Tag Archives: the consultation

The value of rituals to innovators

4182291013_fc4106bde3_zEvery health practitioner engages in rituals. In general practice / family medicine they look this:

Review

Doctor: What do I know about the person about to enter the room next? Review notes.

The greeting

Doctor : Welcome. Please take a seat. How are you today?

The pregnant pause

Patient: Not so good doctor……..

The context

Doctor: Tell me how this has affected your job/ family etc

The examination

This aspect sometimes, perhaps always,  follows a ritual.  Like the one illustrated here.

The decision and the check

Doctor: I recommend you take this test/ take these pills/ see this specialist. Are you allergic to anything? Are you taking any pills at the moment?

Safety netting

If you feel any worse or you develop a rash that looks like this, please come straight back.

Administration

Note writing, charging etc.

Each of these phases in the ritual offers an opportunity to ‘anchor‘ a new habit. In a previous post I wrote about how to trigger health practitioners to act in a specific situation where their motivation and ability are favourably aligned. For example one might like the patient to be offered a particular screening test on or after a specific birthday, the greeting might prove a good trigger. Doctors might look for specific information to include in the greeting e.g.

Welcome, I see it was your birthday last week. A belated Happy Birthday! We might want to talk about a new test we are recommending people at this age. Is it OK to add that to what we need to discuss today?

Another example may be to refer people with a specific problem to a specific place. This trigger can be anchored to the point at which the doctor is completing the medical record. If the trigger results in behaviour that is rewarding to the doctor it will become a habit within a relatively short period. The key issue for innovators is to identify where in the ritual to anchor the trigger, what reward is available immediately and to work with the practitioner to establish the behaviour as a habit.

Picture by Laura4smith

What’s needed to get doctors online?

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Anyone who doubts that doctors will consult patients on line hasn’t heard of the hugely successful Sherpaa. It’s happening already in the US and in some other parts of the world. Elsewhere doctors will soon consult via the internet. It is only a question of how the service will be configured.

In a previous post I offered a way to consider what motivates doctors, what determines their ability to do things and what might trigger that action. The key questions in relation to video consults is how doctors might respond when faced with the variety of clinical problems that could possibly present on line. Also what that might tell us about the implementation of such technology.  We set out to explore these questions recently. You can read our paper and watch videos of how patients might present on line here.

Motivation

A: Rewards for action

Funding restrictions were a major factor in deterring doctors from consulting on line. Unless governments subsidise the consultation it is unlikely to happen for people relying on government funded schemes. Where it is happening, private providers are stepping in to offer the service to paying customers.

T: Time

In a previous study we demonstrated that telephone consultations significantly reduced consultation time relative to face to face meetings. There is no reason to suppose that video consults would be any different.

R: Risk

This was perhaps the greatest factor moderating the motivation for video consults. Some scenarios were regarded as extremely high risk for adverse events and for litigation. Patients presenting with symptoms of an acute life threatening condition were considered the least suitable for a video consultation. Some scenarios were deemed too difficult to manage without a physical examination. Others were considered suitable if there was scope to see the patient in person in the near future. A literature search also raised concerns about potential breaches of patient confidentiality when consults are conducted via video technologies.

Ability

C: Cost

The issue of cost was not explored in our study. However this may be related to the lack of remuneration for video consults. No payment would result in a significant opportunity cost.

E: Effort

Some scenarios were considered too difficult to manage without a physical examination. Indeed the need for physical examination to establish a diagnosis was a common concern. Unexplained abdominal pain and upper respiratory tract infections were of particular concern. In other cases the scope to establish a rapport was considered insufficient, for example in the case of the patient with substance abuse:

…the use of an online consultation in this case inhibits developing rapport particularly with a patient whom I have only seen occasionally.

We also recorded a significant difference in attitudes to video consults based on the demographic profile of respondents to our study. Participants who had been practicing as GPs for longer, GPs in training, those who worked in remote practice, and those from larger group practices were most enthusiastic about video consultations.

Trigger

R: Recognising the suitable patient

Our data indicate that access to video consultations will need to focus on patients with on-going medical illness, where the purpose of the consultation is to offer support. Medical practitioners appear confident about their ability to conduct video consultations however in the context in which we explored this question it is not yet routine practice.

K:Knowing what is available

Doctors in our study were unequivocal in asserting that the video consult option was not available to them at this point in time. In a previous review we explored the possibility that internet speeds and access to the relevant hardware and software may be a rate limiting step in the adoption of video technologies.

