Tag Archives: Patient experience design

Some experiences recalibrate the patient’s response to health practitioner support

6025359063_81a0b67b4c_zIn a review of the impact of breast cancer on women’s lives we reported one woman’s perspective on her relationship with her partner as reported to her Specialist Breast Cancer Nurse:

He’s slowly letting go. And we had a wee talk yesterday actually because [Name]’s very boy like. Never wanted children, never wanted commitment that’s why it’s, I’m more of a mother than anything to him and he spends a lot of time playing games on the video and doesn’t really do a lot around the house and I just said to yesterday, I said this is quite frustrating for me because with what I’ve been through I want to live life and sitting around here having somebody play video games is just not really doing it for me. Jiwa et al

The experience of breast cancer had altered her view on something she had taken for granted. Pre-cancer was very different to post-cancer. A subsequent paper concluded that:

In the absence of cancer specialists, in years 3, 4 and 5 following diagnosis, Australian women would prefer to have their routine breast cancer follow-up provided by a Breast Physician (or a Breast Cancer Nurse) in a dedicated local breast cancer clinic, rather than with their local General Practitioner. Bessen et al

What patient experience drives this preference when nationally experts in cancer care have been actively promoting shared care between GPs and specialists?

We speculated that it is the relationship with the  Breast Cancer Nurse (BCN) from diagnosis through treatment and beyond. At this time in most cases, the GP is hardly involved at all. Our data suggested that if the approach to patients in the period following active treatment was limited to discussing physical symptoms and possible side effects of adjuvant therapies then there will be a lost opportunity to help patients to adjust to the experience of breast cancer. From our data one can only speculate whether this would lead to psychological, social or physical problems or whether patients would find other sources of help. However, the importance of the BCN who has the experience and resources to support the woman throughout the process of readjustment but can also recognise the significance of clinical changes in breast tissue is a critical element of any follow-up protocol. That does not mean to say it can’t be her GP, but the conclusion of research with patients is that often it is not.

Overall, BCNs play an important role in facilitating the transition of patients by supporting the woman in adjustment to a new self-image and bodily functioning. The BCN accompanies each woman through this phase in her life while supporting a new narrative, promoting her ‘rebirth’ as someone with views that have altered significantly after the diagnosis of cancer.

Breast cancer along with many other conditions where the patient is subject to treatment to combat a potentially life-limiting pathology changes the patient’s perspective forever. In crafting support for such patients, it may be crucial to consider what the patient has experienced and with whom and not what would suit health care providers to offer in the way of support. The follow up regimen has to be tailored to the context. That word context again!

Picture by Liz West

Context may explain demand in Emergency Departments

10808093765_7efa339c59_z

You’re heard it so many times before- Why do people go to the Emergency Department when they could see their GP?

Health authorities have revealed some of the more than 210 daily presentations could have been treated elsewhere as a lack of after hours services continues to pressure hospital resources.The hospital’s ED recorded 77,362 presentations in 2015, up three per cent on last year and more than 25 per cent on 2010. In the first three days of 2016, there have already been 683 presentations to the ED, compared with 639 in the same period last, with hospital on track to again break records.The most common reasons for people presenting to the ED in 2015 were possible cardiac chest pain, non-cardiac chest pain, viral infection, abdominal pain and urinary tract infection.Townsville Bulletin

Why do people with seemingly ‘minor’ infections present to a busy Emergency Department? Lots of data but on explanations. Speculation results in misleading conclusions and ineffective attempts to change behaviour. The context was not addressed in the report quoted above.

  • Was it really easier for people to consult a GP on a same-day basis?
  • Why were they more inclined to attend an Emergency Department that may be busier by the day?
  • What are the ideas, concerns and expectations of people in the waiting room of the ED?
  • What triggers a visit to the ED?
  • What experience in the ED sends a message through the community that this is the place to be when you are feeling unwell?
  • What experiences in General Practice appears to send the message that it is better to go to the ED?

