Tag Archives: medical innovation

Why conclusions about doctor performance can’t be based on outcomes only

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It sometimes seems ‘obvious’ why things go wrong in practice. For example, the proportion of people with diabetes prescribed a cholesterol reducing drug is low…. because? You might have your favorite answer at the ready. Others certainly do and will climb their hobby horse with little or no encouragement. ‘Prescribers don’t accept the guidelines‘, ‘patients don’t take their medicines‘, ‘people can’t afford the drugs‘ or ‘doctors don’t monitor patients‘. The truth may encompass any or all of these.

Let’s do the maths with reference to Glasziou and Haynes.

Let’s assume 80% is true in each of the following points:

1. Doctors are aware of the guidelines.
2. Doctors accept the evidence underlying these guidelines.
3. Doctors remember to apply the guidelines when the relevant patients present.
4. It is possible to do something practical to comply with the guidelines.
5. Doctors act to prescribe the relevant treatment.
6. Doctors and patients agree on the need for that treatment.
7. Patients comply with the treatment.

If these statements are true 80% of the time then 21% of people with the relevant problem will be managed according to the guidelines (0.8x 0.8x 0.8x 0.8x 0.8x 0.8x 0.8= 0.21). Experience tells us that in many, if not most, conditions only 1 in 5 people will be managed as per research evidence.

A quick review of the literature confirms this.

1. Only 17% of patients with diabetes were screened for sexual dysfunction despite it being a common complication of this condition.

2. A primary care study has shown that despite an active education program over two years the proportion of treated patients whose blood pressure was controlled to < 160/90 mm Hg remained at only 33%.

3. When examining the referral origin of all Colorectal cancer patients diagnosed in one study only 24% had been referred on a pathway that was consistent with national guidelines.

An agile and cost effective solution could be devised for any problem in medicine if the innovator has a firm grasp of the context in which an innovation is to be deployed. Doctors therefore already have some of the necessary credentials. And also, if a solution is generated that changes the way everyone involved feels when they do the needful. These are a function of the right brain (intuition and imagination) as opposed to the left brain (logic).

Lean innovators know that an innovation will only change outcomes if that treatment is less of a threat than any alternative, and or if it increases good feelings. We also know that the actions of doctors alone are never enough to result in a particular outcome. If medicine is a partnership then so are the results. As always context is everything.

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Don’t trust data out of context

5331111591_5352e900cd_zIn the drive to solve healthcare problems, it’s tempting to tinker with the essence of what medicine has to offer. When we are trying to give patients answers we often fall back on what we can measure, like blood pressure, cholesterol levels and so on. It’s easy to offer people a number that is a barometer for their health. However it’s just as important to understand our patients and the context in which they seek help. What worries them about their current situation or problem? Can they earn a living whilst they have this problem? How are they coping?

If we rely too much on big data we are failing to recognise the role that the practitioner plays in facilitating the recovery from disease. A fundamental truth is that technical medicine- surgery and drugs have very little to offer most people who seek help. There is plenty of evidence that such interventions may even be harmful. There is no occasion when technical assistance alone will make any difference to a person’s distress. That is not to say that there is no place for surgery or powerful drugs. In most circumstances though it is the interaction between an interested practitioner, who gives their undivided attention, who enables the patient to understand and acknowledge the source of their distress that makes all the difference. The best medicine helps patients to find the resources within themselves to improve their circumstances or alter an unhelpful perspective on a difficult situation. Innovations that enable the patient and the practitioner to arrive at this point sooner rather than later are most likely to make a difference to patients.

Not everything that a healer offers can be replaced by facts and figures, or enhanced by gadgets or gizmos. In fact the true value of the encounter between doctor and patient cannot be audited. Failure to factor this truth into our attempts to innovate will lead to sterile and inevitably harmful efforts to improve the outcomes in healthcare. This is especially true when those innovations are a distraction to either the doctor, the patient or both. How are your attempts to solve problems disrupting the business at hand?

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We have to be part of the solution because we are part of the problem

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She blinked at me expectantly. Her companion sat in the corner of the room, arms folded staring at the floor. She glanced at him side ways and then said in a loud whisper

We are here about that business last week. You know.

