Most people with symptoms don’t seek medical advice. Those who choose to make an appointment with a doctor are more likely to have a disease and those who are referred to a hospital specialist are even more likely to have pathology. Lean medicine takes account of Bayes’ theorem that demonstrates this simple truth mathematically.
I like to think of it as ‘the four circles rule’.
This schematic tells us that many people with pathology do not seek medical advice and some don’t even have symptoms. It also tells us that doctors have to find those with pathology from among the many who do seek their advice. Often patients present with a host of problems, so that the four circles become 8, 12, 16 or even 20 different circles, one set for each condition.
My team have applied this principle to study people with bowel symptoms. It is a fact that most people with bowel symptoms do not have pathology, or at least not cancer. Epidemiologists have identified groups of symptoms which when they occur together are most likely to signify pathology. This isn’t always reliable and there are lots of false positives, leading to anxiety among the worried well. On the other hand it is also true that people with pathology may or may not seek medical advice. The latter is especially true of men who find discussing their bowels embarrassing. Sometimes so much so that they don’t mention the diarrhoea or rectal bleeding to anyone, least of all their doctor. The consequences are that in some cases they delay seeking help for potentially life limiting disease until it is too late for curative treatment.
We also know that colorectal cancer is diagnosed in most cases only after the patient has developed symptoms and sought medical advice. Only a minority of cases are diagnosed from among those with no symptoms who have been screened for the disease. Whatever the case the sooner a diagnosis is made the better the chances of successful treatment. Because the symptoms can be so embarrassing and to some extent because some men procrastinate with seeking advice colorectal cancer has a worse prognosis in men.
It’s in situations like these that innovations which are low cost, personalised and offer creative solutions to healthcare problems come into their own. The focus could be to provide opportunities for as many people as possible to get convenient, reliable, personalised information in privacy without necessarily going to a doctor. What’s more such an innovation needs to make life easier for the practitioner and the patient.
Every day doctors advise patients to lose weight, stop smoking, take more exercise, drink less alcohol and take time off. And yet obesity, depression and alcohol abuse are set to feature among the top health care problems for some time to come.
Associated with these problems is the rising incidence of cancer, heart disease and diabetes. There are also a number of parallel trends that aren’t obviously linked to these issues. More people are online and using smartphones. More people are having cosmetic surgery. More people are spending money on gym membership and health clubs. Common sense suggests that there must be some way to help solve the health problems by tapping into the trends.
It is contested how well doctors know their patients. But they cannot ignore these other behaviours. Doctors complain about patients who answer their phones during consultations, or those who come with questions via ‘Dr Google’. So where does this leave health innovators? The old way was to preach the message of abstinence, exercise and fruit and veg. It isn’t working. Taxing cigarettes might be a good public health policy, but it doesn’t change how young women feel about the happy side effect of appetite suppression.
Communicating statistics hasn’t enabled us to solve these problems. Far more effective is the notion that smoking and obesity might impact adversely on your appearance. Smartphones enable us to get up close and personal. Not just in order to communicate and connect with patients and their quantified self, but to add meaning, personal relevance and context. As a ‘lean medicine’ innovator you can do all this with a minimum of technical skill, but not without imagination, observation and interpretation.
No big investment required, other than the determination to make a difference for people working to solve the problem from their perspective.
Hello Jill, Oh, I’m sorry I have no appointments to offer you today. the doctors are all fully booked. If your son has a fever try him with some paracetamol and call back on Friday when I might be able to squeeze him in with Dr. Jones. Ok, bye.
Many years ago I overheard this conversation in my reception. Our receptionist giving medical advice without any qualifications. The surgery was over booked. She was harassed, doctors were grumpy and the patients were being turned away without being assessed by anyone.
We noticed that there was a seasonal pattern to this demand for appointments. Most doctors were aware of this trend because there were specific weeks of the year when they avoided taking holidays. Our reception staff kept meticulous colour coded records of such ‘same day’ appointments. When we entered this data on a statistical database there could be no doubt of a seasonal pattern with definite peaks and troughs. What’s more, we could predict the demand for ‘same day urgent appointments’ with reasonable confidence. At this point, it may be important to stress that doctors in the UK are paid a ‘capitation fee’ for serving patients. That means they are paid an annual fee no matter how many times they see the patient.
Understanding that people have a fundamental desire to talk to the decision maker, we settled on the notion of putting the doctor in charge of making the appointment. Patients who requested a ‘same day’ appointment were offered a telephone consultation with a general practitioner initially. Not with a nurse, as happened in some practices, but with their doctor. We believed patients wanted to speak with a medical practitioner, not because the advice they received was necessarily better than that given by another member of the team, but because people in distress want a doctor. Whatever the reason it worked. Important policy makers noticed. Doctors could deal with most requests within a couple of minutes, offer a ‘same day’ slot or something else without the need for a face-to-face appointment. We calculated a 40% reduction in demand for such appointments. Patients loved it, reception staff loved it too (no more arguments about lack of appointments with irate patients) and doctors found themselves in control of their workload. What’s more, we could prove that this simple intervention worked from the impact on longitudinal seasonal trend.
By allowing patients to speak to their doctor when they felt they couldn’t wait our practice chose to treat this small minority of patients differently to those who were happy to make a routine appointment. We acknowledged that these patients had a need that warranted a creative solution. Perhaps you have a group of patients who would benefit from being treated differently too? What is the context in which they seek help? The tired mother with a fevered child does not have the same needs as the young professional who requires a convenient appointment to obtain a prescription for the contraceptive pill. Both might seek an urgent appointment.
The consultation between a doctor and patient is private. Innovators hoping to improve outcomes in that context can’t observe the exchange directly because some presentations are very uncommon and because neither the doctor nor the patient welcomes the intrusion. There are many outcomes of the encounter between patient and doctor that we still don’t fully understand. Why are some patients’ cancer symptoms not recognised as early warnings? Why do carers of patients with a life-limiting illness fail to have their own medical problems addressed? Why do people living with some chronic conditions continue to have problems with intimacy?
People deploy verbal and non-verbal cues to communicate. They choose when and how to disclose their ideas, concerns and expectations. However in an average consultation in my country, the patient has fifteen minutes to ‘spit it out’. Similarly, clinicians vary in their ability to pick up cues or to probe with the right question, assuming they get the right answer. Hence errors of omission and or commission.
Lean medicine is about being intuitive, creative and agile. Lean innovators, clinicians, are already on site. Therefore, they can reproduce the context in a way that can be observed and where they can be tested with other clinicians. Video technology and a fusion of skills across disciplines allow the depiction of those encounters in such a way as to present the critical decision point for close examination. Do you prescribe, refer or investigate in these circumstances? What do you say to the patient?
How do you explore hard to reach elements in your practice or business? How can you hope to innovate for encounters that are strictly private and confidential but where mistakes or misunderstanding can be very bad for business. Who has the insight to show you? How can you generate valid hypotheses? How do you test ideas without a real risk of casualties?