The future of healthcareLearn More

Please don’t ask for my time as refusal may offend

In an article from the Economist, the authors advise that we appear to perceive ourselves as short of time. Every minute of the day can be filled ‘doing’ something or several things simultaneously, often badly. We are also increasingly wedded to the demands of our mobile devices. People spend time texting while eating, driving and even on the loo. In fact it is estimated that we spend one third of our waking hours interacting with our phone.

In an experiment carried out at the University of Toronto, two different groups of people were asked to listen to the same passage of music. Before the song, one group was asked to gauge their hourly wage. The participants who made this calculation ended up feeling less happy and more impatient while the music was playing. Participants reported experiencing greater impatience while listening to the music when prompted to think about their time in terms of money.

This has some important resonance in healthcare where practitioners who earn a living through fee for service may, and often do, become impatient about engaging with researchers or academics. This is a significant problem because in countries where primary care is the first port of call for most people we desperately need research to ensure that the service offered is both evidence based and cost effective. But what is the order priority: appointments with patients, results of tests, administrative paperwork, continuing medical education, family commitments, surveys or recruitment to research? There is an opportunity cost to all of these activities.

Research in primary care is challenging not least because as has been observed repeatedly it is very difficult to recruit participants to trials in primary care. Practitioners are not funded by the paymaster to do research. Costing the recruitment to adequately compensate for the time taken to seek informed consent is prohibitive and the medical defense organisations do not indemnify doctors to do research.

Therefore, it is often if not almost always, very challenging to conduct randomised clinical trials in that setting. Other methodologies, such as prospective observational studies may be more likely to yield data whilst at the same time acknowledging that this would not be classed as level one evidence. Nonetheless, we need to work within a paradigm in which neither patient nor practitioner is likely to participate or if they do attrition is substantial and threaten the validity and generalisability of the data.

We need more creative ways to test hypotheses and collect data in primary care. Methods that capture data from a substantial number of representative participants. Methods that generate a minimum disruption to the business of doctoring. Traditional research approaches are failing or are only really possible where doctors and patients have unlimited funded time. I don’t know where that is, meantime remain sceptical about results of trials that appear to have recruited and retained thousands of participants but where the practices were involved in a significant effort to recruit to research. In that scenario somebody has paid, always ask who and why.

Picture by M01229

Observations of healthcare workers may be better than big data

Apparently when a message is put alongside a cardboard cut-out of a person it is more likely to be noticed and actioned. How the message is relayed to the ‘customer’ matters. This has implications for the sort of results we seek in health care. I am sure the reader could think of many ways this observation can be deployed to improve outcomes in healthcare, just as retail and law enforcement organisations use the concept to communicate with their customers. For example, would you consider having a full sized cardboard representation of a doctor in your practice encouraging people to have their children immunized? Richard Wortley offers some other interesting insights and strategies for behaviour change albeit in the context of law enforcement. What healthcare needs is interventions and ideas, whatever their provenance.

The observations and insights of your staff and colleagues are often, if not always, more valid than so-called ‘big data’. Big data sets are often used for some other purpose (e.g. healthcare administration) and then extrapolated to understand why people are referred inappropriately or prescribed the wrong drugs. More often than not without reference to the people who collected the data in the first place. It is even more fashionable to ‘link’ this data to other information collected for yet another purpose ( e.g. cancer registry). The results may lead to dubious conclusions and wide-ranging policy changes endorsed by a professor or two who have never been on the shop floor, or at least not recently.

‘Big data’ may be easy to collect, despite the limitations of its validity, it offers substantial numbers for a statistician to ‘crunch’. National conferences are now themed on ‘big data’, there are substantial grants available to those who choose this ‘methodology’ for their research endeavours. Meanwhile, the local and contextualized reflections and observations of those delivering health care are seldom accorded the same credibility. The desire for a fast and cheap solution to the increasing cost of healthcare drives funders to throw dollars at anyone who promises a quick-fix and can cite a p-value.

