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It is time for primary care to enter the triggering business

It has been suggested, some would say demonstrated that doctors know very little about their patients. If you are a doctor could you identify your patient’s partner from a line-up of strangers (other than people you see as a couple)?  Or could you tell without seeing the name on the document if this bank statement belonged to that patient? Or whether that utility bill was from where that person lives? Is this internet search history theirs? Do you know how much they spend on lottery tickets? Alcohol? Vegetables?

A few years ago our team then based in the UK was evaluating an intervention to increase access to general practitioners. If the intervention worked we would have to demonstrate improvement over the course of a whole year. Here’s the thing, we noted that year after year there was a pattern to the demand for same day (emergency) appointments- with definite peaks and troughs. So if the intervention worked it would have to be sustained during both the peaks and the troughs. It did. The data on out-of-hours services exhibited very similar patterns- with definite peaks and troughs and at unexpected times of the year. We could not explain the patterns but noted that when the meteorological office recorded  22 hours or more of sunshine in the week the demand for appointments dropped. Not the prevalence of viral or other community pathogens but sunshine of all things! Okay may it was some factor that we hadn’t modelled in the analysis but there was a definite pattern that we could not immediately explain on the basis of what seemed plausible at the time. We called it the Spring Cleaning Effect– we hypothesised that people in the UK were less likely to attend doctors in general practice when there was a run of sunny days on which to do outdoorsy things. We didn’t anticipate this- nor did clinic managers because the patterns of demand were not used to inform the scheduling of doctors’ on-call rosters. It was clear that they were blind to a phenomenon nobody understood fully.

More recently I reviewed some data on certification for low back pain and noted the pattern that as unemployment rates in a locality increased the rates of certification dropped and then plateaued.

Our team is now investigating similar data from a large employers’ records. We hypothesise that rates of submission of sickness certification will show a sharp drop when vacancy rates fall and other markers of economic health decline. People may be far less likely to take time off sick if they are fearful of upsetting their supervisor. With respect to primary care, it is unlikely that doctors will know everything that impacts on their patient’s choices. Time spent with the patient in discovering these things is unlikely to increase as it comes at a financial cost. Therefore doctors will never fully anticipate all the drivers to patient behaviour. Why does that obese person fail to take action on weight management? Why does this other person take ‘medication holidays’ when they need to take the treatment consistently to benefit? Why does the next person refuse to have an X-ray? Why is there a rush of people with relatively minor conditions demanding appointments this week and not last?

Some drivers lead people to behave in unexpected ways as I have commented here previously. Not only that but as Mullainathan and Shafir have postulated people are often unable or perhaps unwilling to follow doctor’s advice. In the end, the best we can hope is to trigger the relevant behaviour in people who are already motivated and seek teachable moments to inspire people to act for their benefit. Primary care may be more about recognising or fishing for opportunities and much less ‘educating’ for change. Such triggers need to fit within the final moments of a 15-minute consult. The work to develop and evaluate such triggers is only beginning. Counselling patients to stop smoking will yield 1:20 quits in a year, showing them a trigger (in less than 5 minutes) that appeals to their vanity results in 1:7 quits. A substantial number (1:5) of obese people will lose weight in 6 months if they are shown what difference that would make to their appearance without having to be extensively counselled on diet and exercise.

Picture by Aimee Rivers

Does encyclopaedic technical knowledge make a doctor?

Life as a clinician is challenging.  Hours are long and resources limited. People may not be helpful, not even the ones who are supposed to be working with you or even for you. There maybe joy but there will also be sadness and even anger. You can expect to feel tired. You may be concerned and even confused. Occasionally you will be very intuitive but just as often you can expect to be wrong. However, you cannot let any of that have an impact on the care provided to patients. And yet each day clinicians respond as if none of this is ‘fair’ and should not be so.

The practice of medicine is more than a technical science. Medicine requires a great sense of personal mastery. An uncommon mastery in which the doctor is resilient and resourceful. Do we prepare young people for such a life?