I didn’t know. So I frantically searched through the notes. The man in question had been seen here several times recently for various dressings. Nothing to say how he had been injured or the nature of the wound. At that point she lost it.

I don’t like talking about it in front of him! Because of his you know……well I told the doctor everything a couple of weeks ago. We need a report for the police and a referral for counselling.

I was mystified. The cryptic notes mentioned an injury to the arm and the application of various dressings but nothing about a bashing. She would have to see ‘the other doctor’ for the report. He was on holiday and not expected back for 10 days. Neither of us was satisfied. The next patient didn’t help matters. She had been pushed to the ground at the railway station and injured her wrist. She had been to the Emergency Department a couple of days ago and had been sent to the practice for an X-ray report. I assumed that someone had seen the X-rays and that she hadn’t been discharged with a bony injury. But there was no note from the Emergency doctor, hand written or otherwise and I now had to spend the next 20 minutes listening to musak while the ward clerk searched for a copy of the report and faxed it to me. In any other industry this waste of time would be tweeted as an example of bad service.

Meanwhile we are spending millions of dollars in search of electronic records that will somehow transform continuity of care. The assumption is that given such a record a doctor will document the circumstances in which she has come to reviewing a patient repeatedly or that the emergency department will reliably record why a patient was fit to be discharged. All of this is possible now if only doctors will plan for when the patient turns up when they are on a day off or choose to go to another provider. Hours can be saved each day, millions of dollars can be redeployed to make a system that already serves us well even better.

Assuming the technical challenge of a personal electronic record can be overcome the question is whether such a record will deliver its promise given that not all who work in healthcare are committed to treating the patient as they would wish to be treated themselves. There is no doubt that the free flow of information will help improve healthcare provision however the most valuable data that helps us serve people (history and examination) have to be documented by a human rather than a machine. Innovation should start with a change in the mindset of those who work in an industry. Are you confident that no one you served today would have to have their problems reassessed if you didn’t show up for work tomorrow? If so then we will be on the way to better outcomes overnight.

It’s also hoped the new system will reduce the high rate of medical errors (18%) that occur from inadequate patient information, reduce unnecessary hospital admissions, and save doctors from collecting a full medical history each time they see a new patient. The conversation

Picture by Ben Hussman

 

Why your employer might already be considering replacing you

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According to the Australian Bureau of Statistics

While it may seem as if Australians are working longer hours than ever, the average actual hours worked per employed person have decreased over the past 32 years. However, the average actual hours worked by full-time and part-time employed people have both increased (although average actual hours worked by full-time employed people have been decreasing since 2000). This total decrease, but component increase, can be attributed to the changing full-time to part-time composition of the workforce.

Sometimes there’s no choice, that critically ill patient, that urgent project, that last minute adjustment to an important document or the call to support the team. You burn the midnight oils. But when it isn’t any of the above why do you work longer hours then you are paid to work?

I remember working ludicrous hours.

As a junior doctor it was considered necessary that doctors with a barebones grasp of medicine should spend ridiculous hours on the wards, with no rest, hardly any food and no life outside of the wards to gain clinical experience for a lifetime in medicine. I don’t think those experiences contributed one jot to my clinical expertise. Then there were the hours demanded of GPs by the government, which required doctors to provide care for patients 24-7 regardless of whether the doctor was in any fit state to perform the day after the night before.

I am forever thankful for those opportunities to learn because I grew determined to control my own working life. It was challenging. Challenging only because it meant ceasing to meet the expectations of other people.

When the choice of how long you work is your own the reasons you work long hours become more interesting.

Occasionally it is because you fail to focus on what is important but not urgent, until as a consequence of your lack of investment in priorities you end up fire fighting and dealing with only the urgent and important.

Sometimes it is because you believe that you do not have the resources you require to do you job.  So you invest your own time and sometimes resources and let your employer off the hook. Because tackling the employer is perceived to be either dangerous or frustrating.

I have also seen people doing it because by earning more but being less available to their families they maintain their preferred lifestyle. Private schools, foreign holidays, big mortgages and new cars come at a price.

