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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

Much of what’s wrong with healthcare is in the consulting room

It’s not that complicated. Not really. So where do you look for pathology? Inspection, palpation, percussion and auscultation. How does it look, how does it feel, how does it sound and what do you hear when you know where to listen closely. I’m talking about healthcare. Take a helicopter ride through your business.

Access

What is the route to your service? Where is the delay? How long do people wait in the waiting room? How do you know? What do you know about the people who use your service even before they are seated in your waiting room?

Greeting

What happens when people call or arrive in person? What message is conveyed?

Welcome we’ll do our best to help you today OR you are lucky we are ‘fitting you in’.

Just stand there- I’m dealing with someone on the phone.

We have no time- go complain to the manager/politician/ bureaucrat-consider yourself drafted to the cause.

Hold the line. We are dealing with something far more important but your call is really important to us so just listen to how good we are as conveyed by our prerecorded message.

Associated with that is what is perceived about your attitude that is not verbalised?

Look at ALL these posters and the many ways you can be helping yourself instead of wasting our time.

People vomit and pee while they wait so the seats have to be cleaned with detergent. Plastic is the best option.

If you want a drink go buy one at a cafe.

We rely on donations for our toys and magazines- we don’t have to provide anything OK? Now if you don’t like the stuff just watch Dr. Phil.

What do you mean you have been waiting a couple of hours? This isn’t McDonalds now take a ticket, sit down, shut up and wait. And turn off your phone so you can hear the old lady at the desk who has an embarrassing problem.

Communication

How long is the meeting with the provider? How does that meeting unfold? What is conveyed during the meeting?

Welcome- I’m so sorry you are not well. Tell me what happened? OR I haven’t got long what do you want exactly, spit it out be quick about it I need to get on with the next guy. Didn’t you see the queue out there?

I’m the important one around here- you are lucky I’ve chosen to be here today. Let me tell you about my holiday, my kids, my new car. It’s fascinating really!

Room 5. Quickly. Never mind my name.

Test/ Referral and Prescription

What action is taken at the consult and are you confident that is the best possible action?

I don’t have time for talk- have this test and take another day off to see me next week.

I don’t have time for you to take off your umpteen layers- go have a scan.

The rep told me this works- I only have to write a script.

If you want to get better take my medicine/advice/ referral or get lost.

What medicine do you want? How do you spell that? Tell me slowly I’m writing it down on your script.

Outcome

What proportion of people takes your advice/medicine/test? How many people stopped smoking? How many were triggered to lose weight? How many are addicted to prescribed medicines? How many were prescribed treatment or tests that were not indicated? Where’s your data? What are your plans for dealing with this?

Team

To what extent can you say that when people transition to another healthcare professional either on site or elsewhere that the relevant information follows them? Is everyone on the same page with the same patient?

All of this matters. All of it. Some of you can fix tomorrow. No need to wait for another round of healthcare reform. No one said it was easy. And whatever their business the best don’t compromise.  A lot of what can be fixed in healthcare takes place behind the closed doors of the consulting room.

Picture by Daniele Oberti

We don’t have to agree but it doesn’t have to end in tears

I told him NO. You don’t need antibiotics you have a virus. Now leave.

This is the rather macho way in which the story of how a patient’s ‘unreasonable’ request was rejected is sometimes recounted. In some cases the law was changed to allow people to access some items much more readily:

In some countries, potent drugs are now losing their efficacy because of unregulated access. The stage is set for disagreement and inevitably it comes when the provider does not have a plan for how to tackle the request that is not in the patient’s best interest or does not address associated risks that patient is taking. Arguments might be even more common were it not for the evidence that healthcare providers sometimes act without assessing the requests fully. This makes matters worse because it raises unreasonable expectations. In one recent study it was reported:

In spite of the requirement that pharmacists sell restricted medicines, shoppers often found it difficult to distinguish pharmacists from other pharmacy staff. Shoppers were able to confirm that a pharmacist was definitely involved in only 46% of visits. In 8.8% of the diclofenac visits, and 10.8% of the visits for vaginal anti-fungals, no counselling was provided. The vaginal anti-fungal visits tended to be more product-focussed than the diclofenac visits. When they purchased diclofenac, most pharmacists asked shoppers if they had, or had had, stomach problems (74.6%) or asthma (65.4%). A minority asked about the symptoms of the vaginal fungal infection which the female shoppers presented with. While most pharmacies recorded patient names, many did so in a way which compromised patient confidentiality. Pharmacy World and Science

