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Can the patient relay what was done for them?

A perennial source of dissatisfaction in healthcare (as documented here and here) is the poor flow of information from one sector to another. ‘Joe’ (speaking here– video from BMJ open) couldn’t tell me, his doctor, anything helpful about what had been done while he had been in hospital. That means we have to schedule several appointments to try to unpack it all. He was an in-patient for two weeks and someone had decided one Thursday morning that it was time for him to go home. It wasn’t really clear to Joe or to me why that particular morning or what was to happen when he got home other than that he should contact his ‘local GP’. A letter would follow some time in the future. There may have been good or bad reasons for sending him home. We could only guess what was in the mind of the person who made the decision:

We needed the bed. Joe was fine. His observations were normal, he was ambulant his wife was happy to take him home.

But of course Joe comes home with lots of questions, which I now struggle to answer without making phone calls to track down the busy medical team. The problem is articulated by several ‘stakeholders’ members of the ‘multidisciplinary team’ on the ward none of whom feel they own the problem of telling this man what he needs to know. There is only one constant in this story- Joe. If Joe can collect the information we need during the course of his hospital stay we might begin to improve the outcome:

In addition to increasing the burden on GPs, it engenders a need for a subsequent GP appointment; it limits GP capacity to respond to patient concerns and queries, at least on one occasion; it may result in a re-referral to the specialist; and it increases GP dissatisfaction with the care provided to the patient by the hospital. BMJ

The problem is Joe often does not know what he needs to know by the end of his hospital stay. It isn’t impossible to work out how to trigger questions for Joe to ask throughout his hospitalisation. What is far more difficult is to motivate every hospital ward and every discipline in a team to address this challenge consistently. It is ‘easier’ to nudge one individual than enlist the cooperation of the dozens of health professionals who will come into contact with Joe. Making people active in healthcare processes has achieved results before:

Influence at Work, a training and consultancy company that Cialdini founded, worked with the United Kingdom’s National Health Service (NHS) in a set of studies aimed at reducing the number of patients who fail to show up for medical appointments. They did this by simply making patients more involved in the appointment-making process, such as asking the patient to write down the details of the appointment themselves rather than simply receiving an appointment card. Sleek

Picture by Michael Coghlan

General practice can evolve- it just has!

 

It’s Thursday night- I don’t blog on a Thursday night. But this isn’t any ordinary Thursday. Today I believe I walked in on the future of general practice in bricks and mortar– designed and run by a couple whose combined age is not much more than mine. I’m not quite sure what I was expecting when I made the appointment to visit. I suspect I was just being nosy- could a practice really do business without a big reception counter? I was prepared to be disappointed. To see the waiting room damaged and tired after more than a year in business. To see little more in the way of big ideas than the loss of that big ugly barrier. What I wasn’t expecting was to meet a couple whose energy and passion for general practice could easily power a small city and to leave feeling overawed by what they have created.

I saw attention to detail in everything that makes for an extraordinary patient experience. From the music in the waiting room, sounds that could be controlled from smartphones with a different selection possible in each room. Removal of the desk in the consulting room, replaced by a tablet computer fully loaded with the latest clinical software. It is a place I want to be- as a doctor, as a patient, as a visitor or in any capacity they will have me. I can’t begin to describe the impact of each room with windows designed to maximise the natural light even deep in the heart of the building, the removal of clutter (no posters anywhere), the exquisite choice of everything on display with an emphasis on less rather than more. Even the treatment room stocked in a way that makes a Toyota factory the most efficient place on earth.

I heard patients being welcomed, smiling faces everywhere, staff who said they were never happier at work. Doctors who clearly enjoyed what they were doing and a sense of purposeful calm in all that was being done.

This is what can be achieved without relying on any external agent even in a so-called area of need. It has been created by people who care enough to work very hard and want nothing less than they expect for themselves. People who want to create an experience that makes it more likely that people will value what’s on offer. Today I believe I was given a rare glimpse into what it will be like in medicine when these ideas are universally adopted because nothing less than the feelings that this place engenders is good enough.

Picture by AmadeoDM

Create your own working conditions or deal with the headaches

It was Friday morning. S/he looked well so I was surprised when s/he said:

I woke up with a headache this morning. I’ve taken paracetamol. I feel a bit better but I couldn’t go to work this morning.

What do you do for a living? I asked. Insert into his /her response:

Teacher/nurse/social worker/call centre operator/forklift driver

Is it busy just now? I asked. Wondering how his/ her boss would take the news of this absence. The smile slipped.

It’s been terrible this year. Lots of demanding (patients/ clients/ kids/shifts).

Then- tears.

I’ve got to hold it together. I’m only six months away from ( holiday/ long service leave/ wedding/ boss leaving)

Is this sustainable? Really?

