Tag Archives: specialist

The welcome rise of alternative providers

Two weeks ago an 80-year-old waited without food or drink for 14 hours in a Dublin city emergency department having fallen in her local supermarket. She was black and blue from head to toe a response to the call of gravity when she was launched off a faulty escalator. She was ‘triaged’ and seated next to drunken revelers who also managed to injure themselves on that fateful evening. She was seen for all of 10 minutes by a medical student and then briefly by a doctor who recorded that her visual acuity couldn’t be assessed because she didn’t have her glasses. With that, she was sent home with her granddaughter and asked to return a couple of days later when she again waited another 9 hours for a five-minute consultation presumably so that the doctor could make sure she hadn’t really injured herself and wasn’t going to sue the hospital as well as the supermarket.  I know this person and read the discharge summary even though her daughter and I live on the other side of the world. As far as we know the provider believes we should be thankful because they are very busy and at least ‘someone’ saw her.

What’s it like to be your patient?

  1. How long do your patients wait?
  2. How are they greeted on arrival and how do they feel about waiting?
  3. What do they do while they wait?
  4. How long do they see you on average?
  5. What do they expect from the visit?
  6. Why do you order tests? What difference do these tests make to the outcome?
  7. Why do you prescribe those drugs? How many people take them as prescribed?
  8. Why do you ask them to return for a review appointment?
  9. Why do your refer them to someone else?
  10. What do they tell their family about your service?

No business would survive without a handle on this information. Arguably some sectors of the business of healthcare only survive because of a monopoly.

A newer take on the organizational environment is the “Red Queen” theory, which highlights the relative nature of progress. The theory is borrowed from ecology’s Red Queen hypothesis that successful adaptation in one species is tantamount to a worsening environment for others, which must adapt in turn to cope with the new conditions. The theory’s name is inspired by the character in Lewis Carroll’s Through the Looking Glass who seems to be running but is staying on the same spot. In a 1996 paper, William Barnett describes Red Queen competition among organizations as a process of mutual learning. A company is forced by direct competition to improve its performance, in turn increasing the pressure on its rivals, thus creating a virtuous circle of learning and competition. Stanford Business

Certainly, the 80-year-old had no option but to go to a state hospital emergency department because there was a very real possibility that she had fractured something coming off that escalator. The hospital manager might say in her defense that they have no option but to offer the service as described, but where is the data to demonstrate that it is the lack of options rather than a lack of interest or talent in managing one of the most important services the state is charged by taxpayers to provide? The monopoly may be around a little longer when it comes to life-saving treatments but what about primary care? If this 80-year-old can wait 14 hours to be seen by a medical student there may be real scope for the service to be provided by someone who is qualified, will see her much sooner and offer her a cup of tea while she waits for the X-rays to be reported. What about the scope to provide better than what you offer?

Picture by Toms Baugis

Will patients ever benefit from dubious surveys published in academic journals?

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The headline in the newspaper was provocative:

One in 10 parents do not trust GPs with their child’s healthcare: survey

Three questions arise:

  • Is it new?
  • Is it true?
  • So what?

It didn’t resonate. Children under the age of fifteen constitute at least one in ten encounters with General Practitioners (Family Physicians). That means there are at least 12 million consultations with children in Australia every year. The notion that parents don’t trust their GPs is questionable. Even in the study reported by the newspaper most parents (91%) had a regular GP and more than one in three children had visited a GP at least five times a year. The conclusions reported by the journalist were based on a study in which 666 parents were approached in a paediatric outpatient clinic to participate in a survey by a ‘trained research assistant’ and offered $10 for participating.  The context is important given that the conclusions as reported in the newspaper headlines were about people’s views on GPs.

100 parents in each of five specialties and 50 parents in each of the subspecialties was the ‘target number’- but we are given no justification for that number. The validity of the survey depends, in part, on the sample size which is governed by what was anticipated to be the likely response.

The questionnaire was ‘developed’ by the research team and pilot tested with 39 parents across both hospitals. We are not told how the questionnaire was developed and refined or how the validity and reliability of the responses were tested. Nor are we told why piloting ceased at 39. No scientific framework is cited. Without this information the interpretation of the findings is speculative.