Similarly, it has been shown that performance varies in general practice:

In more than one-in-eight cases, the patient was not investigated or referred. Patient management varied significantly by cancer type (p<0.001). For two key reasons, colorectal cancer was the chosen referent category. First, it represents a prevalent type of cancer. Second, in this study, colorectal cancer symptoms were managed in a similar proportion of options—that is, prescription, referral or investigation. Compared with vignettes featuring colorectal cancer participants were less likely to manage breast, bladder, endometrial, and lung cancers with a ‘prescription only’ or ‘referral only’ option. They were less likely to manage prostate cancer with a ‘prescription only’, yet more likely to manage it with a ‘referral with investigation’. With regard to pancreatic and cervical cancers, participants were more likely to manage these with a ‘referral only’ or a ‘referral with investigation’. BMJ open

In summary:

  1. People often present with ideas that are at odds with those of the provider.
  2. The law sometimes enshrines the right to over the counter treatments that may not be indicated or may actually harm people.
  3. Patients are not appropriately assessed in all cases which mean they either acquire things that are not appropriate or denied things that are.

Once the decision is made to say no it isn’t always handled well. This has also been demonstrated in the literature. What has been published suggests that one of the most potent tools in the armory are good consultation skills. The more worrying issue is how this comes as news to some in a profession that pride itself on members’ ability to communicate. The bottom line is that any business that loses the relationship with its clients is heading for the rocks. Every business knows that there are polite ways to reject a customer. Therefore the answer to the question of whether and what to prescribe is a function of the consultation skills taught to every medical graduate. The issue at stake when things go wrong is how well those skills are being exercised. The quote at the top of this post suggests that some doctors need a refresher.

Picture by Jens Karlsson

The country needs general practice to be the provider of choice

Ever since I came to Australia as a foreign graduate I have been obliged to work in a so-called ‘area of need’. Directly opposite one practice in such a location, there is a large shopping centre. I sometimes go across the road to get my lunch. I noticed several very busy outlets full to the brim with customers. Here is a price list of some of what they offer:

  1. Reflexology Foot care (20 mins) $40
  2. Deep tissue and relaxation oil massage 30 mins: $50
  3. Headache treatment (30 mins) $30
  4. Sciatica relief $45

The practice across the road is a ‘bulk billing practice’ (i.e. they do not charge more than the government subsidy). The practice feels that people ‘can’t afford to pay’. I often see the same people queueing up for the treatments mentioned above. Today ( Sunday 26th February) there is a full page add in local newspaper headed:

Hope has arrived for men over 40 with low testosterone. Now, as part of our national health drive , a limited number of Australian Men can get free assessment before 5/03/17.

A box on the page asks:

Do these symptoms sound familiar?

  • Sleep problems
  • Increased need for sleep/ feeling tired
  • Physical exhaustion /lacking vitality
  • Deceased muscular strength
  • Irritability
  • Nervousness
  • Depressive symptoms
  • Raised cholesterol
  • Erectile dysfunction
  • Lowered libido
  • Prostate symptoms

The advertisement claimed that:

Studies show that only 10% of men are receiving treatment for low testosterone.

Citing as evidence one academic paper. The other citations are to reports on a news channel. The conclusions of the academic paper are based on a survey of 2165 men attending a primary care clinic in the United States regardless of the reason for attendance. Hypogonadism was defined as follows:

Given the lack of a widely accepted single threshold value of TT to define hypogonadism, <300 ng/dl, which has been used in clinical studies of hypogonadal men, seemed a reasonable choice. (Mulligan et al)

On this basis man with testosterone, levels below 300ng/dl were classified as hypogonadal and their symptoms were attributed to that condition. The team concluded:

The difference in the occurrence of four of the six common symptoms of hypogonadism (decrease in ability to perform sexually, decrease in sexual desire or libido, physical exhaustion or lacking vitality, and decline in general feeling of well-being) was greater in hypogonadal vs. eugonadal patients (p < 0.05).