Summary

Video consults will become routine practice in most countries when they are supported with the infra structure to make is easy for doctors to make the choice to offer the service to their patients. In many scenarios motivation and ability appear to be high.  The majority of doctors in our study would either conduct video consults or consider doing so. The service is most likely to be offered to patients who either will be seen in person in the near future or seeking support for an established condition.

Picture by Matthew Hall

How are you today?

4704953402_631194c066_zAustralians do a lot of flying. That’s what comes of  living mainly in coastal cities on the edge of a huge land mass. So we spend a lot of time watching cabin crew run through safety procedures. I’m wondering if that’s something we should do before we consult our patients or clients. Here are three things you might ask yourself during consultations this week:

1. Am I fully with this person in the room just now?

2. What do I know about this person and the impact of their problem?

3. What happens if whatever it is that’s bothering them doesn’t improve or gets worse?

I sometimes wonder if I could be replaced by someone who hasn’t spent 6 years at medical school, four years training and then more years than I care to count ‘practicing’. The answer depends on the extent to which I am able to reach beyond myself on the day the question is posed. On the best days I can pick up on subtle cues. When it’s not so good it’s because I’m not all there.

There are lots of reasons why that might happen. Maslow’s hierarchy of needs explains it succinctly. Hunger, fatigue or boredom are not conducive to caring. Yet we have, and in some cases still expect, our health care staff to function despite those feelings. Roger Neighbour developed a wonderful model for the consultation in primary care. This remains the only guide that specifically includes ‘housekeeping’ as an essential step:

Neighbour acknowledges the need for the practitioner to take care of their own feelings, particularly those brought about by a consultation. If not, the emotions, possibly negative, engendered by one consultation, may spill over into the next.

Perhaps we could take it one step further and determine if someone is fit to work as a health professional on a specific day and especially if they are far too grumpy to care. Many have witnessed objectionable, rude and insensitive behaviour from those who should know better. It was once accepted as the senior doctor’s right to be ill tempered. It may still be. If it is then it should be no longer because anger clouds effective communication. And effective communication is vital to the art of medicine. We aren’t always at our best. Being aware when we aren’t is a first step to ‘safety netting’ as Neighbour put it.

Cancelling the flight because the pilot has a cold isn’t always an option. However replacing the pilot may be wise if she has lost interest in flying the plane. It matters how we look as health practitioners but perhaps it matters even more what we are thinking, and therefore feeling, as the patient enters the room. For those with an interest in innovation, here is the first and perhaps vital focus for improving the quality of the experience for the consumer.

Picture by Ryan Hyde

The case for shared care

People are uncomfortable, if not alarmed, when the behaviour of someone they live with suddenly becomes ‘deviant’, ‘offensive’ or embarrassing; Grandfather becomes disinhibited, son becomes violent, wife starts shoplifting, daughter steals money from home. The unfamiliar moves us out of our comfort zone and we start to question the future, often catastrophising. Many chronic medical conditions result in behavioural changes. People hope that there is something that can be done to remedy the situation quickly so one of the first steps is to seek medical advice. It may be that the person has one of a host of acute or chronic conditions including life limiting pathology; Depression,  psychosis, dementia, substance abuse or cancer. The reaction to the behaviour may also result from misinterpretation or the complainant may be the one with the problem or feel stigmatised by the experience. Once an explanation is found it is often the case that medicine could make things worse- prescriptions, hospitalisation and tests may be harmful. There is also a risk of medicalising the problem as noted by Dworkin.

In the past, medical science cared for the mentally ill, while everyday unhappiness was left to the religious spiritual or other cultural guides. Now, medical science is moving beyond its traditional border to help people who are bored, sad or experiencing low self esteem- in other words people who are suffering from nothing more than life.