It is reported that only half of the new patients seen in the paediatric speciality clinics were referred by a GP. The remainder were referred by other doctors. Therefore these participants were receiving their care from specialists and hospital doctors and it is reasonable to assume that their views were influenced by this experience.

If we are to read on notwithstanding the limitations evident early in the paper we note that only 45% of respondents were ‘completely confident’ that ‘a GP’ can provide general care to their child. From the way the question is posed we don’t know why the respondents were not ‘completely confident’. It could be because they think:

  • A GP doesn’t have access to the resources their child might need
  • Their child has had an illness that requires specialist to monitor their care
  • A GP doesn’t offer appointments when it suits them
  • A GP doesn’t do blood tests, X-rays, scans or prescribe the drugs they think their child needs
  • A GP isn’t qualified to look after their child
  • Someone they trust told them their child should see ‘specialists’ every time

Our understanding of this paper depends on which of these was meant by the respondent but the question was never posed in a meaningful way. The paper does not report the perspective of either the referring doctor or the specialist about the need for that specific referral. Without that information we can only draw conclusions based on our perspective on the issues. We certainly cannot conclude that GPs need more training in paediatrics unless we were looking for an excuse to come to that conclusion. Why publish a survey that cannot be interpreted meaningfully?  The concept explored is not new, the data can’t be safely interpreted and the only question is so what? Who benefitted from this ‘research’?

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Rehearse a plan for best care

It was a Saturday morning. Michael (43) popped in to get the results of his test as requested by the message left on his phone. He was told that the doctor who ordered the test wasn’t on duty that day so he asked to see whoever was available. That’s how I came to be involved.

From the records it wasn’t clear why the cortisol assay had been requested along with a battery of other tests all of which were normal. All the man could tell me is that he had asked for the test because:

It might explain a lot.

We had to start again. He was tired. He was stressed. He was working long hours at two jobs to pay a mortgage and service his debts. He had three young children and had been on antidepressants on and off for years. He wasn’t taking any tablets at the time. Didn’t smoke or drink. He was attending a counsellor.

There must be a reason I’m feeling so tired.

There was no obvious explanation for the borderline low result. Physical examination was entirely normal. No recent change in weight, normal blood pressure and no hint of major depression. No history of tuberculosis. No evidence of Addison’s disease.

I thought the ‘cortisol’ levels would be high I’m under a lot of stress.

We could now be on the way to more tests to determine what I suspected would be the final outcome that there would be no explanation. Life can cause people to feel this way with multiple physical symptoms including dysphoria, fatigue, insomnia, sexual dysfunction, weight changes and anxiety. Reasons may include poor choice of occupation, poor choice of partner, poor money management, poor time management, poor parenting. All of these can be associated with unfulfilling social interactions and or job dissatisfaction. Poor coping mechanisms then lead to physical sequela. People can be trapped in a spiral of increasing adverse consequences until lessons are learned and either alternative choices are forced upon them or circumstances conspire to offer the opportunity to start again.

People may not be ready to face their demons and that means they will ask to go searching for something more palatable than a need for a education,  honesty, economy or help.

As for doctors ordering tests could add to the complexity of the situation. Rare causes of fatigue are legion.  However typically people will ask if their fatigue is caused by some malfunction of their ‘hormones’ or if they are anaemic or diabetic.

In the case above there was no hint in the records what the patient had been told to expect after the test. His understanding of hormones was not recorded. He had read that cortisol is related to stress but not what the results might mean.

Because of the very low prevalence of pathology the Positive Predictive Value of ‘abnormal’ tests for middle aged patient without any positive history or examination findings is low for example:

Therefore the probability that one simple test will make the diagnosis is unlikely. People will need multiple tests and possibly a referral to a specialist once we embark on the hunt for the elusive physical cause. The likelihood of finding one when the patient doesn’t have any physical signs is vanishingly low. In sporting terms what’s needed is a set play. The question can be anticipated and the response to the initial request for tests needs to be crafted in advance. There is no better start then taking a full history and examining the patient before looking for the needle in the haystack.