Here the business literature may be relevant:

The study identified a number of factors that influence the success or inhibit progress in terms of performance and sustainable improvement. The findings identify what companies perceive to be inhibitors and enablers for sustainability, within 21 companies who have conducted process improvement (PI) activities using a common intervention approach…..The general and cultural nature of the identified enablers indicates that managers perceive progressing PI activities are reliant on a change of culture within their organisations in parallel with “up‐skilling” the technical knowledge of employees for change to be successfully enacted. The lack of specific processes to change culture, identified in the enablers, also indicates that managers do not know what to do to change their cultures or how best to deal with the inherently challenging and demanding nature of process improvement with shop floor operators. Rich and Bateman

Sounds like healthcare. Perhaps the methodologies deployed in successful care studies hint at a better approach. No big database was dissected in this example which resulted in sustained business performance in an Australian company:

Using data collected through in-depth interviews, the case study describes how the company progressed from an earlier initiative based on quality control to the present initiatives that emphasize customer focus, product development, and innovation. Several important insights are drawn from the case study, including the importance of aligning the quality programmes or initiatives with a clear strategic focus. Prajogo and Sohal

Stand by for the launch of a new academic forum which will focus on the patient experience as the driver of innovation.

Picture by Aranami


Innovating for one of the climate’s biggest public health challenges

4265056770_b589d0437a_zIn a cohort of U.S. women, we found that sun exposures in both early life and adulthood were predictive of BCC and SCC risks, whereas melanoma risk was predominantly associated with sun exposure in early life. Wu et al

Furthermore according to the editor of Nature in July 2014

It is accepted that sunscreens protect against squamous cell carcinoma, and this work [research] suggests that they also protect against melanoma.

This message is not getting through to those who might be able to influence public opinion

To win the U.S. Open, tennis players must overcome fearsome opponents, grueling matches and searing heat. But for some, none of that causes quite as much angst as the prospect of rubbing on a gob of white lotion. Of all the accessories that players have at their disposal, sunscreen may be their least favorite. Some don’t wear it at all. Some apply it before daytime matches, if somewhat begrudgingly. But nobody seems to like it. Brian Costa and Jim Chairusmi

The ambient temperature in many parts of Australia early this year will be well over 30 degrees with a UV index of 11- in other words, extreme. Intelligent and well-informed young men and women may be found fully exposed to the midday sun and for hours on end. Many will not be wearing sunscreen, a hat or sunglasses. This can be observed on the beaches, on the tennis courts and on the cricket field.

The message to seek protection from harmful UV rays needs to be crafted in the context to which it is being targetted. It needs to take account of the ideas of young people who are resistant to messages that appear to impose limitations on what they can do:

Tennis players tend to sweat profusely, especially during day sessions at the U.S. Open, where high temperatures and humidity are typical. When the heat mixes with sunscreen, the sweat can form a gooey substance that gets into players’ eyes and onto their hands, affecting both their vision and their grip.

We need to understand and adapt to the perspective of those to whom the public health message needs to get through. There may be other ways to deliver the messages that are more potent. Watch these videos:

  1. The sun damages your looks
  2. It can harm your vision

Therefore, within Foggs model, the motivation to seek protection from UV light could be targetted better. Ability to apply sunscreen or wear sunglasses also needs more attention. Technology may have more to offer with more user-friendly products. Equally making the equipment currently on the market more readily available when and where they are needed will also help. Finally, it may be worth considering a trigger for the behaviour. Something that gets motivated people with the ability to perform the action to then act on a regular basis. The recipe for such behaviour is typically the traffic light. Red means stop every time. The teenager who gets on the cricket field with sunglasses and sunscreen in his bag needs to be triggered to wear them without mum or dad’s nagging voice to remind him. The behaviour needs to be anchored to something familiar- e.g. stepping onto the sand or grass and the message delivered at a teachable moment. The trigger of television advert is not enough for behaviours that need to be repeated. There is still scope to develop an effective innovation by an enterprising researcher based on the principles of patient experience design. I hope it is you.

Picture by Colin J

No we can’t


Oh yes doctor, we would like to have you present at our conference. In fact we would like you to run a three hour workshop and do a plenary. And sorry no we don’t pay speakers. We offer budget travel and basic accommodation.

I couldn’t believe what I was hearing. The preparation for this would take weeks. According to the glossy brochure the conference was to be held at an expensive venue overseas and the delegates would be paying handsomely to attend. The young man who called me couldn’t see anything wrong with asking me to work on his business at the expense of my employer in order to make a profit for his company. My response as far as he was concerned was unexpected. Which means he was probably used to hearing:


Academics give it away for a plane ticket and a cheap hotel room. They are just so pleased to be noticed.

The word for 2016 has to be:


  • No to urgent and not important
  • No to someone else’s priorities
  • No to time wasters
  • No to projects that don’t serve the mission
  • No to lack of self respect

If you are being asked, as you will be daily, to give up your time and pay an opportunity cost to be distracted then your boss has the right to ask difficult questions at your annual appraisal.

