The future of healthcareLearn More

Are you addressing the right problem or the one you think you can fix?


The act of consulting a doctor has been shown to be highly ritualized.

Ritual has long been thought to play an important role in the healing processes used by ancient and non-Western healers. In this paper, I suggest that practitioners of Western medicine also interact with patients in a highly ritualized manner. Medical rituals, like religious rituals, serve to alter the meaning of an experience by naming and circumscribing unknown elements of that experience and by enabling patients’ belief in a treatment and their expectancy of healing from that treatment. John Welch. Journal of religion and health

There are five elements to this ritual:

  1. The stage- office, clinic room, cubicle.
  2. The props- what can be seen and or felt.
  3. The actors- doctor, patient and sometimes nurse or therapist.
  4. The script- what is said.
  5. The action- what is done.

All have an impact on the outcome. The doctor’s ‘script’ is of particular importance as it is what the patient hears. The literature offers evidence of the impact of what is said and how it is said on outcomes for patients:

 The quality of communication both in the history-taking segment of the visit and during discussion of the management plan was found to influence patient health outcomes. The outcomes affected were, in descending order of frequency, emotional health, symptom resolution, function, physiologic measures (i.e., blood pressure and blood sugar level) and pain control. M.A Stewart CMAJ

One conclusion of the literature review published in CMAJ was that the process of sharing information includes a discussion about what the patient understands to be the problem and their options with regard to treatment:

These four studies taken together debunk the myth that the only alternative to the physician’s total control of power in the therapeutic relationship is his or her total abdication of power. They indicate that patients do not benefit from the physician’s abdication of power but, rather, from engagement in a process that leads to an agreed management plan.

This issue assumes great significance when it comes to difficult consultations in which it is perceived that the patient is seeking an option that is not in their best interests. Greenhalgh and Gill wrote the following commentary in the BMJ in 1997:

Two thirds of consultations with general practitioners end with the issuing of a prescription. The decision to prescribe is influenced by many factors, to do with the doctor, the patient, the doctor-patient interaction, and the wider social context, including the effects of advertising and the financial incentives and disincentives for all parties. Hardline advocates of rational drug use do not look kindly on variations in prescribing patterns that cannot be explained by purely clinical factors. The prescriber who allows the “Friday night penicillin” phenomenon to sway his or her clinical judgment tends to do so surreptitiously and with a guilty conscience.

The team go on to conclude that:

The act of issuing a prescription is the culmination of a complex chain of decisions. It is open to biomedical, historical, psychosocial and commercial influences, no aspect of which can be singled out as the ”cause” of non-rational prescribing. The search should continue for methods to measure the interplay of these disparate factors on the decision to prescribe.

Michael Bungay Stanier offers an approach to business coaching by focusing on what a person perceives to be their challenge, what they want and how that choice might be impacting on their other options. A similar approach can be taken in medicine. Two decades after Trish Greenhalgh’s editorial in the BMJ there are still many circumstances in which doctors find it challenging to negotiate options these include but are not limited to:

In this context our team surveyed nearly 9000 patients who had been prescribed antibiotics for Upper Respiratory Tract Infections during the latest flu season. We surveyed patients using a validated tool on the third day and the seventh day after a prescription was issued. We look forward to presenting the results at the forthcoming GP17 conference. We will be offering information on the following questions:

  1. What is the profile of patients who were offered a prescription?
  2. What was the symptom profile at these time points and how does this compare with data on patients who have been offered no treatment in other studies?
  3. What are the characteristics of the respondents to the survey?
  4. What proportion of respondents completed the course of treatment?
  5. What proportion of respondents also took regular symptomatic measures?
  6. What is the profile of patients with relatively severe symptoms at each time point?
  7. Are longer consultations or type of antibiotic predictive of compliance with treatment?
  8. Within the limitations of a study that offers only the patient perspective what might help people with Upper Respiratory Tract Infections?

Picture by US Army Garrison Red

The encounter could end well if you give it a chance

There is a moment in any consultation when someone could take an unhelpful perspective. That perspective could severely undermine the subsequent exchanges between those concerned.