This week after 30 years I stepped into one of the rooms now decommissioned but where I once spent my teens learning anatomy. It was a core part of that school’s curriculum, the only subject in clinical medicine that was introduced within the first year of a six-year course. The author of one of the seminal texts taught there. His dissections were legendary and the specimens are still preserved to perfection. I reflected on whether the experience of being taught by his protege prepared me in any way for the subsequent years in practice. Did my encyclopaedic knowledge of how the body is constructed allow me to better handle the following years in clinical practice?  By comparison, we learned relatively little about what drives people to make decisions that make no sense. And yet over the 30 years, I have practised medicine it has been more often problematic knowing how to handle someone whose choices will lead to self-destruction than working out exactly which nerve is responsible for the numbness of a portion of his thigh.

Picture by Rosebud23

Deploy rituals and be present in practice

Your next patient or client will want you to:

  • Smile (23.2%);
  • Be friendly, personable, polite, respectful (19.2%);
  • Be attentive and calm, make the patient feel like a priority (16.4%);
  • and make eye contact (13.0%).

(An Evidence-Based Perspective on Greetings in Medical Encounters- Arch Intern Med)

Showing up this way for every patient has to be a habit. Essentially you need to be “present or “mindful”. The issue of mindful practice has also been the focus of academic interest:

In 2008, the authors conducted in-depth, semistructured interviews with primary care physicians .. mindfulness skills improved the participants’ ability to be attentive and listen deeply to patients’ concerns, respond to patients more effectively, and develop adaptive reserve. Academic Medicine.

To make a habit of showing up in this way it may be worth considering deploying a ritual.

Hurdler Michelle Jenneke has her famous warm-up dance, long-jumper Fabrice Lapierre competes with a gold chain in his mouth, Usain Bolt points to the sky before breaking yet another world record, while Michael Phelps blasts Eminem to fire him up before hitting the pool. My body+soul

Consider the distinction between a habit and a ritual:

Habit

An acquired behavior pattern regularly followed until it has become almost involuntary: the habit of looking both ways before crossing the street.

Ritual

An act or series of acts regularly repeated in a set precise manner.

Rituals support habit and focus. Rituals support you to repeat habits and create new behaviour patterns over time. Daily rituals can support you to make new habits stick. You can move from doing something that might take a lot of effort, to it becoming almost automatic or done unconsciously. Mary- Ann Webb

Establishing a ritual can be the prelude to a habit.

The term ritual refers to a type of expressive, symbolic activity constructed of multiple behaviors that occur in a fixed, episodic sequence, and that tend to be repeated over time. Ritual behavior is dramatically scripted and acted out and is performed with formality, seriousness, and inner intensity. Rook, Dennis W. (1985), “The Ritual Dimension of Consumer Behavior,” Journal of Consumer Research, 12 (December), 251-264.

The pathway goes from behaviour, to ritual and then to habit. Charles Duhigg  spoke of the ‘habit loop’.This loop has three components:

  • The Cue: This is the trigger that tells your brain to go into automatic mode and which habit to use.
  • The Routine: This is the behaviour itself. This can be an emotional, mental or physical behaviour.
  • The Reward: This is the reason you’re motivated to do the behaviour and a way your brain can encode the behaviour in your neurology, if it’s a repeated behaviour.

All habitual cues fit into one of five categories: location, time, emotional state, other people, and immediately preceding action. An immediately preceding action is the most stable cue because it’s triggered by an existing habit. So to build a new habit match it with an old habitual cue.

B.J. Fogg, asks:

“What does this behaviour most naturally follow?”

To implement this technique, decide on an existing habit and complete the following sentence:

“After I [EXISTING HABIT] I will immediately [NEW HABIT]”.

Therefore to make a habit of being present for the next patient the “cue” is when you terminate the previous consultation.

The “routine” or ritual: At the end of one consult you might close the notes, tidy your desk and wash your hands. Metaphorically you also wash the previous consult out of your mind. This has physical and psychological components.

Then when you are happy that the previous consult no longer lingers in your thoughts proceed to the next consult, stand in a specific spot, call the patient, introduce yourself and smile. Shake the patient’s hand. Walk with them to the consulting room. Don’t start the consult until you make eye contact. How the patient responds to such a greeting is the “reward“.

Picture by Rob Bertholf

Doctors need better tools to help people recognise danger

Doctors see it all the time. The fifty-year-old with a BMI of 28, the teenager who is developing a taste for cigarettes, the twenty-year-old who now binge drinks every weekend, the soon-to-be-mum who is ‘eating for two’. Small choices that may become habits and habits that lead to consequences. Where I work the average consultation is fifteen minutes. In that time we address whatever symptoms or problems have been tabled. The list may be long. Occasionally it’s possible to raise a topic that I’m worried about. The problem is the patient may not be worried about that issue.