In all cases working longer hours ultimately comes at the expense of productivity. That means being less creative. In the end what we need, in medicine or any other calling are problem solvers rather than automatons. Is what you do for your employer sustainable? What happens if you fail to turn up for work tomorrow? What happens if you need to take time to be with a loved one or fall ill? Can you keep this up forever? If you aren’t thinking about it your employer is and that might mean that they are already considering how to replace you with an even more reliable machine.

Picture by A. Strakey

Your idea could save lives

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You don’t have to see the same doctor twice. In fact you don’t even have to go to the same practice. Come to think of it you don’t even have to go to a practice. In many countries including where I work you can dial-a-doc. He or she will turn up Uber taxi style. All you have to do is make the call. There is a cost of course. That’s the whole point. But is medicine a special case? Choice is a good thing but is there a down side to the commercialisation of health care?

Suppose you experience some worrisome condition. Something that isn’t painful but shouldn’t be ignored. Let’s say you notice blood in your pee. You might go to a doctor eventually because you, quite rightly, decide you need to find out what’s causing it. You go to the first doctor who can see you. It might not be the one you’ve seen before and if you are worried enough you might even go across town to someone who can ‘fit you in today’. The doctor might order a test or two. Possibly ask you to provide  sample of your urine, perhaps organise some blood tests and may be recommend a scan. The next day the blood is not so obvious and you think there is no need for all this fuss. Either that or you have the tests and they come back negative or you decide that there is no need to make another appointment with the doctor when the blood seems to have disappeared. You breathe a sigh of relief and leave it there. No need to worry. But of course there is. Painless frank haematuria warrants thorough investigation.

Understand, however, that hematuria may be intermittent in patients with significant urologic disease and a repeat urinalysis should be obtained if the clinical suspicion is present. American Urological Association.

If you are a doctor reading this:

  • How does your practice deal with the possibility that people may fail to follow up positive test results?
  • What is your policy for people who have negative test results in the context of significant clinical signs or symptoms?
  • How do you take into account the possibility that a patient may fail to attend for investigations for reasons various?

In some countries it is easier to track people who fail to turn up or return after tests. In other countries it is up to the practice to have a fail-safe mechanism. In healthcare, occasionally, the ‘customer’ falls between the cracks and the consequences can be a delayed diagnosis or worse. First and foremost  it requires the service provider to know the circumstances in which it is prudent to go the extra mile. If you work in a place where it may be possible that people might be harmed by the way they use healthcare services what are the circumstances in which you take more precautions? What do those precautions look like? It might be that your approach could scale to protect more people who wish to exercise choice.

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Meet the emotion that drives fresh ideas

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Whose choices would be limited by the adoption of your ideas?

  • Users
  • Your boss
  • Funders
  • Your employer
  • Government
  • God
  • All of the above

If the answer included any of the above you will experience the mother of innovation aka frustration. The same can be said of job satisfaction or happiness. Frustration is a powerful emotion to be greeted as the most effective teacher. It can literally drive you to think again so that eventually, some but not all people who experience it will find wisdom if not satisfaction lurking on the other side. Those who refuse to learn her lessons remain in the classroom unhappy. First work out which is the horse and which is the cart.

Two notable examples:

Instagram is changing the way we eat:

While looking at pictures of food can provoke a physiological reaction that makes the observer hungry, taking pictures of food can be an effective means of sticking to a diet. Menulog

Google searches are helping to identify epidemics of infections disease.

One way to improve early detection is to monitor health-seeking behaviour in the form of queries to online search engines, which are submitted by millions of users around the world each day. Ginsberg et al

In both cases the driver- Instagram and Google do not require the user to deploy their services specifically in order to achieve the requisite goals above. Innovations that depend on any one using a tool to solve one specific problem, for someone else, are going to meet our friend frustration.

People’s fundamental needs have been described long ago. First and foremost people need food, fresh air and rest. Then they need to feel their future is secure. After that they want to feel a sense of connection with others and to be valued in their social circle. Then and only then will they to compelled to creatively solve problems for other people.

