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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 have worked the average consultation lasts fifteen minutes. In that time we address whatever symptoms or problems have been tabled. The list may be long. Occasionally it’s possible during the conversation to bring up a subject 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

Picture by Marcelo Nava

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

Innovating for one of the climate’s biggest public health challenges

4265056770_b589d0437a_zIn a cohort of U.S. women, we found that sun exposures in both early life and adulthood were predictive of BCC and SCC risks, whereas melanoma risk was predominantly associated with sun exposure in early life. Wu et al

Furthermore according to the editor of Nature in July 2014

It is accepted that sunscreens protect against squamous cell carcinoma, and this work [research] suggests that they also protect against melanoma.

This message is not getting through to those who might be able to influence public opinion

To win the U.S. Open, tennis players must overcome fearsome opponents, grueling matches and searing heat. But for some, none of that causes quite as much angst as the prospect of rubbing on a gob of white lotion. Of all the accessories that players have at their disposal, sunscreen may be their least favorite. Some don’t wear it at all. Some apply it before daytime matches, if somewhat begrudgingly. But nobody seems to like it. Brian Costa and Jim Chairusmi

The ambient temperature in many parts of Australia early this year will be well over 30 degrees with a UV index of 11- in other words, extreme. Intelligent and well-informed young men and women may be found fully exposed to the midday sun and for hours on end. Many will not be wearing sunscreen, a hat or sunglasses. This can be observed on the beaches, on the tennis courts and on the cricket field.

The message to seek protection from harmful UV rays needs to be crafted in the context to which it is being targetted. It needs to take account of the ideas of young people who are resistant to messages that appear to impose limitations on what they can do:

Tennis players tend to sweat profusely, especially during day sessions at the U.S. Open, where high temperatures and humidity are typical. When the heat mixes with sunscreen, the sweat can form a gooey substance that gets into players’ eyes and onto their hands, affecting both their vision and their grip.

We need to understand and adapt to the perspective of those to whom the public health message needs to get through. There may be other ways to deliver the messages that are more potent. Watch these videos:

  1. The sun damages your looks
  2. It can harm your vision

Therefore, within Foggs model, the motivation to seek protection from UV light could be targetted better. Ability to apply sunscreen or wear sunglasses also needs more attention. Technology may have more to offer with more user-friendly products. Equally making the equipment currently on the market more readily available when and where they are needed will also help. Finally, it may be worth considering a trigger for the behaviour. Something that gets motivated people with the ability to perform the action to then act on a regular basis. The recipe for such behaviour is typically the traffic light. Red means stop every time. The teenager who gets on the cricket field with sunglasses and sunscreen in his bag needs to be triggered to wear them without mum or dad’s nagging voice to remind him. The behaviour needs to be anchored to something familiar- e.g. stepping onto the sand or grass and the message delivered at a teachable moment. The trigger of television advert is not enough for behaviours that need to be repeated. There is still scope to develop an effective innovation by an enterprising researcher based on the principles of patient experience design. I hope it is you.

Picture by Colin J

Innovation is a product of leadership

339113868_1052c8c6a0_zInnovation is ‘a new idea, more effective device or process’. Innovation can be viewed as ‘the application of better solutions that meet new requirements, inarticulated needs, or existing market needs’. It is the fruit that appears on the branches of an organisation where every active component or member has at least what they need to thrive. Maslow identified the hierarchy of those needs. Not every ant in a colony is the queen. Not every ant has to gather food. However if the colony is to thrive every ant must play its part or work with others to solve a problem creatively.

The leader is only ever accepted in nature when the colony thrives. If the leader or potential leader has a limited capacity to facilitate the success of their colony, they are replaced or ejected. At the moment when the team faces a challenge that could impact on their capacity to be productive the individual team members must rise to the challenge. Any solution must not risk the colony. That means that foot soldiers need to live the mission of the colony, they must know the limitations of their mandate but not have to ask the ‘most senior manager’ if it’s OK to do something that brings success in their tasks.

Leaders embody the behaviours and attitudes that give the foot soldiers confidence. They communicate effectively. They ensure an adequate supply of that which underpins creativity. They ensure that the needs, as opposed to the wants of their team are satisfied.