Afterall doctor I don’t drink any more than my mates do or I don’t really eat that much.

What’s needed are tools that help frame the issue from the perspective of the patient, not the practitioner. Tools that help us address public health priorities that speak TO that person, not AT everyone. Before making any changes the person needs to agree that their choices might blight their hopes for the future. These are not inconsiderable challenges given the gloomy predictions for the future.

At the other end of the malnutrition scale, obesity is one of today’s most blatantly visible – yet most neglected – public health problems. Paradoxically coexisting with undernutrition, an escalating global epidemic of overweight and obesity – “globesity” – is taking over many parts of the world. If immediate action is not taken, millions will suffer from an array of serious health disorders. The World Health Organisation

Diabetes is likely to cement its place as the fastest growing epidemic in history. The Medical Journal of Australia

In addition, youthful drinking is associated with an increased likelihood of developing alcohol abuse or dependence later in life. Early intervention is essential to prevent the development of serious alcohol problems among youth between the ages of 12 and 20. NIH

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No plan, no progress it’s a simple equation in healthcare

Every business manager can lay her hands on plans and policies and can probably recite the ‘vision statement’. I like the one for Lexmark printers because I think it works for healthcare clinics:

Customers for life. To earn our customers’ loyalty we must listen to them, anticipate their needs and act to create value in their eyes.

The manager’s shelves might house annual accounts, a policy for Human Resources,  a policy for health and safety, a policy for recruitment. The practice may have a chartered accountant, a registered financial advisor, a recruiter and an HR manager. Rarely if ever does a clinic have an appropriately qualified research consultant or a five year R&D plan or policy.

Therefore the manager relies on anecdotes and other people’s data to decide if the practice is delivering accessible and effective services. The practice relies on others to advocate for them and to defend the charges that are levied on their behalf. It’s all left to persons unknown in a far away bureaucracy.

The consumer relationship starts with the brand. Before you even meet the consumer, you must fully understand your brand. If you don’t know who you are as a brand, and what makes you different, better, and special, how do you expect a consumer to? You must clearly define a brand’s product benefits to set up more intimate, emotional bonds. It is these emotional bonds that will form the basis of a lasting consumer relationship. HBR

If you are a clinician in a practice what aspects of the practices’ vision are non-negotiable and how will you know if something is undermining that vision? How reliable and valid is your understanding of the following:

  1. What is the context in which the practice is located? What drives morbidity locally?
  2. How are people greeted at the practice? What do they notice about your premises?
  3. What is the commonest reason for attendance?
  4. How long is the average consultation?
  5. What is the outcome?
  6. How many people receive less than evidence based care? Why? What are the consequences?
  7. How many people take your advice? How many go elsewhere after coming to you?
  8. Which innovation is going to be introduced and tested in your practice in the next five years?
  9. What information will guide investment decisions in the practice?
  10. Are you participating in externally funded research? Why those projects and not others?

These questions are of great interest to the better companies. Companies that are ‘lovemarks’:

Lovemarks reach your heart as well as your mind, creating an intimate, emotional connection that you just can’t live without. Ever. Lovemarks

Never let innovation for a brand be something that happens randomly. It should fit strategically under the brand. At Beloved Brands, we believe the best brands build everything that touches the brand around a Big Idea, that guides the 5 magic moments to create a beloved brand, including the brand promise, brand story, innovation, purchase moment and the brand experience. beloved brands

If these issues are of interest to you I invite you to contact me to develop a plan for your practice.

Picture by UCL Mathematical and Physical Sciences

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

How can medicine compete against the new normal?

Joanna was exactly the person we are being urged to help. In her forties, overweight verging on obese. Hypertensive, asymptomatic but well on her way to chronic diseases. We discussed her diet.

I like salt. So my food tends to be salty. Also most people in my house are my size. I thought about reducing my portions but I like meat, lots of meat. I’m a member of a gym but I rarely go there.

We talked about her risk of heart disease and encouraged her to banish the salt cellar from the table, perhaps think again about reducing the portion size and making time to go to the gym. She looked at me pityingly her eyes said

Well that ain’t gonna happen

This was not a teachable moment. She was not ready to make an investment in changing her habits. She could not see that she was at risk. She was ‘normal’ as far as she could see. So she was not going to change her diet to deal with a problem that she did not perceive as real.