Nonetheless people seek help from doctors and there is great scope to assist by sharing care with others who may be able to help with a problem for which there is no pill and people have to revise their ideas, concerns and expectations. It may be that doctors are reluctant to engage people in these circumstances because they do not perceive that they have the resources or expertise to assist with what they consider outside their sphere of influence. Nonetheless people will continue to expect assistance. Epidemiology records that the rates of chronic and complex conditions are set to rise almost exponentially as the population ages and suffers the pathological consequences of poor life style choices. At the same time the cost of healthcare is increasing to the extent that services may be rationed. Already in Australia, even with a relatively healthy economy, the government is proposing cuts to healthcare expenditure. Meanwhile the number of people living with a family member who has a condition where behavioural changes are possible, if not likely, will increase. For instance the prevalence of dementia in Australia will increase from 332,00 to just under a million by 2050. The proportion of people with behavioural changes in the context of  this diagnosis is the majority of patients with an average duration of about 8 months during the illness. Such behaviours may have a profound impact on the emotional well being of the caregiver. It is  acknowledged that some caregivers do not easily adapt to the stresses of caregiving and are at risk in terms of their ability to continue in their role. A failure to maintain this unpaid caring role would have a significant impact on the cost of caring for the patient who may have to be institutionalised sooner rather than later. The conclusion of a study from Sweden was that:

Informal care, measured as hours spent caring, was about 8.5 times greater than formal services (299 and 35 h per month, respectively). Approximately 50% of the total informal care consisted of time spent on surveillance (day and night).

Therefore innovations that allow the medical practitioner to quickly incorporate assistance from organisations that specialise in supporting caregivers will enhance the prospects of sustaining an effective health service for all. The services of organsiations such as Alzheimers’ Australia may be underutilised because of a failure to respond to calls of help from stressed carers. Similar observations can be made about other chronic illnesses including substance abuse, cancer and palliative care where changes in behaviour may be common and medication has a limited role.

 

Semiotics and the placebo

It has long been acknowledged that the ‘doctor’ can have a therapeutic effect without ever ordering a test, prescribing a medicine or performing surgery. Indeed the earliest thinkers about the the role of the doctor talked about the ‘drug-doctor‘. But what are the constituent parts of this most powerful of placebos and what impact does this have on our attempts to improve outcomes?

The placebo pill, the saline injection, and the invasive procedure or device that works by virtue of a placebo effect are each signs, or sets of signs, that convey information to patients or research subjects. Additionally, the placebo intervention, like a standard treatment, is delivered within and surrounded by a context, which includes a host of other signs that convey information with the potential for producing therapeutic (and also counter-therapeutic or nocebo) responses. These include the clinician’s white coat, diagnostic instruments, the appearance of the doctor’s office or hospital room, the words communicated by the physician, the physician’s disposition in listening and responding to the patient, gestures, and touch. The patient does not come to the clinical encounter as a blank slate but with a history of experiences and memories evoked by prior responses to signs related to the milieu of therapy, some of which may influence the way in which the patient processes the information from signs emanating from the present clinical encounter. Franklin G. Miller and Luana Colloca

More recently evidence has emerged that hints at more specific ways in which these elements might be improved. When I was training our mentors recommending that we should never be casually dressed when consulting patients. This was based on their impressions of patient expectations. Later in my career my wife who was a staff nurse at our local hospital was amused that the patients I had admitted overnight were  impressed that their doctor was wearing a neck tie even at 2am. I’m not sure whether that was by design or accident.

Rehman and colleagues conducted a study of patient preferences about how they preferred their doctor to dress. Within a North American context it was clear that patients preferred their doctor to wear a white coat, whether the doctor worked in a hospital setting or not. According to the respondents to the survey doctors in white coats were more likely to be knowledgable, competent, caring compassionate, responsible and authoritative. It was evident from this study as well as a study from the UK that older patients in particular prefer their doctor to wear a white coat. There are differences in attitude based on geography and culture. However it is important to consider the importance of this question if only because patients who trust their doctors are more likely to take advice. It is argued how much of a difference attire makes to patient trust but the consensus appears to be that business wear and formal clothing generally inspire more confidence than tee shirts and shorts.

A second issue has recently become relevant. Research has documented negative stigma by health providers toward overweight and obese patients, but it is unknown whether physicians themselves are vulnerable to weight bias from patients. Puhl and colleagues surveyed 358 adults. Respondents were less trusting of physicians who were overweight or obese, were less inclined to follow medical advice, and were more likely to change providers if the physician was perceived to be overweight.  Normal-weight physicians elicited significantly more favorable reactions. These weight biases remained present regardless of participants’ own body weight. A more recent study from Johns Hopkins University School of Medicine suggests that although patients might trust their doctor regardless of his or her weight, those seeing obese primary care physicians, as compared to normal BMI physicians, were significantly more likely to report feeling judged because of their weight.

Therefore attending to how we come across to patients might be an important place to start improving the chances that they will trust us. This is based on intuition and a little bit of evidence, it doesn’t require a grant or a change in government policy. If you think it needs work- start today.

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.