Neither Instagram nor Google was set up only to help tackle obesity or infectious diseases. Both serve more fundamental needs in human society. How do your ideas fit in this paradigm? Is your latest innovative idea designed to be useful in very limited circumstances? In that case it will be of value to only a limited market and you will please a few people a little of the time. If that’s okay you will you have avoided frustration otherwise it’s back to the drawing board.

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Do you know if you stand in the way of your own success?

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Whose is the voice that helps you decide? Whose is the voice you listen to always? For you there is only ever one person in the room even though the room may be packed. In the end it is your own voice that will determine the outcome because without your input a team will only achieve partial victory or worse.

What is your self-talk?

This is dreadful. It’s a catastrophe. A disaster. We’ll never achieve this. It won’t work. It’s all too hard. We don’t have time. We can’t. We won’t. It’s always like this. What does he really want? We are going to fail.

Listen carefully to your prophecy. Because if you think you can or if you think you can’t- you will be right.

Catastrophe, Disaster, Never, won’t, can’t, don’t, always.

To dramatically improve the prospects for success revise this language. That doesn’t mean becoming a Pollyanna. Here’s an alternative dialogue

This is interesting. It’s a challenge. It’s a small hiccup. It’s an opportunity. What can we learn from this? How can I contribute? Can we make this better? Can we help this become a victory for everyone?

If you can’t change what you are saying to yourself at work then you have to ask three questions:

  • Why am I here?
  • Have I said this before?
  • Am I the problem?

If your self-talk is negative then the chances are that you are neither fulfilled nor satisfied with your role on this team. Your duty is to find out why and fix it or find an alternative place to be where your skills will bring you joy. Ultimately you are responsible for you. A free person’s happiness can never depend on the actions of others. If you don’t feel you fit where you work and decide to quit your colleagues may be disappointed. But they will also respect you for your insight.

Tomorrow you should indicate that you are on-board by voicing the alternative dialogue. Because sooner or later someone will over hear your negative self-talk (it’s not as private as you think) and you will find yourself removed from a seat at the table either figuratively or physically. In healthcare there is no room for those who are not fully committed to improving outcomes. The best place to begin to improve outcomes for patients is nurturing a can-do attitude. It costs nothing to make this change if required. Tony Teegarden offers a helpful short presentation on this issue.

Picture by Kevin O’Mara

Lead your team or leave

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It is tempting to think that all solutions to your team’s problems, all efforts to enhance your productivity can be imported from some wise expert. You can’t please everyone. But the chance of pleasing your patients or clients becomes drastically reduced if you can’t work as a team. The insidious and toxic nature of some workplace disagreements can easily overturn any attempt to improve the quality of your services. No amount of innovation or advertising will compensate for the team’s habit of sabotaging it’s own efforts especially when person X in this department does not like person Y in that department.

If you need a survey to gauge if there are effective working relationship where you work then you have failed and need to spend more time with your people. If, knowing this as a leader you have not tackled this matter head on then you need to consider your own position.

It takes a great deal of courage to stand up to your enemies, but a great deal more to stand up to your friends. Albus Dumbledore

There is no easy way to remedy some situations. Years of resentment can spill over into acts of guerrilla warfare. Everyone will know why and many will chose to ignore the elephant in the room. This one was promoted, that one was not, this one gets to go to conferences, that one does not. The list is endless. The real issue is that their colleagues tolerate this behaviour. Perhaps because they depend on both for something that lets them get on with their day. There lies your real problem. While they may complain about ‘things not being done, or done properly’, they will not see that they are complicit in this dreadful set of circumstances. In this situation neither individual can continue to remain on board. Both have demonstrated that in their opinion their needs must come before the needs of those they serve. Your job as leader is to pave the way for their exit. Here’s Dumbledore again:

We must all face the choice between what is right and what is easy.

Your next task is to work out why your colleagues tolerated the situation and why you didn’t spot this coming until now.

Picture by Craig Sunter

How to deliver good ideas quickly and cheaply in healthcare

12643873903_7860231974_zBad news-the words ‘good’, ‘quick’ and ‘cheap’ are incompatible. There are no short cuts in this business. To be a successful innovator you have to be intimately familiar with the healthcare business, you have to evaluate your innovations within the very strict rules that govern how to test ideas in health and you have to enlist and fund the support of a team that can negotiate the hurdles along the way.