According to BJ Fogg three things must be aligned in relation to behaviour- Motivation, Ability and a Trigger. The result of these factors must make it more likely that people will rush to an ED rather than make an appointment with their GP.

The reasons why demand at EDs is increasing begins with an understanding of context in which that trend is taking place. An alternative outcome can be designed with reference to considering the patient experience. Such information can be gleaned directly from the patients but also from the ED staff, the local GPs and especially their receptionists.

In a study of adult Emergency Department attendances we concluded that any attempt to reduce attendance would be challenging. Attenders to EDs are not a homogenous group.

Most patients (97.6%) attended Perth EDs fewer than five times a year. The more frequently patients attended, the more likely they were to be male, middle-aged and late-middle-aged, have self-referred, have mental and behavioural disorders and alcohol intoxication, to not wait to be assessed, and to arrive by ambulance. The groups of patients attending between 5–9 and 10–19 times per year (97.4% of FAs) had more urgent conditions, more circulatory system disease and higher admission rates than all other patients. Jelinek et al.

On the other hand frequently attending children may be a very different case where interventions may be more fruitful:

Frequent attenders (FAs of 5–9 times a year) may be no sicker or more in need of hospital services than those who attend less frequently. The preponderance of respiratory and infectious disorders across all FA groups suggests these could be the focus of further research. We advocate a holistic approach to take into account parental expectations, and a systems approach to change ED attendance behaviour. Gibson et al.

As always context is key and as always there can be no policy making before we fully appreciate what we are observing in these data.

Picture by UW Health

Why the common cold must be seen in context

imageI was there to buy sunscreen. The pharmacy assistant served the next customer.

I’d like something for a cold. Something to stop the runny nose and help me sleep at night.

Upper respiratory tract infections are the commonest reason that patients consult doctors in primary care. What can doctors do about these infections? In the vast majority of cases nothing. And still they come in there hundreds of thousands. Will you go to work the next time you catch a cold?

If not why not?

Surely regular paracetamol is about all you can take and it’ll get better ‘in a few days’. That’s what the chemist told her customer and I nodded in agreement.  But perhaps we are missing the point. For many people the runny nose and aching limbs is more than they can cope with on top of boredom, anxiety and that hour long commute on a crowded bus to work at a job that only just pays the bills. What with the sleepless night, the wheezy toddler, the noisy neighbours, the hang over and the barking dog.

In the case of sickness absence an employer may demand a ‘doctor’s note’.  This infection more than any other medical condition teaches us that context is everything in medicine. For the medical practitioner it’s not a case of treating an infection, it’s about seeing the patient within the backdrop of their lives. The common cold offers an uncommon opportunity to connect with people when they are expressing something that they may scarcely be able to articulate in words. Something that impacts on their experience of all discomfort and disappointment they may experience.

When we frame the epidemiology of respiratory tract infections as a microbial assault it’s like attempting to navigate a route with reference only to ‘Google Earth‘. The impact on human behaviour is only discernable in finer detail. Perhaps people consult doctors in these circumstances when there are many other things that are wrong in their lives. The medical response to upper respiratory tract infections can best be crafted with reference to Patient Experience Design. The patient requires more than platitudes about a ‘viral’ illness that doesn’t respond to antibiotics.  The time out may offer an opportunity to reflect on more fundamental problems. The best response in medicine may be to acknowledge the ‘troublesome’ symptoms and accept the reasons for consulting without harming the patient with unnecessary drugs. To do this well and to promote a more resilient attitude to discomfort requires an understanding of what people need when they are suffering but not moribund. Those with upper respiratory tract infections who seek help are not malingerers because more than a virus causes their morbidity. As well as an opportunity to stimulate reflection on what ails them more generally it is a teachable moment to instruct on self care.

Picture by William Brawley

 

See demand in context and respond creatively

9645066390_babd98c3f1_zHello 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.

Picture by Marjan Lazerveski