None of the men were examined for other causes of their symptoms or problems. And on the basis of this research, a clinic operating in Australia is marketing therapy that:

….stimulates natural testosterone production

There is no mention of the cost of this treatment anywhere on the advertisement. The only protection that we offer people in the face of this very questionable marketing are the services of a trained general practitioner able to help people navigate this minefield of nonsense designed to part people from their hard-earned money. However, we need to create an experience that competes effectively with the powerful commercial offerings that are triggering people to spend their money so that they are then considered ‘unable to afford to pay’ for better advice.

Picture by Angie Muldowney

Junk used to wallpaper doctors’ offices

Of all the things doctors can do in their practice they can certainly choose what to display on their walls. In 1994 a group of researchers reported:

To determine whether patients read and remembered health promotion messages displayed in waiting rooms, 600 patients in a UK general practice were given a self-complete questionnaire. Two notice-boards carried between 1 to 4 topics over four study periods. Three-hundred and twenty-seven (55%) of subjects responded. Twenty-two per cent recalled at least one topic. Increasing the number of topics did not in crease the overall impact of the notice-boards. The numbers of patients recalling a topic remained constant, but increasing the number of topics reduced the number remembering each individual topic. Patients aged over 60 years were less likely to recall topics, but waiting time, gender and health professional seen had no effect on results. Very few patients (<10%) read or took health promotion leaflets. Wicke et al

It would appear that the notices are basically used as wallpaper. They do not seem to serve any other useful purpose. Researchers suggest that the design of such ‘community communication channels’ requires further thought:

Our results highlight how they are used for content of local and contextual relevance, and how cultures of participation, personalization, location, the tangible character of architecture, access, control and flexibility might affect community members’ level of engagement with them. Fortin et al

Essentially the role of the notice board with its myriad of posters and leaflets is to ‘sell and inform’ not to decorate and distract. They sell ‘health’ or services related to health. Vaccinations, antenatal care, weight loss, smoking cessation, early diagnosis, screening, the list is endless. They might also inform about practice policy. The notice board, or as it often seems almost every available space on the walls is used in a vain attempt to ‘communicate’ with people. But this sort of communication is carefully choreographed in the retail and service industry:

Businesses like gas stations and banks regularly provide information about the availability and price of particular items, such as gas, convenience items, loans, and savings certificates. The display of this information plays a central role in these companies’ business strategies for increasing traffic and sales. Indeed, the value of a corner or other highly-visible location rests largely on the ability to use signs to inform passers-by about the availability of a business’ goods and services. University of Cincinnati Economics Center

The way these notices are displayed can have an impact on the bottom line of the business:

In conclusion, exterior electronic message boards offer business a lift in store sales performance and generate a relatively quick return on investment. While the overall 2.12 percent lift in sales is modest, in a high-volume store with low installation costs, the investment returns to using this technology can be significant. University of Cincinnati Economics Center

Your bank, department store, hairdresser does not stick everything they have on their walls and hope for the best. The walls in a doctors’ premises are high-value real estate, not a back street that can be pasted with whatever junk is sent by whoever wants to get attention until the material becomes dog-eared or torn. The key is to focus on ‘content of local and contextual relevance’. However, in the end, the wall space should prepare the patient for the consultation. It is in the consultation that the advice can be tailored to the patient and as Wicke and colleagues concluded in 1994:

More modern methods of communication such as electronic notice-boards or videos could be used. However, the waiting room might best function not as an area where a captive audience can be bombarded with health promotion messages, but rather as a place for relaxation before consulting a health professional, making patients more receptive to health advice in the consultation. Wicke at al.

Would it really do any harm to jettison this confetti altogether?

Picture by Bala Sivakumar

Start the consultation as you mean to continue

What I consider this week requires no renovations, no insurance rebate or government subsidy. It does require clean hands. Yet the humble handshake has the power to catapult a meeting into an entirely different dimension.

