Tag Archives: the consultation

Innovating for multimorbidity

Most people who consult doctors in primary care have more than one problem. The proportion of people with so called multimorbidity is set to rise exponentially as the proportion of older people in many countries rises. The problem is that the length of consultations is limited and therefore the patient and practitioner are already at a disadvantage before they begin. Do you focus on the rash which the patient is anxious about today and which may be the beginnings of eczema, or the hypertension which isn’t at target despite therapy, how about the cigarette smoking and the aching hip and to what extent does the chemotherapy treatment in the past have a bearing on the fatigue that the patient has complained about in the previous consultation. In theory consultations can be extended for patient with greater need, assuming that the need is expressed. According to one team:

Approximately 9% of the patients had 1 or more unvoiced desire(s). Desires for referrals (16.5% of desiring patients) and physical therapy (8.2%) were least likely to be communicated. Patients with unexpressed desires tended to be young, undereducated, and unmarried and were less likely to trust their physician.

Bell et al JAMA 2001

The bottom line is that there is significant unmet need. In theory, in many countries the general practitioner has a longitudinal relationship with the patient and will eventually get around to some of these other issues.  Even in those countries that espouse the concept of  primary care as the first point of contact for people with the healthcare system, the reality is that people tend to consult more than one GP, either by choice or because they have no option and therefore continuity of care is theoretically possible but never actually achieved. The consequences include poor outcomes. It’s even worse in the specialist sector where regular turn over of junior staff means that people seldom see the same doctor from visit to visit.

Here is an opportunity for lean innovators to proactively screen people with a specific problem- for example all patients who have been treated for cancer attending a practice or by offering people an opportunity to have their needs met in another way– either by empowering self care or by enlisting the support of a nurse or allied health care provider. People in distress who are in contact with healthcare organisations cannot be left to fend for themselves or allowed to live under the impression that a diminished quality of life is the best that is now on offer.

Innovation doesn’t always have to mean new

In a world of new gadgets and gizmos we have lost sight of the fact that medicine is a social construct and that there have been some extraordinarily successful doctors who never ordered an X-ray or prescribed penicillin. That does not mean to say that X-rays or antibiotics don’t make us better healers but if we lose sight of the reasons why people have always needed doctors then we face a very uncertain future. In the world of business it is recognised that people buy ( i.e. make decisions or commitments) based on how they feel about something, not just, and sometimes in spite of , the information available. Heart always trumps mind. How else do you explain so many of our questionable decisions in life? By corollary we need to invest in the experience we offer as health care providers, perhaps more than the devices we chose to purchase that keep us at arms length from the patient.

What that means for innovators is that we occasionally have to rediscover the ‘innovations’ that are already in our offices. Possibly the most celebrated research I led was a study that demonstrated that people trust you more when you are seen wearing a stethoscope. It followed on from research that confirmed other things we have ‘always known’- what you wear matters, how you greet your patients/ clients matters and if you seem distracted in the consultation then it detracts from the patient’s experience.

At medical school one of our tutors offered this advice:

Always stand to greet the patient, never sit down before the patient and always find a reason to touch the patient even if it is only to take their pulse.

Simple advice that speaks to the art of healing- because in the end that is what gives medicine its mandate to be involved with people in distress. We were reminded that for some of our patients, perhaps those who need us the most, the unemployed, the marginalised, the unfortunate  the doctor may be the only person in any authority who will greet them with respect that day. Therefore innovation begins and ends with a review of the basics- What is it like for your patients or clients? How are they welcomed to the service? Is your telephone message welcoming? Are your reception staff professional? Do you offer privacy at all times? Do you seem interested or concerned? Would you trust someone who presented themselves the way you do?  Would you feel better after a visit to your clinic? Do your staff need a new machine more than a better way to make people feel they care?

Innovating to save precious time

When I was at medical school Pendleton’s book on the consultation was required reading. Pendleton maintained that one of the tasks in the consultation was to consider ‘at-risk factors’. It’s one item on an otherwise long list of tasks to be completed. Today it is often the case  that a discussion of  those ‘at-risk factors’ take over the focus of the consultation. Doctors are urged, even rewarded for moving the agenda to- diet and exercise, responsible drinking, colorectal, breast and cervical screening, hypertension, safe sex….the list is endless. The impact of having the doctor’s agenda up front and central in the consult is what has been described as

High controlling behaviours.