Picture by Henti Smith

Cases too complex for a specialism other than general practice

It was a Friday evening. It’s almost always a Friday when this sort of case presents. She was in most ways unremarkable. She smiled readily, wasn’t evidently confused and worked in a senior administrative role. She came after work. This was the story:

I have a pain in my shoulder that becomes intense in my left arm pit. I can hardly bear to touch my arm pit. My hand becomes numb and cold. Today it’s so bad I’m finding it hard to turn the steering wheel.

I had 15 mins to sort this out, no scans, no blood tests, no discussion with a ‘team’ of young doctors working to pass their exams. She was describing symptoms that may have indicated a neurological emergency. And yet none of it made sense. She hadn’t fallen or been involved in any other trauma. There was no rash, no swelling. She swung her left arm over her head without any difficulty. I could not detect neurological signs, reflexes were normal. No Horner’s syndrome. No breast lesion. No obvious sensory loss. Twenty minutes later I could find nothing in her records or in her presentation that gave me any clue to the cause of these symptoms. And yet she was clearly worried. Regardless of the outcome I had to achieve one thing- this person like every other person who seeks help from a general practitioner needed to know that she had been taken seriously. Not for us the option of sending her back to whence she came with a note:

No organic pathology. Refer elsewhere.

A number of possibilities came to mind. Top of the list was ‘brachial plexus neuropathy‘ or Thoracic Outlet Syndrome. There were no objective signs at the time of presentation and I had never seen this before albeit that I had read about it sometime while at medical school. But then that’s primary care. We are the first port of call for anyone entering the healthcare system and often they present too early for anything to have manifested objectively. Not for us the text book presentation. About this diagnosis we know that:

Damage to the brachial plexus usually results from direct injury. Other common causes of damage to the brachial plexus include:

  • Birth trauma.
  • Injury from stretching.
  • Pressure from tumours.
  • Damage from radiation therapy.

Brachial plexus neuropathy may also be associated with:

  • Birth defects.
  • Exposure to toxins.
  • Inflammatory conditions.
  • Immune system issues.

There are also numerous cases in which no direct cause can be identified.

We also know that:

Signs and symptoms of thoracic outlet syndrome vary from patient to patient due to the location of nerve and/or vessel involvement. Symptoms range from mild pain and sensory changes to limb threatening complications in severe cases. Physiopedia

Diagnosis is difficult, tests and examination can be normalprognosis is variable. By the time a diagnosis was made weeks later and she presented to a specialist everything was obvious. But on that Friday evening with a surgery full of patients I was on my own. My patient trusted that I would not let her walk out of there only to lose a limb. Assuming a benign cause she would be back and need more. This was the start of a longterm relationship and how I managed this episode would set the tone for the duration.

While improvement may begin in one to two months, complete functional recovery may not be achieved for up to three years or longer in some cases. Tsairis et al

Picture by Mahree Modesto

Why healthcare outcomes are resistant to policy change

13799802965_b07db37bf2_zAfter every match, the cricket coach gives feedback about how the match was won or lost. Whenever the team wins it’s usually because of high scoring batting, or a great performance by the bowlers. However, when they lose there’s almost always one reason—poor fielding, dropped catches, easily conceded single runs and inaccurate throws.

In medicine surgeons are the batsmen, in most games they are seldom in play for very long. When the surgeon gets involved the crowd holds its breath for something magical to happen and when it does they celebrate with ‘Mexican wave’. Physicians are akin to bowlers, trying different deliveries, aiming to make it difficult to concede runs, patiently waiting for an unforced error. Occasionally screaming at the umpire for a decision in their favour. In the limelight an over at a time.

General practitioners are the fielders, rarely flamboyant and hard to tell apart. Constantly moving across the field, often to simply return the ball back into play. Standing for hours in the hot sun, occasionally chasing a ball to the boundary. Always trying to limit the damage. No matter how good the batting or the bowling is, if those in the field are not fully engaged, or solving problems creatively, if they are not intuitive, or working for the common good, without waiting for instruction after every ball is delivered then the game is lost.