Many of our social interactions may go wrong for a reason or another, and a simple handshake preceding them can give us a boost and attenuate the negative impact of possible misshapenings.  Dolcos

The importance of any act that makes for a more positive interaction is that doctors are more often than not in the ‘sales’ business. They ask us to ‘buy’ all the time:

  • Buy my advice
  • Buy the recommended tests
  • Buy this diagnosis
  • Buy the suggested lifestyle change
  • Buy these pills

On the other hand ( pardon the pun) some researchers have called for a ban on handshakes because they can spread infections. But are you more or less likely to ‘buy’ from someone who does not shake your hand?  The evidence that the simple handshake can make a huge difference to the outcome of a meeting is overwhelming but there is precious little written about it in the medical literature.  As recently as 2012 researchers at the University of Illinois noted that:

Despite its importance for peoplesʼ emotional well-being, the study of interpersonal and emotional effects of handshake has been largely neglected. Dolcos et al

We have all heard that handshakes have an impact on the outcome of job interviews. But perhaps more than any other literature consumer psychology has a lot more to say on the subject:

A successful sale depends on a customer’s perception of the salesperson’s personality, motivations, trustworthiness, and affect. Person perception research has shown that consistent and accurate assessments of these traits can be made based on very brief observations, or “thin slices.” Thus, examining impressions based on thin slices offers an effective approach to study how perceptions of salespeople translate into real-world results, such as sales performance and customer satisfaction….Participants rated 20-sec audio clips extracted from interviews with a sample of sales managers, on variables gauging interpersonal skills, task-related skills, and anxiety. Results supported the hypothesis that observability of the rated variable is a key determinant in the criterion validity of thin-slice judgments. Journal of Consumer Psychology.

We now have very sophisticated was to assess the impact of our behaviour on each other. And when functional MRI is deployed the data suggest:

A handshake preceding social interactions positively influenced the way individuals evaluated the social interaction partners and their interest in further interactions, while reversing the impact of negative impressions. Journal of Cognitive Neuroscience

David Haslam (Said by the Health Service Journal to be the 30th most powerful person in the British National Health Service in December 2013) wrote:

Touch matters. Really matters. It is a highly complex act, and touch has become taboo. Touch someone’s hand in error on the bus or train and both parties will recoil with hurried exclamations of ‘sorry’. To touch someone has become an intimate act–generally limited to family, lovers, hairdressers and healthcare professionals. The very word carries significance. We say we are touched by an act when it moves us in a strongly positive emotional way. And all manner of other phrases have connotations that link touch to emotion–giving someone a shoulder to cry on, or saying ‘you can lean on me,’ ‘hold on,’ ‘get a grip,’ ‘a hands on experience,’ ‘keeping in touch,’ ‘out of touch’ and so on. For doctors, touch can be a vitally important part of our therapeutic armamentarium. I’ve lost count of the times that I’ve leant over and held someone’s hand when they started to cry in the consulting room. The healing touch

In a small study now a decade old, Mike Jenkins suggests that a spontaneous handshake proffered by the patient at the end of the consultation is a very good sign:

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’. Mike Jenkins

It cost nothing- although, in some cultures, it may be taboo to shake hands. In most cases, it can only help to establish trust and improve the outcome of the consultation. Of course, if you care enough to want to engage with the patient you would wash your hands thoroughly before sticking out your hand but failing to make physical contact at the outset comes at an enormous cost of reducing the ability to put the patient at their ease.

Whatever we decide patients notice:

I saw one of your doctors today, she didn’t shake my hand, listen to my heart, do any type of extremities tests to verify my condition. Just referred me to another doctor. Is this the kind of poor medicine I can expect from the rest of your professionals? Mark Roberts, Facebook

Picture by Rachel

Aren’t general practitioners already working hard enough Mrs May?

Right on cue in 2017 one government has made public pronouncements that the healthcare service is failing people because doctors, and specifically general practitioners, are not working hard enough. And their prime minister is prepared to penalise them:

Mrs May wants GPs to provide services 8-8pm, seven days a week, unless they can prove there’s no demand.

Her three point plan would see extra funding for docs slashed unless they provide weekend and evening appointments when patients need them– not when they offer them.

Practices getting extra cash for opening outwith core 8-6.30pm hours during the week will also be asked to expand online services. Lynn Davidson

It is as if the health of the nation can only be managed in one way- increase the number of people who consult a GP. It implies that the quality of those consultations couldn’t possibly suffer because tired doctors are forced to work longer hours. The government appears to be armed with a hammer and to them, everything looks like a nail. If these are the public pronouncements of the UK government, and there is a GP shortage how are they making a career in general practice an attractive option? Five experts presented their views on the subject of the current crisis in another article in a different national newspaper:

Nursing: Poor strategic decisions and budget cuts to care services have exacerbated pressures on emergency care.