Ong et al.

The resultant style of consultation is described thus:

It involves… asking many questions and interrupting frequently. This way the doctor keeps tight control over the interaction and does not let the patient speak at any length.

Recently medicolegal defense organisations have taken to issuing advice against this pointing out that when the patient does not feel they have been heard they are more likely to complain. Research has shown that patients don’t ask for much. They won’t take long to spit out the reason for their visit. In one study:

Mean spontaneous talking time was 92 seconds (SD 105 seconds; median 59 seconds;), and 78% (258) of patients had finished their initial statement in two minutes.

Langewitz et al.

Allowing the patient to speak first is a good start. Then how do we support practitioners to earn a living by also attending to those topics for which they must tick a funder’s check box? Tasks introduced by policy makers as if the primary care consultation was replete with redundant time. In some ways it’s like what happens when you buy a new television, it’s not long before the sales assistant wants to sell you insurance and other products- ‘just in case’ but really because their commission depends on it. What we need in medicine is to stop eating into the time it takes to explore a patient’s ideas, concerns and expectations, time needed to examine the patient and express empathy. We need cheap, agile, intuitive and creative solutions that will quickly offer the patient an indication of their risk from whatever the latest public health issue happens to be- smoking, influenza, prostate cancer…but also the benefits and why they might want to consider ‘taking the test’, accepting ‘the jab’, or changing the habit.  My colleague Oksana Burford invested three years testing one such innovation. What Oksana realised is that in the end it’s the patients choice and the key is to introduce the idea of change in a way that speaks to her but only when she is ready to hear the message.

The reasons why primary care is selected to relay public health messages is that people trust their health care provider and are more likely to comply if that practitioner recommends it. However that does not mean that we should assume the patient can only get the necessary information from one source. What the practitioner can do is sign post where that information can be found and effectively convey why the choice being recommended is better than the status quo. I recommend the food swap app– its downloaded free and saves a lot of time which can then be used to deal with the reason the person had come to see me in the first place. There is lots of room for innovation but it should meet the needs of the patient and the practitioner.

Managing demand for primary care

Why do people consult doctors? At first glance because they feel unwell. However research suggests that the reasons are far more complex than that. Innovators also know that the answer to this question is vital for those seeking an agile, intuitive, creative and cheap solution to the demand for their services. Theories predict the consultation habits of many patients. I especially like this summary:

The overall prevalence of symptoms in the community is not closely related to general practice consultation rates, and the consulting population is a selected population of those who are in need of medical care. The literature reviewed suggests that poor health status, social disadvantage poor social support and inadequate coping strategies are associated with higher consultation rates. Some populations subgroups may experience particular barriers to seeking care. Campbell and Roland

Innovators might also ask why are those patients sitting in my waiting room? I remember a hoary old tale of a doctor who was feeling especially grumpy one day and stormed through the waiting room announcing that anyone who thought they had a ‘real’ problem should stay everyone else should go home- half the waiting room emptied.

It seems quite a few people who go to doctors will have symptoms- however a proportion will be back there by invitation. How big a proportion and why have they been invited back? There are many reasons to schedule a repeat appointment. It conveys the notion that the patient will be harmed if they don’t see a doctor on a given day for one or more of these reasons:

1. Their response to treatment is unpredictable and the dose or drug may need to be revised

2. They have a condition that can’t be diagnosed or may progress or need additional measures by a specified date

However other reasons for requesting a review include:

1. The doctor isn’t confident that the diagnosis is correct and wants a chance to review the advice issued.

2. The patient is required by someone (e.g. an employer) to produce evidence of a visit to a doctor

3. A full waiting room ensures the doctor looks busy for whatever other reason.

4. The doctor needs to reinforce the impression that the condition has been taken seriously.

The time cost for doing everything that could possibly be recommended for patients with chronic conditions  has been shown to be untenable. Either the guidelines are wrong or a different solution needs to be found for at least some of these people. What is the evidence for asking a patient to return within a week or two with a specific new condition and within a month with a longstanding condition?

There is a need to be proactive in some cases. However is it possible that we encourage people to attend for review appointments when there is a low probability that they will benefit? Are there other reasons to fill the waiting room?

The most successful health innovation ever

What medical innovation is:

1. Available worldwide
2. More likely to yield a diagnosis than an X-ray
3. Cheaper than the cheapest stethoscope
4. Requires less training to operate than a tendon hammer?