In social categorization, we place people into categories. People also reflexively distinguish members of in-groups (groups of which the subject is a member) from members of out-groups. Furthermore, people tend to evaluate out-groups more negatively than in-groups. In this way, social categories easily lend themselves to stereotypes in general and to negative stereotypes in particular. Cohen

The problem with such categorization is that we then rate aspects as positive and negative disregarding evidence to the contrary. In a series of classic studies researchers recruited a group of 12 year old boys to attend a summer camp. The boys were divided into two teams which were then pitted against each other in competitive games. Following these games, the boys very clearly displayed in-group chauvinism. They consistently rated their own team’s performance as superior to the other team’s. Furthermore 90% of the boys identified their best friends from within their own group even though, prior to group assignment, many had best friends in the other group. M&C Sherif

Healthcare professionals can also be prone to social categorisation:

It is equally important to recognize that physicians and other health care workers are not mere empty vessels into which new cultural knowledge and attitudes need to be poured. They are already participants in 2 cultures: that of the mainstream society, in which some degree of bias is always a component, and the culture of medicine itself, which has its own values, assumptions and understandings of what should be done and how it should be done. Reducing racially or culturally based inequity in medical care is a moral imperative. As is the case for most tasks of this nature, the first steps, at both the individual and societal levels, are honest self-examination and the acknowledgement of need. Geiger

The patient opened the consultation saying ‘I don’t sleep well’. He wore a raggy teeshirt, torn jeans and old trainers. A baseball cap was perched atop an untidy mop of greasy hair. He was overweight verging on obese and had two days of growth on an unshaven face. He worked in a warehouse. Thirty seconds into the encounter I caught myself thinking ‘he wants a prescription for a hypnotic’ but stopped myself launching into a prepared speech on the addictive dangers of hypnotics. It turned out that he had worked to lose 15kgs, studied and practiced sleep hygiene and was keen to explore any option other than drugs. He was far from interested in a script for Temazepam. It turned out that he was keen to hear if I approved of his low carb diet and wondered if yoga and meditation might help. The next seventeen minutes were a mutually satisfying consultation which ended with a handshake. A sure sign that it had gone well.

This small study suggests that most handshakes offered by patients towards the end of consultations reflect patient satisfaction — ‘the happy handshake’. Indeed, many reasons were recorded using superlatives such as ‘very’ and ‘much’ representing a high level of patient satisfaction — ‘the very happy handshake’ BJGP

Therefore there is a point in the consultation when the healthcare professional needs to scan their impressions for evidence of  stereotyping.

Picture by David Baxendale

Small changes big impact in healthcare

According to the Royal College of General Practitioners, UK:

The consultation is at the heart of general practice… As a general practitioner, if you lack a clear understanding of what the consultation is, and how the successful consultation is achieved, you will fail your patients. RCGP

The impact of the consultation varies because of the different perspectives between doctors and their patients:

…. in the consultation the patient is most commonly construed as a purely “biomedical” entity—that is, a person with disconnected bodily symptoms, wanting a label for what is wrong and a prescription to put it right. Even under this guise the patient still sometimes fails to report their full biomedical agenda. Not all symptoms were reported and not all desires for a prescription were voiced. Barry et al BMJ

Much of what transpires in the consult is a ritual. Over the course of a professional lifetime most doctors will greet the patient in the same way, say the same sort of thing, prescribe similar drugs and order the same sorts of tests.  This occurs for a variety of reasons perhaps because a doctor learns to present herself and behave in a specific way but also because the doctor’s training and experience has a significant impact on their clinical practice. There is ample evidence that how doctors interact with their patients is crucial to the outcome of the consultation and ultimately to outcomes in healthcare:

An increasing body of work over the last 20 years has demonstrated the relationship between doctors’ non-verbal communication (in the form of eye-contact, head nods and gestures, position and tone of voice) with the following outcomes: patient satisfaction, patient understanding, physician detection of emotional distress, and physician malpractice claim history. Although more work needs to be done, there is now significant evidence that doctors need to pay considerable attention to their own non-verbal behavior. Silverman BJGP 2010

With this in mind, if you are a doctor you may want to consider seven components of your interaction with patients that warrant occasional re-evaluation:

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Why our jobs are making us fat

We spend most of our time at work.