  • What did you accomplish today?
  • How does this work towards the mission of your team?
  • What tangible can you show when you reflect on progress this week?

Learn to say


Here are some different ways to say it. Practice today. Say it politely but say it emphatically.

No, Nein (German), Non ( French), Hapana (Swahili), Naheen ( Hindi).

If you practice it judiciously then you are less likely to hear it said to you.

Picture by Michael Sissons

Yet more reasons GPs should not be distracted by pay for performance


There is no doubt that doctors make mistakes. Mostly people forgive them, the charitable view is that it’s because people recognise that their doctors are human and by and large are trying to do a good job. The issue becomes most problematic when the error might cause a delay in the diagnosis of a condition that is best treated sooner rather than later. And especially when the red flag symptoms of that condition are well documented.

Late in 2014 Devesh Oberoi interviewed men who had presented to a specialist late with symptoms that were later diagnosed as cancer. One of the interviews suggested that the delay might in part be due to a late referral:

I spoke to my GP …that time … and. … I was concerned about the symptoms. I told him that I had seen some blood on my toilet paper and he said … umm … yeah that … since it is fresh blood it could be piles (haemorrhoids) or something. Patient with Rectal carcinoma.

Such delays are widely reported in the literature with some experts calling for better research to establish why the diagnosis of cancer is sometimes late in primary care.

Last week our team published secondary data from an experimental study in which we report that the diagnosis of cancer can be missed even when the presentation is straightforward and there are no distracting issues in the consultation (e.g. co-morbidity, psychiatric illness or social problems). One in eight ‘cases’ presented as short video vignettes to doctors in the study failed to elicit a response that included a referral to a specialist or investigations to establish the diagnosis of cancer. What’s also of concern is that where the management decision was to prescribe something, it was hard to see the benefit. In some cases it might even have resulted in harm. Where the decision was to investigate, the indications for some of the investigations were not immediately apparent. Delays may also have occurred in those investigated if the findings were negative or misleading.

None of this is new. Numerous audits have established similar patterns including one we published in 2004 in which three reasons were given for a failure to recognise patterns of cancer:

  • A failure to consider the diagnosis of cancer. ‘Blinkered’ approach in assessing patient.
  • Inappropriate or incomplete investigation.
  • False-negative investigations.

Despite such findings some policy makers think that it is appropriate to pay GPs to focus more on preventive health; to drive payment structures to reflect this public health agenda and distract doctors at the front line of the health service from their core business, namely giving a patient, who consults very briefly, their undivided attention. Doctors need to reflect when they have failed in someway to deliver a satisfactory outcome especially in cases of life threatening illness. That requires a renewal of the commitment to the process of history taking and examination and to updating the skills to make the diagnosis of conditions that are best treated ASAP. When done properly this is time consuming. When doctors are otherwise incentivised to either collect data or tick boxes the result can be less than satisfactory. That it may be already unsatisfactory even before we are driven to adopt practices for which there is very little proven benefit should lead to a rethink.

In relation to pay for performance the King’s Fund reported in 2010:

What evidence does exist suggests that significant improvements have been made in some areas – particularly for diseases such as diabetes, heart failure and chronic obstructive pulmonary disease –but less progress has been made for depression, dementia and arthritis, and these require a more collaborative care model for a higher quality of care to be achieved.

Alternatively it may be that what we can’t afford is to pay GPs to do better at something at the cost of deskilling them in other aspects of their work.

Picture by David Goehring

What do you already know before you consult your patients?


I tried this experiment today- given only a person’s name and address from a phone book what can you find out about them from the internet?

Location and state of home: Using Google street view I can see where the person I selected lives, or at least what her home looked like in May 2014. The house is a bungalow with a double garage, the garden is unkempt, and litter is strewn on an overgrown lawn. The fence with the neighbours is in a poor state of repair and has pieces of junk leaning against it. There are multiple old cars in the driveways or on the grassed areas of all the homes along the street; this suggests that there are many youngsters over the age of 18 living nearby.  The neighbour’s bin, which is on the kerbside, is full to overflowing, so it looks like the photo was taken on bin day. There are no children’s toys in the garden or on the lawn or anywhere in neighbouring yards. I can see a car on the driveway and Google has not blacked out the number plate. It is a new but cheap and small hatch back. At least one neighbouring home has a ‘for rent’ sign outside it. From Google earth I can see that none of the homes in the immediate neighbourhood have a swimming pool and that this home occupies most of the plot on which it has been constructed. From Google maps I can work out that she lives 10 minutes drive away from a doctors clinic, 11 minutes from the largest shopping centre, 7 minutes from the railway station (39 minute walk), 6 minutes from various fast food outlets and 15 minutes walk from the leisure centre. The house is not within a short stroll to any major amenities; there are no shops or cafes nearby. There are no bus stops on the street.