Think Tank: More people attending hospitals and more of them are older and sicker. In many hospitals, beds are fully occupied, making it difficult to admit patients and causing waiting times in A&E to lengthen

Medical association: Demand is so great that hospitals are now full all year around, meaning there is no spare capacity to deal with a seasonal spike in demand

General practice: Cold weather inevitably brings more illness. But while we hear a lot about the crisis in our A&E departments, the explosion in demand for GPs is being overlooked or ignored.

Emergency medicine: It is not inappropriate patient attendances that are causing this; it is simply the volume of ill, elderly people made more complex with the wide range of existing medical conditions many suffer from.

The answer according to each expert is to ask for more money. But there are hints of an understanding that there is a more fundamental problem:

More money on its own will not help when the current system is fundamentally flawed and needs to be redesigned from scratch. Admissions should be prevented through early intervention and supporting people in their homes by anticipating their needs before they experience a crisis. Chris Ham

If that is so what does a ‘redesigned from scratch’ health service look like? In the UK there has been reform of the National Health Service by every government in the past thirty years. We have known about the coming tsunami of chronic and complex conditions for decades. How then is it that at least one developed country has woken up to this nightmare seemingly unprepared?  What happens in the interaction that matters the most- the one involving only two people- the health practitioner and the patient? What is needed to prevent a crisis in the patient’s life? In a society where autonomy is a fundamental right who makes the choices that lead to the need for medical intervention? How can we redesign the system so that we are turbo-charging the very interaction that has the most potential to prevent the crisis? It surely isn’t to ask doctors to work hours that are unsustainable.

Picture by Damian Gadal

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

Healthy living is a hard sell- time to redesign the shop


Doctors set difficult challenges:

  • Eat a lot less
  • Exercise a lot more
  • Stop smoking
  • Drink less
  • Take tablets twice a day
  • Reduce salt

This takes effort and the reason you need to do any of it is because your bad habits have consequences. What is worse is that you may not recognise that you have a problem. You might say to yourself:

It’s not THAT bad.

Everyone in my family /neighbourhood looks like this.

I drink less than my mates.

I like salt, it makes my food taste better.

I won’t remember to take the tablets every day

It’s not like retail- you see something, you like it, the assistant treats you like royalty in a very pleasant environment,  you take out your credit card- that’s it. And there’s also the pay nothing-till- February deal. To please the doctor your habits must change. These habits are reinforced by cued-up behaviour on happy-making dopaminergic pathways. Research has repeatedly reproduced these results:

A sample of Norwegian adults (N=1579) responded to a self-administered questionnaire about seafood consumption habits, past frequency of seafood consumption, and attitude towards and intention to eat seafood. Structural equation modelling revealed that past behaviour and habit, rather than attitudes, were found to explain differences in intention, indicating that forming intention does not necessarily have to be reasoned. The results also indicated that when a strong habit is present, the expression of an intention might be guided by the salience of past behaviour rather than by attitudes. Honkanen et al

You might not see that doctor any time soon. The triggers to the behaviours that you need to change act when you least want them. What’s worse is that some of these triggers may not be obvious to you. You might find yourself chomping on sweets while you watch television. You might crave biscuits with your hourly cup of tea. You might watch television or stop for cups of tea because you are bored or stressed. The problem may not be the sugary snack but the boredom or the way you perceive your current life situation. Recognising that and dealing with is the real challenge. The boredom may be related to the mind numbing job that pays the bills in these ‘hard times’.

Doctors cannot possibly achieve behaviour change simply by pointing out that we are fat or drink too much.

If we conceive of a significant value of  primary care as something that promotes health doctors need to be able to sell the benefits of healthy living so that the patient considers them a priority. Something they wish to do even though it may hurt. It means creating an experience that will impact on the patient’s deepest psychological self. Can we do it from the current base?

  • An office style centre with boring notices and last year’s magazines.
  • Short consultations (ultra short in areas of greatest need).
  • Ineffective communication in uninspiring surroundings.