It takes years to develop something that might make a difference in clinical practice. First and foremost you have to know something about the business you hope to improve. Those who are more likely to become frustrated have a very limited understanding of the paradigm which operates in healthcare. In particular those who develop well meaning ideas to improve ‘prevention’ in primary care. There is a growing focus on this from the misguided view that we could all be healthy if only our family doctor would tell us to notwithstanding the many other factors that are operating to keep us fat, drunk and smoking.

As our team reported last week there is little or no redundant capacity or ‘spare time’ in the short primary care consultations to devote to delivering effective health promotion advice. In fact the attempt may harm the patient because that would take time away from a focus on the symptomatic patient’s ideas, concerns and expectations. It is possible, on some occasions that the patient is specifically seeking advice on how to lose weight, stop smoking or reduce their alcohol consumption but that is unusual. Therefore innovations that are aimed at increasing the effort on health promotion or worse still policy that redirects the doctor’s efforts in that direction may distract from the core business of communicating effectively and devoting time to the patient’s agenda rather than a public health agenda. As was reported by Richard Wender:

Practitioners and patients face three types of obstacles: provider-specific obstacles; patient-specific obstacles; and health care delivery system obstacles. Provider-specific obstacles include lack of time, distraction by other health issues, lack of expertise, lack of positive feedback, and disagreement with recommendations.

Secondly ideas that are likely to work have to be tested and shown to be promising but sadly lack of data rarely discourages people from thinking they can become rich and or famous from their latest brain wave. Testing innovations in healthcare is a painstaking and often frustrating business. Several things can and do go wrong: it is difficult to find a suitable place to test ideas; it can be challenging to get approval to test ideas on ‘real’ people; it can be difficult to source consenting subjects to test ideas in the relevant clinical settings; it requires skill to collect and interpret the data and it can take a long time to get data published following review by an independent set of experts in a reputable forum. Research in primary care in particular is not for the faint-hearted.

Finally what you need most is a team, led by a determined champion who have worked out how to negotiate the many obstacles towards a clear outcome. Such teams are rare and must be funded. Therefore it is not possible to deliver successful ideas for healthcare quickly and those who attempt it will do more harm than good.

Picture by Neil Moralee

Only one in four can locate the lungs

 

16665700260_ec2c765d31_zTopol says the writing is on the wall. People are more likely to consult google than make an appointment with a doctor. However that assumes that the human response to a threat, physical or psychological is logical.  There is seldom logic in much human behaviour. The myriad of factors that impact on a person’s decision to consult a doctor were explored by Campbell and Roland in 1996

Only one in 37 new symptoms were reported to a general practitioner…

A key reason why someone might seek medical advice is that they consider themselves susceptible to disease. However for that to be the case they have to understand how their body functions. Recent research suggests that this is not reliable. Weinman et al demonstrated in a survey of the general public that while most people knew the location of the human intestines, less than half could locate the liver, less than a third could place the kidneys and astonishingly just over one in four could locate the lungs. If knowledge of anatomy is limited than knowledge of pathophysiology is even more problematic. This was demonstrated in a study of perspectives on a child with symptoms of asthma from mothers of different ethnic backgrounds in London.

Some mothers mentioned avoiding certain foods; e.g. banana since it ‘contains a liquid that irritates the throat’, and cold milk or ice cream..Some mothers said they would utilise their normal strategy of what they do when their child is unwell with respiratory difficulties (e.g. menthol rubs, types of foods). In two sessions discussion involved remedies e.g. honey and lemon tea or remedies such as ‘bush tea’…Only one mother said she would find out what was wrong before trying a remedy. Most would first seek advice from their own family, friends and medical books. Cane et al.

In a recent study (2014) by Quaife and colleagues people were asked about their help seeking behaviours in relation to symptoms that may indicate a cancer diagnosis including a persistent cough, rectal bleeding and breast changes.

Recognition tended to be lower for men, older people, and those from ethnic minority and less-educated groups. These effects were significant for all three warning signs (P < 0.05).

This indicates that it may be some time before we can conclude that people will be safely self diagnosing.

Picture by Wellcome images