From I can see that this home sold for over $300,000 in 2011 and that it occupies 500 square meters of land. The estate agent described it thus:

A good sized home with 4 bedrooms, 3 separate living areas, a huge kitchen meals area complete with bench space, 5 hotplates and dishwasher as well as wall oven. Ducted heating, reverse cycle air con, 2 bathrooms (ensuite to master) and a 2 car carport as well as a large driveway complete this house. Catching a train to work? Well, you are only 5 minute drive to the town CBD and station. Schools and buses are nearby and petrol station around the corner for your fuel, milk and bread will give you convenience plus.

I can see inside the house and note that there is Jacuzzi in the back yard. The real estate site tells me that families with adult children occupy one in five properties in this area and that one in ten people living here are retirees. According to sixty nine percent of home locally are owner-occupiers and the average age of people here is 40-59. If this person has a mortgage they are likely to be paying just under $600 per month or if renting $350 per week. Manufacturing is the largest employer in the area. As this person is female, she may be a widow or a divorcee.

Facebook: I also note on Facebook that there is someone by the name of this person from this town. I couldn’t be sure if this is the same person. It is unlikely as the person on Facebook looks quite young and the vintage of the name is more likely to be of a person in their 40s. Google didn’t have any information on this person and this suggests she doesn’t hold a senior position in employment locally and hasn’t been in the news for any reason.

Would any of this information help in a consultation with this person as a patient?

What I already know leads me to suppose that this person is working, probably locally and has a modest income. She probably lives with other adults, possibly her children and moved into the home in 2011 when the property was sold. Given the poor state of the garden it is likely the home is rented.  In addition from her medical records I will know her age, her occupation, her current medications and any significant past medical history. That’s even before I set eyes on her.

The information above will be of limited value if she presents with a minor self-limiting illness, except that she may be very keen to get a medical certificate because she will not want to risk losing her job. She probably has a modest income and may be at risk of work related stress. She may also find it difficult to attend the clinic during office hours unless she works close to the clinic. This is unlikely. If in middle age she has a chronic illness and she requires to attend the clinic regularly or she needs to go to a gym four times a week then her address is going to be a significant risk factor. Secondly the cost of medications and the availability of quality food may be a challenge to an individual living in this location. Matters would be worse if she can’t drive for any reason. Some research our team has just completed suggests that people who are at increased risk from the adverse consequences of diabetes, and possibly other chronic conditions, tend to live in close proximity to one another. Therefore if my computer was to alert me, in addition, that this address is in such a hot spot area, then the information I have freely gathered from the internet and from my own clinic records before I see her may offer useful insights into my patient’s circumstances. It may be that we would have to work hard to find someway to help her cope with the rigors of a demanding medical problem should it exist. Of course all of this is speculation, the best thing I can do is to ascertain the whole truth by giving her my undivided attention when she attends. Nonetheless if I didn’t have to spend a lot of time playing detective I would be much better placed to understand her needs.

Picture by Duncan Hull

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

Four ingredients for innovation (in rank order)

1.People want to retain their youth, remain potent, be connected and yet products which ultimately harm what people value are being successfully marketed. People buy these products believing the promise of youth and glamour. Health promotion will pass mustre when their boring message is translated from what you can ‘prevent’ that seems to you unlikely (cancer) to what you can retain or regain that you value at a primordial level.

I want it.

Question for innovator: Why would anyone choose to act on your promise above some other that also promises youth, potency and or social connection?

2. Deliver messages about your product by someone the person trusts – ideally the person themselves. Messages that are deposited deep behind the person’s psychological defences are highly effective. Such messages are especially potent when they appear to come from what the person perceives to be their future self.

It’s about me.

Question for innovator: Can your quarry clearly see themselves in the story of  your product?

3. Make the user of your product a hero. Persuade him that he can have or do something that will make him feel and or look very good, very soon. Something that he did not think was possible but is now with your help within his grasp.

I will feel good very soon.

Question for innovator: How does your product make the target feel good?

4. Talk about your ideas when the recipients are ready and willing to hear them. Ideally not when you are competing with other things that the customer, client or patient considers urgent and important.