  • Expressed as terms of a percentage of your life, this 39.2 hours a week spent working is equivalent to:
  • 14% of your total times over the course of a 76 year period (based on the average projected life expectancy of 76 for people born in the year 2000 according to the ONS’s National Life Tables for the United Kingdom.)
  • 23.3% of your total time during the course of a 50 year working-life period
  • 21% of your total waking hours over a 76 year lifespan, assuming 8 hours of sleep a night.
  • 35% of your total waking hours over a 50 year working-life period assuming 8 hours of sleep a night
  • 50% of your total waking hours during any given working day. ReviseSociology

This is a significant chunk of our lives. Yet we note that many people are disengaged at work.

Gallup

This is a problem because being disengaged at work is also associated with other behaviours that are problematic. Faragher and colleagues reported in the BMJ:

A systematic review and meta-analysis of 485 studies with a combined sample size of 267 995 individuals was conducted, evaluating the research evidence linking self-report measures of job satisfaction to measures of physical and mental wellbeing. The overall correlation combined across all health measures was r = 0.312 (0.370 after Schmidt-Hunter adjustment). Job satisfaction was most strongly associated with mental/psychological problems; strongest relationships were found for burnout (corrected r = 0.478), self-esteem(r = 0.429), depression (r = 0.428), and anxiety(r = 0.420). The correlation with subjective physical illness was more modest (r = 0.287).

There is increasing evidence for an association between job dissatisfaction and the most significant health challenge we face in the next decade- namely obesity. A survey of nurses in Ohio concluded that:

..disordered eating differed significantly based on perceived job stress and perceived body satisfaction. Nurses with high levels of perceived job stress and low levels of body satisfaction had higher disordered eating involvement. King et al

A more recent paper in BMC obesity reported that obesity rates varied across industries and between races employed in different industries:

Obesity trends varied substantially overall as well as within and between race-gender groups across employment industries. These findings demonstrate the need for further investigation of racial and sociocultural disparities in the work-obesity relationship to employ strategies designed to address these disparities while improving health among all US workers. Jackson et al

Lui and colleagues suggest a possible explanation:

Study 1 sampled 125 participants from 5 Chinese information technology companies and showed that when participants experienced higher levels of job demands in the morning, they consumed more types of unhealthy food and fewer types of healthy food in the evening. In addition, sleep quality from the previous night buffered the effect of morning job demands on evening unhealthy food consumption. Study 2 used data from 110 customer service employees from a Chinese telecommunications company and further demonstrated a positive association between morning customer mistreatment and evening overeating behaviors, as well as the buffering effect of sleep quality. J Appl Psychol

Possibly a very useful question we can ask people seeking medical advice with weight management: ‘ What do you do for a living and how do you feel about it?’. It may be that they are eating their feelings. Review what people are eating at their desk or during breaks. Snacks have become the fourth meal of the day — accounting for 580 extra calories per day, most of which come from beverages — and may be a primary contributor to our expanding waistlines. Here’s why employees become disengaged at work. A summary:

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What’s the shortest route to where you want to go?

As the conference season begins we note that response rates in the order of 10-20% are not unusual in primary care research. Hardly generalisable. And yet we need sustainable and workable solutions that will promote health and well being in an ageing demography with increasing multimorbidity. Researchers take note the traditional gatekeeper in primary care, the general practitioner is occupied just keeping up with demand. There is no time to recruit, to seek informed consent or to deliver interventions that are being tested in a traditional randomised trial. At one time membership of networks with ‘committed’, well meaning practitioners were considered essential to successful research. In 2017 relying on anyone or any organisation that purports to guarantee recruitment rates or ‘collaboration’ seems at best naive and at worst risky.

Health requires people to make different choices. Eat better, drink less, take more exercise, jettison bad habits, consider when and where to seek medical advice. The traditional model of healthcare is evolving. The evolution is driven by technology that has fundamentally changed our experience of many if not all things. People consider themselves more time poor than they ever were.

The ability to satisfy desires instantly also breeds impatience, fuelled by a nagging sense that one could be doing so much else. People visit websites less often if they are more than 250 milliseconds slower than a close competitor, according to research from Google. More than a fifth of internet users will abandon an online video if it takes longer than five seconds to load. When experiences can be calculated according to the utility of a millisecond, all seconds are more anxiously judged for their utility. The Economist

The lesson for those hunting for better ways to reach people is to consider the least that can be done to get there. The answer may be waiting in all of our pockets.