How much time do you spend on things that are either distractions (not-urgent or important) or someone else’s emergency (urgent /not important)? How much time do you spend on the most valuable quadrant not urgent and important? Why are you always fire fighting (urgent and important) ? Icon made by Ocha from www.flaticon.com

What are you doing during the most productive time of the day? What do you focus on first in the morning? When you are fresh and rested? What are you leaving till later when you should be heading home? Icon made by Freepik from www.flaticon.com

 

It’s your responsibility to set limits to your accessibility. If your boss wants you to do this then s/he doesn’t expect you to do the other.  Are you sure you clarified the situation? YOU have created these unreasonable expectations because the word ‘no’ isn’t in your vocabulary. Icon made by Freepik from www.flaticon.com

 

Finally how much energy, stamina, good will or creativity is left in the tank? There is a limit- even for you. Icon made by Freepik from www.flaticon.com

You are not exempt even if you are a doctor. If you don’t create the life you want then one will be created for you. And it might just give you a headache. You have some thinking to do while you nurse that headache.

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There are no prizes for caring for people the day after you graduate

Hoards of young people in gowns and mortar boards are everywhere in the city this month. For some it will be a very special occasion as they step up to collect prizes bestowed in the name of some worthy luminary. For a few it will be a bumper crop with multiple awards. Others will have to content themselves in the knowledge that he or she who simply passes the final exams is still called ‘doctor’.

Some medical students will also recite the Hippocratic oath. Of which my favourite version appears below:

I swear to fulfill, to the best of my ability and judgment, this covenant:…

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.

I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and used in many medical schools today.

Living by this oath does not earn the annual Hippocratic Award for Excellence. If only all graduates could hear Simon Sinek deliver a commencement speech. This is what they might hear. Prize winners might reflect on what it will feel like to inhabit a world where being excellent at your job doesn’t mean you get to wear a gown and hear applause. If you have the good fortune to call yourself doctor then innovation in healthcare is detailed in the oath and begins with yourself.

Picture by klbradt

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

 

Are medical students already healers?

I recall the awkward silence when I couldn’t decipher the carotid angiogram thrust at me on Monday morning. As a newly qualified doctor who’d spent the weekend on-call, I would not have been able to describe my route home much less recognise the stenosis in the relevant cerebral artery. Never mind ‘doctor’ spat my boss. Tell us is the patient I’m about to operate on a nice man? He said winking at the gathered retinue.

Actually professor he is. Trouble is he asked me the same question about you and as you can see I’m not a very good liar.

That cheeky reply probably spelled the end of my surgical career. This style of ‘education’ was known as pimping and that day I had just refused to accept it. Among the legions of would-be doctors, there are a few who will go on to be brilliant in the course of their careers. There are those who will one day discover the cure for Alzheimer’s or cancer. There are those who will perform surgery to save life against impossible odds. There are those whose pills or devices will earn fortunes. But brilliant are also those who will reassure and revive. They will be the unsung heroes whose name won’t appear on any honour’s list. They will offer that undefinable quality that helps us to prime our regenerative capacity and immune systems, more often than not in spite of the limitations of technical fix-its. Those who will be the healers of tomorrow already have the qualities within them even before their first anatomy or physiology lecture. They are intelligent and resourceful but also have an innate sense of what to do when faced with a human being in distress. Our job is to hone those qualities and help them to recognise the precious gift that lies dormant until it is needed on the wards, in the clinics and at the bedside. It is truly a privilege to be part of their journey to nurture their talent despite the many disappointments and frustrations that are part of the landscape of any medical career.

We conclude that compassion is everyone’s business and that learners require early and sustained patient and client contact with time for reflection to enable the delivery of compassionate care. Davin and Thistlethwaite

What the world needs is healers, not technicians because doctors care for people and not machines. So in answer to my boss’s question the man he was about to operate on was an incredibly nice person. He would hail us over in the middle of our shift and insist that we took the fruit that his family had brought knowing that we were unlikely to have made it to the canteen before closing time. My boss really was an excellent technician. What helped the patient through this episode wasn’t just this technical skill, it was the compassion and concern that was lavished on him by the dedicated team of nurses and doctors who would ensure that he was pain free, that his questions were answered, his wounds were dressed and that his family were informed of his progress through intensive care and on the wards as was his wish. I’m sure he remembers his surgeon fondly as the brusque, brilliant and efficient man who helped keep him from a stroke but I’m sure he also remembers the junior doctors who would come to him in the middle of the night when his temperature spiked and the staff nurse was worried that his wound was infected. Without this care what was a difficult time for the family would have been a nightmare and the outcome may not have been as good. There were many times during that illness that we came close to losing that patient except that he had the resilience to hold firm to life and we were in his corner.

Picture by Spirit-Fire

Your staff shouldn’t have to gauge your mood in 2016

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You are going to be disappointed in 2016. Much as you were in 2015 and every year before that. Disappointment, complaints and failure are part of the experience for every leader, innovator, clinician and researcher. That’s actually a very good thing.

How you respond when (not if) that happens will also predict how much success will flow into your experience.