As a primary care practitioner I am aware that most of the patients I see won’t have life-threatening pathology, but occasionally I’ll get a chance to make a game-changing difference, and on other days, my patients feel safer knowing that I am there. I don’t need to make any fancy moves, most of the time what I do is simply ensure that I nip things in the bud.

In medicine, most people consult a general practitioner and not a surgeon. That’s where innovation has the scope to make a difference to most people. Without reference to the practitioners who work at the coalface no amount of policy change is likely to make a difference to outcomes. That’s because fielders can’t do their job with one hand tied behind their back or by ignoring the evidence of their own eyes, or by focusing other than on the ball. According to the experts good fielders:

  1. Don’t move. When the captain puts them somewhere they stay there until they are moved again.
  2.  Show confidence. Looking confident in the field can save many runs.
  3.  Will throw at the stumps whenever there is a chance.
  4. Back up.
  5. Want to get every ball.
  6. Are close enough. If they are on the boundary their job is to save fours so they stay as deep as possible without giving away two runs if they can.
  7. Know themselves. If they have a setback in the field, they are aware of how they will react to it.

These simple rules tell us that it is imperative to work with the fielders if the team is to win the match. Failing to do so, like failing to work with the doctors most likely to come into contact with patients leads to frustration. The emotion that most funders experience perhaps because they do not understand the business of doctoring. We need to reframe problems in healthcare as a failure to engage with front line staff.

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How improving the experience of hospital death can help redesign healthcare

 

The residents always approached my father as if he was a person and there weren’t any divisions between them. They didn’t come in and say, “I’m Doctor so and so.” There wasn’t any kind of separation or aloofness. They would sit right on his bed, hold his hand, talk about their families, his family, golf, and sports. From Steinhauser et al.

The chances are when the times comes you will die in hospital. It may be sudden or it may be expected and either you will die a good death or the experience for you and those who are left to grieve will make a bad situation worse. Charles Garfield put it like this:

A good death is no oxymoron. It’s within everyone’s realm of possibility. We need only realize its potential and prepare ourselves to meet it mindfully, with compassion and courage

John Costello concluded his research on patient experiences of death as follows:

The findings also challenge practitioners to focus attention on death as a process, and to prioritize patients’ needs above those of the organization. Moreover, there is the need for guidelines to be developed enabling patients to have a role in shaping events at the end of their lives. John Costello

Therefore, the needs of the ‘organisation’ may impact adversely on the experience of death. These might include the need to adhere to routines such as ward rounds, meal and medication time on open wards which may make it difficult to cater to the needs of the family when the patient dies.

A good place to start with innovation is to consider what, how and when things go wrong. Costello’s interviews with nurses identified several determinants of a bad death:

  • Sudden, unexpected or traumatic deaths especially soon after admission
  • Death other than on the ward
  • Family not aware of impending death or family conflict a major feature
  • Lack of dignity or respect
  • Diagnosis uncertain

Therefore, the key features are the circumstances surrounding the death. The consequences are far from trivial:

Dying patients with unresolved physical and psychological problems, such as pain, nausea, vomiting or spiritual distress, and who were unresponsive to treatment or nursing care, were invariably regarded as experiencing bad death. John Costello

This begs the question why not prepare for death in every hospital admission especially where death is a less than distant possibility. The majority of hospital deaths occur in those over 75 years of age. How is the team prepared if there is a death on the ward expected or otherwise, whether it’s convenient to the routines or not?

Achieving seven goals appear to mark a ‘good’ death:

  1. The patient should be physically, psycho-socially, and spiritually pain-free
  2. Recognize and resolve interpersonal conflicts.
  3. Satisfy any remaining wishes that are consistent with their present condition.
  4. Review their life to find meaning.
  5. Hand over control to a trusted person, someone committed to helping them have the kind of death they desire.
  6. Be protected from needless procedures that serve to only dehumanize and demean without much or any benefit.
  7. Decide how social and how alert they want to be.

Many of these goals are in the purview of the doctor and her prescription pad, others require all those involved to help prepare for an event that will impact on everyone associated with the patient. Healthcare is now a team effort and nowhere more than at the end of life.