There are many things that are regarded as ‘normal’.

It is now normal:

  1. To have to wear extra large clothes.
  2. To be offered larger portion sizes when we dine out
  3. For more than one in three Australians aged 14 years and over to consume alcohol on a weekly basis
  4. For friends or acquaintances to be the most likely sources of alcohol for 12–17 year olds (45.4%), with parents being the second most likely source (29.3%)
  5. For more than one in three Australians aged 14 years and over to have used cannabis one or more times in their life
  6. For more one in ten people to drink and drive
  7. For one in three people to lose their virginity before the age of 16 ( i.e. before the age of consent) and also to have multiple partners
  8. For 66 percent of all men and 41 percent of women to view pornography at least once a month, and that an estimated 50 percent of internet traffic is sex-related.
  9. For most people who join a gym to never use it

These and many other trends dictate what is ‘normal’ to the average person. It’s OK to eat and drink far too much because everyone else does. It’s OK to be promiscuous, watch pornography and take risks because that’s what people see happening all around them.

Against these trends the challenge is to seek opportunities when ‘normal’ is seen as risky and hopefully before that risk has manifested as pathology.

Picture by Mario Antonio Pean Zapat

Doctor now that my ears are older I can hear you so much better

He was much more willing to listen than the twenty nine year old who was only interested in his sprained ankle. The attitude that millennials consider themselves invincible might explain it. Dave on the other hand wanted a certificate for work. Bit of a headache that morning. Didn’t go to work.

So, we got talking. He coaches a local football team. Now 50 can’t keep up with the young blokes on the field. Can still drink ten pints of beer on Saturday night at the club but most other nights happy to settle for two and some nights doesn’t drink at all. He snores. His trouser size gone up to 36 for the first time ever. Feels too stiff and breathless to do any real exercise. His blood pressure is borderline though be feels well enough.

Just under 1 million Australians were born between 1962 and 1966. Even though birthdays at each decade are usually marked by a special celebration, those for 50 are often unusually large. Being fifty is a bid deal.

It is in their 50’s, for example, that most people first think of their lives in terms of how much time is left rather than how much has passed. This decade more than any other brings a major reappraisal of the direction one’s life has taken, of priorities, and, most particularly, how best to use the years that remain. NY Times

  • 50 year olds are now officially “middle aged” technically ‘Generation X’.
  • Retirement benefits are only going to be available when they reach 67 and the money may have to last another 20-30 years.
  • At 50, many couples still have kids in the nest, with educations to be financed, teaching them to drive with attendant expenses , and, perhaps, weddings and helping with house purchase.
  • They may have parents in their 70s and 80s. They are watching mum and dad and their worries about healthcare and long term care expenses.
  • At 50 the majority of people are over weight or obese, the risk of hypertension begins to rise at this age, some men suffer erection dissatisfaction, many may start to have problems seeing clearly at close distances, especially when reading and working on the computer, the prevalence of hearing loss ranges from 20 to 40 percent. Things just don’t work like they used to!

Gen X has to stay healthy because in this economic climate early retirement is not an option. Within this context Dave and I began the work of focusing on his physical well being. The conversation was much more satisfying. This ‘teachable moment’ allowed us to engage in some simple strategies- reducing portion size, drinking less, taking up gentle exercise and keeping an eye on his blood pressure. Now Dave is earnest in his desire to invest in his health. That’s a good thing because at 50 one in 15 men will have heart disease by the time he is 60 one in four men will have developed that condition. Now is the time to invest. For his sake if not for the economy.

The average age of GPs in Australia is also about 50. We will make the journey together because that’s what general practice is all about. No gadget, gizmo or app was required to forge the connection, no research grant or policy. Just doing what we are trained to do.

Picture by Rene Gademann

Why hardly any medical invention is better than a six inch wooden stick

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A timeless and effective innovation:

  • Can be deployed in any setting
  • Cheap and easily available
  • Familiar
  • Requires minimal training
  • Acceptable to all
  • Unobtrusive or at least does not impact negatively on the consultation
  • Changes how we feel

The best one yet is the humble tongue depressor. How does your gadget, gizmo or app compare?

I recall our then 14 year old returning from a visit to his GP.

Dad, he didn’t even examine me!

