for adolescents to general practitioners. Simply writing to young people as they reached the age of 16, assuring them of their privacy was enough to boost attendance rates. The results were remarkable. The authors, Aarseth et al conclude:
The proportion of adolescents in contact with a GP increased from 59% in the control group to 69% in the intervention group (P<0.001). For the males, the increase was from 54% to 72% (P<0.001). An information letter about health problems and health rights (such as the protection of the adolescent’s privacy) seems to enhance the accessibility and utilisation of GPs, as measured by contact rate, particularly for males.
The second study, also involved writing to patients and was published as part of a PhD thesis.
The project ’10 Small Steps’ encompasses the development and evaluation of a general practice based RCT designed to improve ten lifestyle behaviours known to be associated with chronic diseases. The low-intensity intervention involved providing computer-tailored feedback, based on a health behaviour summary score, to more than 4500 adult patients recruited through 21 general practitioners in Brisbane, Australia. Participants were followed-up at 3 and 12 months. The intervention was effective in improving the health behaviour score. These findings demonstrate the potential for a low-intensity intervention to improve the adoption and maintenance of health behaviours in a primary care population and for general practice as a conduit for the primary prevention of non-communicable diseases.
These studies exemplify the scope for significant health gains through low cost interventions developed, administered and evaluated in primary care.
The foreign-looking chap in the baseball cap, the one wearing a pair of torn jeans and a singlet, the one on the mobile phone, sporting a dragon tatoo on this forearm might be a famous musician and the only son of a bedridden widow. But you’ve decided he is probably a drug addict and treat him with suspicion and hostility. On the other hand the smartly dressed, attractive white woman carrying the brief case might be a drug dealer and you greet her with a welcoming smile. I was born of an ethnicity that wherever I have lived or worked people I meet for the first time assume things about me that are false, even laughable. Before I open my mouth, my students are invited to guess the nationality on my passport, the city where I was born and my first language. They mostly get it wrong. Therefore I do people the courtesy of not making assumptions. Often in medicine the doctor is the only person who will treat some people with respect in a day when they have to contend with lots of challenging behaviours, whether because of their appearance, their accent, their culture, the clothes they wear, their disability or their needs.
I should not have been surprised by research that suggests that doctors know very little about their patients. And least surprising was the finding:
Physicians were poorer judges of patients’ beliefs when patients were African-American (desire for partnership) (p=0.013), Hispanic (meaning) (p=0.075), or of a different race (sense of control) (p=0.024).
Could a doctor pick out a patient’s partner, whom they have never met from a police line up? Would they know what car that person drove? Would they have any idea what their patient had for breakfast? Where that person is planning to go on holiday ? What they wanted to be when they grew up? In many cases it doesn’t matter but as innovators we feel we are able to develop interventions that will make it more likely that those very people will comply with our prescriptions, give up smoking, eat more vegetables, wear a condom and monitor their chronic condition. Not all at once of course!
Technology now allows us to take a bird’s eye view of our practices. We record key parameters for people who attend our clinics- for example blood pressure, cholesterol and glycosylated haemoglobin and can link that to geographical data- demonstrating where our poorly controlled diabetics live. We might like to guess before we are presented with the data- I bet we would be way off the mark.
Then we can see if there is public transport to bring those people to the clinic. Where they buy their food. Whether there are open spaces and leisure centres within reach. Could those people easily attend an optician or a podiatrist? Only then should we contemplate something locally that will make it more likely to improve outcomes. But only after we check our assumptions with the people for whom the innovation would be designed. This work has a local flavour- ineffective innovations are designed on a ‘one-size fits all’ model as if everyone lives in an affluent middle class neighbourhood and seek care at the convenience of the healthcare provider. To quote Idris Moottee:
The customer is King, Queen and Jack. Any innovation efforts will fail eventually if the end user is not driven to use your new product or service. Most consumers are intelligent and can contribute so much to the process. It is true that people can not always voice their needs and desires in a way that makes sense, but our job is find creative ways to understand their attitudes, values and behaviors and figure out how to include them in your innovation process.
Meanwhile my friend Alan Leeb noticed that people are wedded to their mobile phones and are likely to respond to an SMS from his practice. So now each time his nurse administers a vaccine, the practice sends them an SMS asking if they had any sort of adverse reaction. The practice is now able to monitor reactions to vaccines in real time, that means if there are severe reactions his practice will know within 24-48 hours, probably faster than any other agency. This information might just help to save lives in his practice but perhaps in yours too.