Tag Archives: the consultation

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