What can doctors do to change this experience so that the patient is tempted to act? Can what they promote, not to say sell, be made more appealing? According to psychologist we ‘buy’ things because:

  • We think it will make us secure
  • We think it will make us happy
  • We are more susceptible to advertising than we believe
  • We are hoping to impress other people
  • We are jealous of people who own more
  • We are trying to compensate for our deficiencies
  • We are more selfish than we like to admit

Therefore how can health promotion be designed with such an audience in mind? We need to consider every aspect of the experience doctors now provide. It’s not like selling gym membership or  widescreen television. It is about persuading people to make a persistent effort, to forge new habits and to invest in all sort of ways for a future they can’t immediately experience. We know from retailing that:

The …emotional responses induced by the store environment can affect the time and money that consumers spend in the store. Donovan et al

People can be triggered to make instant decisions. But what about decisions that involve a real commitment to change? Small change perhaps but change nonetheless which may lead to smoking cessation. If we look to the future of health innovation then we might learn from experts who have already managed to change our response to the world we inhabit by working out the art and science of triggering.

Picture by Gerard Stolk

It is time to redesign the consulting room

Those who talk about the future of healthcare often describe the world as if the patient were a robot. They speak of devices and computers that will tell us what nature has already equipped us to know:

I haven’t slept well, I didn’t do much exercise today, I ate too much and I drank too much.

Many futurists appear to believe that providing information on a small screen will be enough to make all the difference to our behaviour. Doctors know this is a fantasy driven by commercial interests because they also know by virtue of their experience that so much of what we choose is contingent on more than just information. Some of these ‘innovations’ are losing market share faster than the receding snow cap of Kilimanjaro.

The overwhelming evidence is that if I decide to stop smoking it isn’t just because of the information that tobacco causes cancer. If  I commit to jogging four days a week it isn’t only because of information on how little I’ve moved today. These decisions are driven by much deeper psychological factors. We are ready to act on this ‘information’ only when the compulsion to make new commitments is greater than the urge to maintain the status quo. This happens in teachable moments. These are unique to each of us. When there is motivation and ability but we are also triggered to act then as BJ Fogg proposes we will do something different. Noting that we will sustain the effort only as long as it is a new habit. Therefore the task in the consultation is to gauge the motivation, enhance the ability, trigger the action and help to generate the habit.

The future of healthcare isn’t simply about access to information, whether on a wrist band or on a video screen. It isn’t only about access to the doctor or some pale imitation of the real thing.  The world of healthcare cannot exclude the physical presence of the practitioner as the one who can address all four aspects noted above by engaging people at the deepest human level. However as a starting point to designing the future we note that doctors are often at odds with the patient in the consultation:

There is evidence of a discrepancy between the numbers of problems noted by the patients and their doctors. It is possible that this is because doctors give priorities to certain diagnoses while ignoring others. Doctors may also focus on a known pre-existing condition of a particular patient rather than attending to the actual reason for the encounter. Thorsen et al

The authors further conclude:

The vast body of literature covering consultation patterns focuses on patients’ reasons for deciding to consult. Little research has focused on what patients have on their minds while in the waiting room regarding the forthcoming consultation.

Policy change that aims to turn back the clock so that people are forced to visit the same doctor who will do the same old thing….sound uninspired. If we consider the consultation as theatre then there are aspects that cannot be changed. Neither the actors nor the the plot (healthcare) can be changed. Patients will attend doctors who are trained to take a history, examine the patient and prescribe treatment. However the props and the script can be used to greater effect. These components impact on what the patient can see, smell, taste, hear and feel. The impact of these on the outcome of the consultation is the same as the impact on the person’s decision to buy anything.

whats-it-about

The economic reality is that people will be reticent to pay for something that is cheaper or readily available free elsewhere. However they are willing to pay for services that offer an experience. What is becoming a driver for innovation in primary care is the need to offer patients not only what they need but also what they want in terms of engagement with the practitioner. It is about changing how people feel in that space that we call an ‘office’ but could be redesigned as a ‘health pod’ in which the choreography aims to make it easier to identify teachable moments and trigger better outcomes.  An office is for bureaucrats, accountants and lawyers. We need to create a new environment that is conducive to selling health and healthy living.

If you are a doctor try this you might be surprised by the result:

seatHow else can you make the patient feel more valued in the encounter?

Picture by Jeff Warren