It seems the doctor did not look into his sore throat and somehow the patient felt ‘cheated’.

But son, it wouldn’t have made any difference if he did look in your throat, doctors can’t tell if a sore throat is cause by a virus or something else just by looking at it.

I know that dad but the ‘magic’ is in the examination.

That from a 14 year old! A few months later an older woman consulted me with the ‘worst sore throat ever!’ I took a history of what sounded like a upper respiratory tract infection and the examined her very unimpressive throat with said wooden spatula. As I turned away to put it in the bin she said:

There’s one more thing doctor. For the first time in ten years I haven’t been able to afford books for my kids going to school. So I’ve been working as a prostitute.

It is possible or even probable that she would have told me this anyway. However I posit that the an examination with a wooden spatula is a profoundly intimate act. It changes the dynamic in the consultation when your doctor is able to see your sore red throat, is able to notice what you had for your lunch, whether you clean and floss your teeth and smell your bad breath. These intimate details are not shared with everyone or even with our most trusted confidantes. Indeed breath odour has been associated with a very significant impact on self image:

…smell from mouth breath odour can connect or disconnect a person from their social environment and intimate relationships. How one experiences one’s own body is very personal and private but also very public. Breath odour is public as it occurs within a social and cultural context and personal as it affects one’s body image and self-confidence. McKeown

In that context further disclosures can follow an examination of the mouth in a way that can change the diagnosis and management.

That is a truly valuable innovation.

Picture by USMC archives

Why wearables don’t work and people don’t floss their teeth

Wearable devices are now a billion dollar business:

Fitbit Reports $712M Q415 and $1.86B FY15 Revenue; Guides to $2.4 to $2.5B Revenue in FY16. Press release.

In a wonderful article from the Washington Post the author reports:

Another friend, a woman in her 40s, explained: “I realized that there were a couple weeks where I took it off because it was making me feel bad when I was ‘failing,’ so why do that to myself?” Steven Petrow

Associated Press pointed out that:

One research firm, Endeavour Partners, estimates that about a third of these trackers get abandoned after six months. A health care investment fund, Rock Health, says Fitbit’s regulatory filings suggest that only half of Fitbit’s nearly 20 million registered users were still active as of the first quarter of 2015. Anick Jesdanun

This is consistent with what my patients are telling me. I’ve seen the same trend with relatives. But it is all very predictable because these devices fail on one fundamental count. People are not logical. Information alone does not lead people to make choices. Humans are driven by emotion and not just information. If that were not the case people would floss their teeth, not text while driving or borrow more than they can afford to pay.

Innovations that rely on people acting on information to improve healthcare outcomes have no longterm future. If we want people to change their choices we need to accept that information alone does not lead to behaviour change. Functional Magnetic Resonance Imaging studies of the human brain have identified that our brains are resistant to change even when the change might be in our best interests. Habits drive our behaviours and are as an old pair of slippers, comfortable, familiar and easy. Change requires us to activate other parts of our brain, expend energy, learn and adopt new habits. Change requires effort which most people find uncomfortable. As a result, change is avoided and the easiest thing is to refuse to heed the message and bin the device.

There are three stages to adopting new behaviours:

  1. Unfreezing current patterns/unlearning old behaviours.
  2. Changing/applying new behaviours.
  3. Embedding new behaviours.

Of these wearables provide information that might get us underway with the first step by getting us to question the status quo. However that is far from what is required to get us to adopt a diet and exercise regimen. This so-called ‘disconfirming data’ is not enough – we can easily dismiss it, ignore it, or deny its validity. Which most people seem to be doing because it isn’t enough to generate new habits. Two other factors that are also essential to get us to the next stage:

  1. We need to accept that something is wrong and
  2. We need to believe that we can do what is necessary.

The ‘something wrong’ is the problem. Many people who are overweight or obese don’t see themselves are having a problem because in most cases the condition is asymptomatic. They may be surrounded by people who are of a similar body habitus and are therefore resistant to any notion that this body shape is in any sense abnormal. Finally for many people the idea that they might be able to change their shape is hard to swallow as in many cases they do not see results after weeks of effort.

For innovators a fundamental message is that there is no quick fix to healthcare problems because fundamentally humans are feeling not thinking creatures and therefore not responsive to messages that only tackle part of the drivers for change.

Picture by Philippe Put