Picture by Toshihiro Gamo

A cough is not minor in any sense

 

 Acute cough, which often follows an upper respiratory tract infection, may be initially disruptive but is usually self‐limiting and rarely needs significant medical intervention. Thorax

In adults or children with acute cough, the evidence does not support the effectiveness of over the counter preparations. Cochrane Review

On the other hand:

Oral syrups segment is expected to expand at 2.9% CAGR (Compound annual growth rate) over the estimated period and be valued more than US$ 10 Bn by the end of 2026. The segment is expected to create absolute $ opportunity of a little more than US$ 300 Mn in 2017 over 2016. The segment is the most acceptable dosage form for cough, cold, and sore throat medicines due to ease of administration and pleasant taste. The oral syrups segment dominated the global cold, cough and sore throat remedies market in terms of revenue in 2016 and the trend is projected to continue throughout the forecast period. Oral syrups segment is the most attractive segment, with attractiveness index of 1.5 over the forecast period. FMI

Cough, cough, cough. Every hour on the hour. There appears to be no end to it this season. No symptom is driving more people to seek treatment than the misery of upper respiratory tract infections (URTIs). The impact of the URTIs season on the population is massive as has been demonstrated in data from the US:

More than half (52%) of Americans reported that their cold impacted their daily life a fair amount to a lot. Productivity decreased by a mean 26.4%, and 44.5% of respondents reported work/school absenteeism (usually one to two days) during a cold. Overall, 93% of survey participants reported difficulty sleeping. Among all respondents, 57% reported cough or nasal congestion as the symptoms making sleep difficult. Drug Store News

One issue that appears to be bound up with the epidemic of URTIs is rates of prescribing of antibiotics. Here the available data are encouraging:

Professor Bell suggests that 20–25% of acute URTIs are likely to need antibiotics…..We have shown that over the last 13 years GPs in Australia have decreased their level of prescribing of antibiotics for acute URTI and to a lesser degree, for ‘other RTIs’. Britt et al

However there is an opportunity here over and above the treatment of an annoying self-limiting infection. Most people who seek help want more than anything else to feel better. By 2026 they will spend $10Bn in the attempt. The conversations in consulting rooms and pharmacies around the country focus on symptoms that will improve, eventually. Antibiotics won’t help. But, in the end what people want is to feel better not a lecture on virology. There is an opportunity for a ‘set play’.

Yes, you have a nasty infection and I see that it is making you miserable. Here’s what you can do to help your self.

There is an opportunity to forge a relationship with the patient. The ritual of the consultation complete with examination has the potential to create enormous deposit of social capital. Something that might be critical when the patient presents later in life with life-limiting pathology. There is the chance to understand a lot more about the patient for whom a cold is the final straw. But what’s the context? Be curious, very curious that’s why it’s called the art of medicine.

Picture by Rebecca Brown

Why when you are sick don’t you do what you can to help yourself?

At 68 Frank has been prescribed the usual mix of medications: three different drugs for blood pressure, a statin and two different pain killers. His problems, as he lists them are fatigue, snoring and back pain. From his doctor’s perspective, the problems are obesity, a dreadful diet, and sedentary lifestyle.

OK doc, but I think I need a referral for my snoring.

Two weeks ago he wanted a different pain killer and the week before that he wanted to be referred to a physiotherapist. The major challenge in helping people who are struggling with chronic disease is persuading them that they have the wherewithal to slow or possibly cease the march towards disability. It seems incredible that someone who cannot walk to the end of the street without stopping for breath several times cannot see any reason to stop eating junk food and sugary drinks while watching telly from 6 pm until two in the morning. Bad habits will drive choices even when people are aware of their growing disabilities. There may be many reasons for this but one that may be worth considering is boredom.

Our culture’s obsession with external sources of entertainment—TV, movies, the Internet, video games—may also play a role in increasing boredom. “I think there is something about our modern experience of sensory overload where there is not the chance and ability to figure out what your interests, what your passions are,” says John Eastwood, a clinical psychologist at York University in Toronto. Anna Gosline.

What is challenging is that some people who have already developed a life-limiting illness cannot be ‘educated’ to make different choices while they don’t admit even to themselves how and why they are contributing to their own demise. If healthcare is to actively promote well-being we need to find ways to help people identify when they are bored and not just focus on the consequences including atheromatous vascular disease. The role of doctors needs to include tackling harmful habits and not limited to therapeutics.