Failure occurs because:

  • People aren’t prepared
  • Accidents happen
  • The team has unrealistic expectations
  • Someone becomes ill or for some other reason can’t support the project
  • The customer didn’t like what you offered on this occasion
  • Bad luck

Your team will watch your reaction closely, even if you don’t notice.

They’ll be asking themselves:

  • Is this fair? (By the way they will be much more inclined to think it isn’t)
  • Is it my fault?
  • Do I have something to fear from the boss’s reaction?
  • Is this a sign that we are on the wrong road?
  • Do I really want to work here?

Prepare. What would you like your team to learn from disappointment?

  • Let’s work out what went wrong and to what extent we could have fixed it
  • We don’t like this feeling so let’s prepare better
  • Let’s find a way round this
  • That was fun. Shame it didn’t work out but we are so much better for the experience

So don’t encourage:

  • Recrimination
  • Despair
  • Anger / Fear (the same emotion)
  • Civil war

The best way to avoid these outcomes is not to initiate, encourage or participate in such behaviour. Don’t vocalise negative emotions because in doing so people will either disagree with you and make a bad situation worse or take responsibility when they shouldn’t, only to regret it later.

You will fail in 2016- the failures may be big or small but the fact that you will be trying is to be celebrated. Disappointment is a good thing because it will make it more likely that you will succeed later because you learned something important. If your reaction betrays extreme commitment to the desired outcome then ponder why the outcome means so much to you that your staff dreads giving you bad news.

At this time of New Year’s resolutions- resolve to accept failure and accept the gifts of wisdom and humility that come with it. Commit to leadership and innovation starting with you.

Picture by photos.de. tibo

 

It’s all part of the plan

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In January you will set sail on the 2016 adventure.

Why

What’s your mission?

Where

What’s the destination?

Where are the friendly ports?

How

Have you charted the course?

What do you need to do to get underway?

How will you know if you are on course?

How did you adjust the map after last year?

Who

Who is in charge of what?

Who buddies with whom?

Who is in the watch?

Are the crew able and ready?

Who is sailing alongside?

When

When will you call into port?

When is it ‘all hands on deck’?

What

Is the ship seaworthy?

What provisions do you need for the journey?

What happens when the sea gets choppy?

Are your crew ready to hoist the anchor and set sail?

Picture by Barbados sunset

Lead your team or leave

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

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

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

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

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

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

Picture by Craig Sunter

My first day as a doctor

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I’ll never forget my first day as a doctor. I donned my freshly laundered white coat, swung my new stethoscope around my neck, clipped the newly acquired Parker pen into my shirt pocket, stuffed a copy of the drug formulary into my coat pocket and made my way to the gynaecology ward of the large Dublin hospital where decades ago on the 1st of August I was to be the new medical intern.

She greeted me with a warm smile as she stood at her desk in the ward office. ‘Sister Eileen Doorly’ it said on her name badge. She must have been in her mid 50s and had the bearing of someone to be respected.

Good morning, doctor.

This was the first time anyone like her had called me doctor and my heart missed a bit.

Me: Good morning, Sister. What can I do for you this morning?

Her: Well, you might want to prescribe an anti emetic for the patients post op doctor.

I hesitated. I knew what the drug was but wasn’t sure about a number of other important details. I hesitated. She watched me closely. Smiling kindly. The formulary was within grasp but I left it in my pocket and chose to ask.

What does the professor like to use post op sister?

Her smile broadened.

That would be stemetil doctor

I unclipped the pen and stood with the nib poised over the first drug kardex.

Me: S..t…..

Her: e..m..e..t..i..l.

Me: Thank you. And what dose does he like to use?

Her: 12.5 mgs i.m. twice a day. 6am and 6pm. The rest, is on your name badge, doctor.

She had a twinkle in her eye. She was teasing me but somehow I could sense that she didn’t mean to be rude. Eileen Doorly spent the following three months teaching me everything I needed to know to get through the most demanding year of my career. She did it willingly, she did it with the deepest respect and she did it with discretion. I am forever grateful to her. I never saw her after that year and because I moved overseas for my specialist training I didn’t have the opportunity to thank her. She also taught me that sometimes it pays to let those who work with you teach you things, to show your vulnerable side and to trust them. I published my first academic paper while working on that ward. It set me up to get a place as one of six to be offered a prestigious training job against stiff competition.

Eileen Doorly inspired that work because in that first week on the ward she explained that my job as an intern was not only to provide basic medical care but to support the catholic Irish women who would be told in the course of their admission that they would be unable to bear children. That experience was critical to my decision to choose to specialise in general practice. In the course of my career I have met a number of people like Eileen Doorly, men and women, older, wiser and more experienced. Always willing to teach, always with the patients best interests at heart. Medicine requires team work, it is a demanding profession in which errors can cost lives. Men and women like Eileen Doorly ensure that patients are not harmed despite the many inexperienced doctors who must participate in healthcare to learn the art.

Picture by Jez