Answer: A tongue depressor

Why? Because when deployed within the context of a medical consultation- when the practitioner gives the patient their undivided attention, the tongue depressor forges a relationship that may lead the patient to express their deepest concerns. In what other social context can you shove a piece of wood into someones open mouth and get them to say ahhh? A few years ago I consulted a fifty year old mother of five, working as a supermarket check out assistant complaining of a sore throat. We talked about how awful she felt and how she was struggling to cope with her job, how she gets frequent bouts of tonsillitis and how she was afraid her boss would sack her. She had a mildly red throat and I thought I could feel a couple of tender lymphnodes in her neck but her temperature was normal and I remember thinking I’d seen worse earlier that day. Then as I turned around to write a prescription she burst into tears and said-

‘There’s something else I need to tell you doctor. I’m now working as a prostitute because for the first time in ten years I haven’t been able to afford my kids school books.’

That was not what I expected to hear, or anything they told me at medical school could result from examining a throat. That consultation took a very different direction, she was screened for other infections and was fortunately negative. We then talked about her dilemma and she decided there may be better ways to furnish her kids with what they needed for school.

There is very little evidence that the appearance of the throat aids the diagnosis in most cases- even a viral sore throat can mimic a bacterial infection. In any case in developed economies penicillin does not help the patients recover much quicker. However, anyone with a sore throat who consults a doctor expects to be examined. Besides why do people seek medical advice about pharyngitis? It is common knowledge that in most cases a couple of paracetamol, fluids and rest is the only effective treatment. In many cases people are expressing concern about some other aspect of their life when they present with minor self limiting illness. What people say, if you are receptive is

‘I’m unhappy, I’m worried, I’m bored, I’m feeling guilty, I’m tired or I’m not coping and this discomfort is the last straw.’

That’s one of the myriad of reasons that general practice is the most challenging medical specialty, nothing is necessarily what it seems at first glance.

Innovations don’t need to be high tech or expensive- a tongue depressor costs 13 cents. That doesn’t mean that in the right hands such simple equipment is not extraordinarily powerful. There are tools we seldom do without- a stethoscope is vital and not only because of what we can hear when we put it to the chest.

The secret to lean health innovation is harnessing the truth

In the later 1990s when I was practicing in a 7,000 patient practice in England we had a system of five minute appointments. Five minute appointments that were really ten minute appointments. In most cases a doctor can’t achieve anything useful during a five minute appointment. Some doctors would argue that ten or even fifteen minutes is scarcely enough. However this was how it had ‘always been done’ so the new doctors to the practice adopted the system that was in place. By the time you got to the last patient in every surgey you were running at least half an hour late. We were kidding ourselves—nobody ever finished by 11am. We were still consulting at midday and then rushing off to do home visits stuffing a sandwich in as we drove from patient to patient. We were back at the surgery by 2pm ready to start the whole thing again—intending to finish at 5, but in reality turning off the lights after everyone had gone at 6.30pm.

The data was right under our noses. Some doctors were known to ‘always run late’, others became adept at pushing patients in an out quickly with a prescription in their hand and instructions to return next week. Patients learned to choose the doctor they thought was best for them, whether that was one who would ‘get to the bottom of it’ or give you a prescription and a sick note but couldn’t be relied on to know when you had cancer.

Consulting style does impact a patient’s choice of doctor. and doctors and patients don’t always share the same view on their consultations.

Meanwhile back at the practice resentments festered because some doctors were having coffee in the staff room at 11 while their colleagues were still working through the list until nearly midday. There were suspicions that the early finishers were seeing fewer patients and never around when the emergency walk-in turned up at 11.45. Stressed doctors couldn’t see what was already evident to everyone else in the practice—we needed to redesign our appointment system and tackle issues engendered by our own delusions. In the end, as a practice, we needed to look at how each practitioner was consulting and how this was reflecting the practices’ values to its patients.

Something had to either change or give and we decided that if it wasn’t going to be us or the patients, then it had to be our system. We had to face the truth that the numbers of patient appointments we scheduled during the day was greater than our capacity to treat them properly in the time we allocated.

Our colleagues in other surgeries thought we were ‘brave’ to move to ten minute appointments. There were implications for radical changes to our appointment system. But the first thing we needed to recognise was that our schedule must treat our patients as if their time mattered at least as much as ours. It was, and is, unacceptable to keep patients waiting because we don’t want to accept reality. This denial leads to patients failing to keep their appointments, choosing to go elsewhere and it ultimately leads to doctors burning out.