Picture by Craig Sunter

Deploy rituals and be present in practice

Your next patient or client will want you to:

  • Smile (23.2%);
  • Be friendly, personable, polite, respectful (19.2%);
  • Be attentive and calm, make the patient feel like a priority (16.4%);
  • and make eye contact (13.0%).

(An Evidence-Based Perspective on Greetings in Medical Encounters- Arch Intern Med)

Showing up this way for every patient has to be a habit. Essentially you need to be “present or “mindful”. The issue of mindful practice has also been the focus of academic interest:

In 2008, the authors conducted in-depth, semistructured interviews with primary care physicians .. mindfulness skills improved the participants’ ability to be attentive and listen deeply to patients’ concerns, respond to patients more effectively, and develop adaptive reserve. Academic Medicine.

To make a habit of showing up in this way it may be worth considering deploying a ritual.

Hurdler Michelle Jenneke has her famous warm-up dance, long-jumper Fabrice Lapierre competes with a gold chain in his mouth, Usain Bolt points to the sky before breaking yet another world record, while Michael Phelps blasts Eminem to fire him up before hitting the pool. My body+soul

Consider the distinction between a habit and a ritual:

Habit

An acquired behavior pattern regularly followed until it has become almost involuntary: the habit of looking both ways before crossing the street.

Ritual

An act or series of acts regularly repeated in a set precise manner.

Rituals support habit and focus. Rituals support you to repeat habits and create new behaviour patterns over time. Daily rituals can support you to make new habits stick. You can move from doing something that might take a lot of effort, to it becoming almost automatic or done unconsciously. Mary- Ann Webb

Establishing a ritual can be the prelude to a habit.

The term ritual refers to a type of expressive, symbolic activity constructed of multiple behaviors that occur in a fixed, episodic sequence, and that tend to be repeated over time. Ritual behavior is dramatically scripted and acted out and is performed with formality, seriousness, and inner intensity. Rook, Dennis W. (1985), “The Ritual Dimension of Consumer Behavior,” Journal of Consumer Research, 12 (December), 251-264.

The pathway goes from behaviour, to ritual and then to habit. Charles Duhigg  spoke of the ‘habit loop’.This loop has three components:

  • The Cue: This is the trigger that tells your brain to go into automatic mode and which habit to use.
  • The Routine: This is the behaviour itself. This can be an emotional, mental or physical behaviour.
  • The Reward: This is the reason you’re motivated to do the behaviour and a way your brain can encode the behaviour in your neurology, if it’s a repeated behaviour.

All habitual cues fit into one of five categories: location, time, emotional state, other people, and immediately preceding action. An immediately preceding action is the most stable cue because it’s triggered by an existing habit. So to build a new habit match it with an old habitual cue.

B.J. Fogg, asks:

“What does this behaviour most naturally follow?”

To implement this technique, decide on an existing habit and complete the following sentence:

“After I [EXISTING HABIT] I will immediately [NEW HABIT]”.

Therefore to make a habit of being present for the next patient the “cue” is when you terminate the previous consultation.

The “routine” or ritual: At the end of one consult you might close the notes, tidy your desk and wash your hands. Metaphorically you also wash the previous consult out of your mind. This has physical and psychological components.

Then when you are happy that the previous consult no longer lingers in your thoughts proceed to the next consult, stand in a specific spot, call the patient, introduce yourself and smile. Shake the patient’s hand. Walk with them to the consulting room. Don’t start the consult until you make eye contact. How the patient responds to such a greeting is the “reward“.

Picture by Rob Bertholf

Are we are obstructing the doctor with gadgets?

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:

  1. Work out what’s wrong together?
  2. Make it easier for them to work together?
  3. Make it easier for them to achieve a goal together?

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 

Doctors get to choose so much of what matters

You choose what you wear. They own the building, they chose the furniture, they employed the staff, they chose the wallpaper, they decided the policies, they set the opening hours. But whoever ‘they’ are there are only two people in the consultation. You and the patient.

You choose:

  • Your mood today
  • If you shake the patient’s hand
  • If you introduce yourself
  • Where you sit in the room
  • Where you look
  • When you stop talking
  • Whether you examine the patient
  • What you think
  • What you say and how you say it
  • What you do
  • How you terminate the consultation

And the patient chooses whether they like it.

Guess what? You get to choose so much of what matters to the patient. Choose well. You can make a difference. Create a better future for everyone.

Picture by Gilbert Rodriguez