When physical symptoms are properly palliated, patients and families may have the opportunity to address the critical psychosocial and spiritual issues they face at the end of life. Steinhauser et al

The point is if we prepare every hospitalised patient who may conceivably deteriorate and die as if we were preparing them and our units for that experience we will treat all patients with greater dignity. That’s the foundation of good outcomes for healthcare staff and the dying.

Picture by Alyssa L. Miller

There is no curriculum for kindness

For months, my wife had been worried about the mole. I couldn’t see anything wrong with it but then it was on my back and I was peering at it through a mirror. In the end, she put the job of getting it examined by a doctor into my diary and it became ‘urgent and important’.

I decided I’d ask my colleague in the office next door if he could recommend a dermatologist.

Do you want me to take a look?

I hated to impose, it seemed hardly worth wasting a surgeon’s time looking at something I was convinced was benign.

Without a second thought, he bounced out of his chair and headed to his car appearing a moment later with a head-mounted magnifier.

It looks benign. However I have three rules with these things. We remove it if your wife is worried about it, if you are worried about it or if I’m worried about it. It’s a five-minute job. We can’t be sure until it’s sent to the lab. But you know that.

He smiled kindly. It was a small courtesy to a colleague,  but a telling example of how a man you had been a surgeon all his life could still be spontaneously kind. His rule made excellent sense. This behaviour is not in any medical textbook. It’s not recognised as an ‘innovation’ that can improve outcomes. It’s just plain old-fashioned, good-natured thoughtfulness. It doesn’t require a grant or a special piece of equipment or anyone’s approval. It makes all the difference to all of us every day. It’s the sort of thing that speaks of vocation. I’m grateful that my colleague works with me, he is a wonderful communicator and that matters when you are training future doctors.

Picture by British Red Cross

Age, occupation and prognosis may filter what the patient hears

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I’m booked in for a check up tomorrow with the doctor who looked after me and called the ambulance so I can thank her in person. My bike doesn’t seem to have a scratch! Tony and Wayne

The experience of an illness, accident or emergency can heighten the trust in a medical practitioner. Primary prevention is more problematic.  People who are asymptomatic and being urged to alter their lifestyle or take antihypertensives may be more dubious:

Well I mean would you trust them with your life? Or would you trust them you know, when you’ve got a bit of a cough? You know, there’s a bit of a difference. You can trust somebody to take a splinter out or whatever but ah, I mean, even if you’ve made some sensible comments, if you’re going to start playing around with anything serious, you know, brain or the heart or whatever, you’d like to know a bit more about it—you’d like to see him in action and…Meyer et al

Three factors appear to influence the attitude; age, socioeconomic status (SES) and prognosis. Our research was conducted with reference to cardiovascular disease. Generalisations in medicine are not safe however these data offered some helpful pointers.

Older patients, lower SES patients and patients with established pathology are more likely to trust, and are less likely to question medical advice. Meyer et al

Our research also suggests that:

Participants who perceived themselves at risk of a poor or uncertain outcome were unlikely to express doubts about medical advice. Meyer et al

Therefore, context is critical when crafting an approach to the patient. Does the patient wish to be involved in decision making or would your presentation of multiple options with the relevant probabilities for each outcome make a bad situation worse? At a time when there is a push towards ‘patient self-management,’ the data suggests that some patients prefer a traditional approach with the doctor recommending a treatment modality. Older people in deprived areas top the list, the demographic that is at highest risk of chronic and complex health conditions. Unfortunately getting this wrong when the patient wants to be more involved may destroy the relationship between patient and clinician.

…he’s always explained—look whatever I’ve gone to see him for he’s explained, he’s gone into details. He, he doesn’t write anything off without doing tests for, for further examinations—whatever. And through the process of elimination as opposed to my previous GP who had the approach of, ‘ah it’s nothing—you’ll be alright’. Meyer et al

We need to understand the business of doctoring as an integral part of designing solutions aiming to optimise patient experience. We need doctors to step up as codesigners. Treatment is often determined locally within the appropriate context rather than a one-size-fits-all. The solution to healthcare challenges starts with having a good General Practitioner whose work is supported by good research in primary care.