We didn’t need a big R&D department to tell us what our staff and patients would say if we bothered to ask. I now work in Australia and still see the same patterns here. My friends tell me you can count on this doctor to prescribe antibiotics no matter what is wrong with you, and that one always gets to the bottom of things but prepare a packed lunch when you make an appointment with him.

Our time is not more important just because we are doctors. Innovation sometimes involves taking responsibility not investing in a new computer program or running a focus group.

The importance of touch in the medical consultation. There is no app for that

When people are scared or in trouble what they want most is to be touched. Information alone is never enough to satisfy the deepest human needs that bubble up when our bodies appear to malfunction. This was recognised generations ago and the role of doctor was socially ordained. Doctors are licensed to examine the body intimately. Any doctor who abuses this trust is severely punished. The examination provides the healer with the information required to make a diagnosis, but more importantly it comforts the sufferer through human contact.

When I was a ‘wet behind the ears’ GP trainee, my clinical mentor offered me two pieces of advice in relation to the medical consultation. He told me to always stand up to greet the patient as they walk into the room and to look for an opportunity to lay hands on the patient, even if only to take their pulse.

Innovators may be tempted to think that everything that takes place in the consultation can be distilled down to the exchange of information and advice. However the consultation is designed to promote healing by allowing people to express concern and empathy through verbal and nonverbal behaviour. The former requires excellent communication skills, the latter is conducted as a series of rituals: ‘inspection, palpation, percussion and auscultation‘. And even as the body is examined the patient needs to feel that the examiner is concerned and respectful. If this is done well, healing can begin, sometimes against the odds.

This has important implications for innovation in health care. It’s not possible to interrupt or diminish the direct association between the doctor and the patient with gadgets or gizmos. If we do we may lose more than we gain.

See demand in context and respond creatively

9645066390_babd98c3f1_zHello Jill, Oh, I’m sorry I have no appointments to offer you today. the doctors are all fully booked. If your son has a fever try him with some paracetamol and call back on Friday when I might be able to squeeze him in with Dr. Jones. Ok, bye.

Many years ago I overheard this conversation in my reception. Our receptionist giving medical advice without any qualifications. The surgery was over booked. She was harassed, doctors were grumpy and the patients were being turned away without being assessed by anyone.

We noticed that there was a seasonal pattern to this demand for appointments. Most doctors were aware of this trend because there were specific weeks of the year when they avoided taking holidays. Our reception staff kept meticulous colour coded records of such ‘same day’ appointments. When we entered this data on a statistical database there could be no doubt of a seasonal pattern with definite peaks and troughs. What’s more, we could predict the demand for ‘same day urgent appointments’ with reasonable confidence. At this point, it may be important to stress that doctors in the UK are paid a ‘capitation fee’ for serving patients. That means they are paid an annual fee no matter how many times they see the patient.

Understanding that people have a fundamental desire to talk to the decision maker, we settled on the notion of putting the doctor in charge of making the appointment. Patients who requested a ‘same day’ appointment were offered a telephone consultation with a general practitioner initially. Not with a nurse, as happened in some practices, but with their doctor. We believed patients wanted to speak with a medical practitioner, not because the advice they received was necessarily better than that given by another member of the team, but because people in distress want a doctor. Whatever the reason it worked. Important policy makers noticed. Doctors could deal with most requests within a couple of minutes, offer a ‘same day’ slot or something else without the need for a face-to-face appointment. We calculated a 40% reduction in demand for such appointments. Patients loved it, reception staff loved it too (no more arguments about lack of appointments with irate patients) and doctors found themselves in control of their workload. What’s more, we could prove that this simple intervention worked from the impact on longitudinal seasonal trend.

By allowing patients to speak to their doctor when they felt they couldn’t wait our practice chose to treat this small minority of patients differently to those who were happy to make a routine appointment. We acknowledged that these patients had a need that warranted a creative solution. Perhaps you have a group of patients who would benefit from being treated differently too? What is the context in which they seek help? The tired mother with a fevered child does not have the same needs as the young professional who requires a convenient appointment to obtain a prescription for the contraceptive pill. Both might seek an urgent appointment.

Picture by Marjan Lazerveski