I hear you.

Question for innovator: Why should the customer choose your product now?

Each of these is a necessary but not sufficient ingredient for successful innovation especially in health care.

Picture by tec_estromber

Twenty minutes every three months


I recently said goodbye to my patients when I moved to another job. One of my general practitioner friends also said goodbye to his patients, albeit it temporarily. He has been visiting Australia this week. I am pleased to recount his story.  For him the light bulb moment came when he noticed that people were concerned that he ‘might never return’. He wondered if he could deploy this connection to encourage his patients to be more active and or stop smoking.

Two months before Dr Klein left ( for one year), he wrote to his patients, challenging them to set 1 health-related goal to work on while he was away. He suggested they consider a lifestyle change, such as losing weight or quitting smoking.

Two of his colleagues offered to support the patients in their efforts to achieve any goals they set in Dr. Klein’s absence.

About 1 in 8 adult patients (48 out of 350) set goals, including losing weight, exercising so many times per week, and quitting smoking; some set more than 1 goal.

The ‘intervention’ took only a few minutes to initiate and 20 minutes of staff time every 3 months. This was essentially a reminder letter every 3 months. The results were impressive.

Among the participants, 18 (38%) did not achieve their goals; another 15 (31%) could not be reached, so their results were unknown. The remaining 15 patients (31%) succeeded, 8 completely and 7 partially reaching their goals, and some meeting more than 1 goal. The successes included 3 patients who quit smoking, 7 who increased physical activity levels, 7 who lost weight, 1 who reported decreased shoulder pain after exercising more often, and 1 who made an overall lifestyle change.

It sounds as if the reminder letters were triggers to keep working towards the goal. This ‘lean innovation’ did not require a research grant or a large team to complete. No drugs were prescribed, no tests were required. It was rewarding and demonstrated the value of the social capital in the doctor patient relationship. A relationship that defines the role of the medical practitioner even in 2015. The same relationship that creates tangible results. Medicine is a people business. We do well to remember that at a time when there is an obsession with quantified self.  You can read more about Doug Klein’s experience here.

Picture by Kellan.

A test has most value when the prevalence is high

4647883696_c564082a24_zA perennial problem in primary care is whether to schedule laboratory tests. This is an issue that is often very perplexing early in clinical careers because there is often a lot of pressure or perceived pressure not to miss the rarest of rare conditions. The secret, if there is one, is to know the prevalence of the condition before testing for it. Supposing a condition has a prevalence of 20% (1 in 5) in a population, this would be considered very high. What if the recommended test detects 95% of cases (sensitivity) and identifies 80% of people who did not have the condition (specificity). If the test were applied to 200 people:

  • 70 would be identified as positive and of these 38 would be ‘true positives’. Therefore 32 people would be told they might be sick when they were not (positive predictive value = 54.29%).
  • On the other hand 130 would be told they were not sick when two of them were ‘false negatives’.

If the same test were applied to the same population but the prevalence was 2% (1 in 50), in other words pathology is unlikely, then:

  • 43 people would be identified as abnormal and of these 39 people would NOT have the condition (positive predictive value = 9.3%).
  • On the other hand 157 would be reported well, which was everyone with a negative test.

The impact of a test is not only on those who are found to have pathology but also on those who are told they might have pathology and need more, often invasive tests, for a very unlikely condition. Prostate cancer testing has been studied in this respect.

In primary care tests for life limiting illness in particular can be calibrated with a high sensitivity (more true positives), so that pathology is not missed and a modest specificity (more false positives) which means that more people might be subjected to further investigations because their symptoms need explanation and they may need more investigations. However a false positive result has a significant impact on the patient’s life. The numbers above illustrate the impact of prevalence on the proportion of people without pathology who would be subject to further tests. The higher the prevalence, the more worthwhile the test and the better the positive predictive value of a test. You can play with these numbers using this on line calculator.

A question to ask whenever requesting a test is how common is this condition in people like the person to be tested?  If it isn’t very common what harm could be caused by multiple tests to ‘prove’ this person doesn’t have this condition? In the business of healthcare no patient, client or customer should be subjected to tests without the practitioner having a firm grasp on how the test will help to manage the case. By corollary there is no short cut to taking a detailed history and examining the patient in order to make a diagnosis. Tests can never compensate for poor practice, nor should they be used to try to impress a patient that ‘everything is being done’, often what is being done is iatrogenic harm.

Picture by National Library of Medicine.