Picture by Tony and Wayne

Innovate for quality first

Use of the term ‘quality‘ needs definition before it can be interpreted in any critique of the health service. I propose a definition of a quality as one which can be measured by the extent to which the person with the problem feels that s/he has been seen and heard by a healthcare professional with the requisite expertise. It has resonance with business where if the customer feels that she is not valued she takes her custom elsewhere. However as is sometimes illustrated by some aspiring healthcare providers they understand business but have no clue about medicine. There is a burgeoning of primary care providers, offering something akin to fast food outlets but these are likely to disappoint their clients.

Quality has four benchmarks:

 

There is no ‘quality’ if the patient has no prospect of consulting the person best placed to assist and especially when need is greatest. There are many examples of disastrous outcomes for people who have not been able to access the required expertise in time. In healthcare that may be a surgeon but it could also be a dentist, a physiotherapist, a pharmacist or an allied health practitioner. On that basis it is telling that in Australia access to general practice may be challenging in some communities but so is access to allied health practitioners. For this reason alone these communities have a diminished quality primary care service regardless of any other benchmark.

However ‘access’ alone is a poor proxy measure of quality although it often seems as if the public believes it is the only one that matters. It certainly makes very bold headlines when it fails. On the other hand there is little point in a very accessible service which is not effective. Once the access issue has been addressed the focus shifts to effectiveness. The Royal Australian College of General Practitioners offers a useful list of indicators that might guide a medical practice. Each discipline or organisation is likely to have its own list of ‘quality’ indicators for effective care.

The integration of care providers is a sensitive marker of quality in health care. There are many healthcare issues where a team approach is of critical importance to timely diagnosis or rehabilitation especially when transitioning from another setting. Practitioners in different disciplines rarely work as an effective team not because they don’t wish to, but because team work is inhibited by funding and or organisational  structures. This may be the one area where collaboration could improve quality for modest investment.

Finally, and crucially, continuity of care is a vital component of quality. Simon illustrates the point well. He has been admitted to three different hospitals in the same town over the past three years. He usually finds his way there in an ambulance or via the emergency department. He has two different problems which have been diagnosed as ‘alcoholism and  neurosis’ or ‘epilepsy’ and ‘stroke’ or ‘migraine’. Simon has certainly enjoyed access and on every occasion he has consulted someone who is suitable trained but there has been no integration of providers and the only hope for a good outcome is continuity of care. By any standard, eight CT scans later, he is at risk of iatrogenesis.  After three years he has been told he is fit to drive and not drive in the same month by practitioners with the same specialist qualifications. He has been commenced on antiplatelet medication by one  and advised to discontinue all medications by another. The only hope is that he has the same general practitioner and that continuity of care might be the light in an otherwise dark and it seems radiated tunnel.

The context is often private and confidential

7257592240_6759efd5a5_zThe consultation between a doctor and patient is private. Innovators hoping to improve outcomes in that context can’t observe the exchange directly because some presentations are very uncommon and because neither the doctor nor the patient welcomes the intrusion. There are many outcomes of the encounter between patient and doctor that we still don’t fully understand. Why are some patients’ cancer symptoms not recognised as early warnings? Why do carers of patients with a life-limiting illness fail to have their own medical problems addressed? Why do people living with some chronic conditions continue to have problems with intimacy?

People deploy verbal and non-verbal cues to communicate. They choose when and how to disclose their ideas, concerns and expectations. However in an average consultation in my country, the patient has fifteen minutes to ‘spit it out’. Similarly, clinicians vary in their ability to pick up cues or to probe with the right question, assuming they get the right answer. Hence errors of omission and or commission.

Lean medicine is about being intuitive, creative and agile. Lean innovators, clinicians, are already on site. Therefore, they can reproduce the context in a way that can be observed and where they can be tested with other clinicians. Video technology and a fusion of skills across disciplines allow the depiction of those encounters in such a way as to present the critical decision point for close examination. Do you prescribe, refer or investigate in these circumstances? What do you say to the patient?

How do you explore hard to reach elements in your practice or business? How can you hope to innovate for encounters that are strictly private and confidential but where mistakes or misunderstanding can be very bad for business. Who has the insight to show you? How can you generate valid hypotheses? How do you test ideas without a real risk of casualties?

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