The list of innovations produced by a company is a litmus test of the effectiveness of its leaders. The most prolific innovators foster a culture that will continue to contribute to human welfare. Their leaders have the capacity to ensure that each and every member of their team feels valued but also understand and accept the mission of the mothership. The employees learn to behave as part of the whole and yet feel empowered to boldly solve problems in their domain. A critical component in innovative human organisations is the enlightened and selfless exercise of power where relying on the natural response to chemical pheromones is not an option. If you believe you cannot be involved in any research or innovation where you work you may have a problem. An inventory of your new ideas may be a good place to start a review.

Picture by Kasi Metcalfe

Prepare to avert a drama in a crisis

128886598_e895d6d0a0_zWe were dismayed that there were no seat back screens for our five hour flight back to Perth and there was a feeling of foreboding as we took our allocated seats on what was clearly an aged plane. As we were taxiing onto the runway the pilot made the fateful announcement:

I’m sorry to report that a warning light has flashed in the cockpit and I must return to the terminal for engineers to investigate. We regret the inconvenience caused.

When we pulled back into the gate the pilot turned off the engine and engineers boarded the plane. 45 minutes later the pilot was heard to say:

Ladies and gentlemen I have good news and bad news. The good news is the copilot has just become an uncle (applause rippled through the cabin). The bad news is that we have discovered another fault on this aircraft and we will be off loading you until safety checks are completed.

We gathered our belongings and when the seat belt signs were turned off we filed back back into the terminal. Everyone headed to the desk where the ground staff were busy apparently seeking telephone advice from supervisors. They seemed oblivious to the many anxious faces queuing for information. Ominously the crew wheeled their luggage past and headed off down the corridor. Some of the 400 passengers pushed their way to the front of the queue and demanded information. These eventually passed on the news that the flight was cancelled. Some people walked away muttering that they had given up on the airline and would stay the night. The rest of us waited for a couple of hours returning to the desk every few minutes, still ignored by the staff until eventually one said that frequent flyers would be boarding the later flight to Perth the rest would have to take their chances with other airlines or stay the night. Surely that was always the plan from the moment we were off loaded?

In such a situation the behaviours the airline would wish to see are:

  1. Staff know what to do and are instantly at action stations, reassuring, advising, assisting and redirecting. Effectively minimising the damage to reputation.
  2. Passengers queue in an orderly fashion, remain calm and reassured that the airline has a plan B. Making it less likely to make a drama out of a crisis.

The pilot could not be faulted he knew exactly what to do in the event of a potential emergency. However ground staff struggled to be polite much less organise themselves to inform all the passengers what contingencies were in place when one of their aging fleet of planes was unexpectedly deemed unfit to fly. Consequence- very unhappy customers who will blog about their experience and write complaints.

This happens in medicine all the time. The surgery is cancelled, the medication isn’t in stock, the patient has a cardiac arrest, the transplant organ is rejected, there is a flu epidemic. What makes a difference is anticipating such a crisis. Medicine too often gets this aspect wrong. Surgeons, like pilots, usually do exactly the right thing- abort the procedure, delay the treatment or place the patient in intensive care. However that isn’t the end of story. If we claim, as medicine does that we aim to support the patient through the crisis, disruption, shortage or adverse event then we need to do more than simply hope they don’t turn up at reception to ask the difficult questions. Flights are cancelled on a regular basis as is surgery. This is a set play just as everyone is shown the brace position on boarding the aircraft and as the safety announcement states:

You must know this instantly in the event that there is an emergency

However ’emergency’ isn’t just a threat to life and limb. Emergency is also a situation where there is a substantial and immediate risk to the brand. The staff behaviour did not trigger the desired behaviour from the customers. And as anyone who has done an Advanced Trauma Life Support course knows the noisiest patient isn’t the one whose life is at greatest risk. Find the one who really is going to die without a timely intervention. It seems the airline policy was to attend to those customers who were most vociferous. Many of us deemed it rude to push our way to the front of the queue. But those who had no such compunctions were rewarded with boarding passes to the few flights leaving the city that evening. We can all learn from these experiences. Health innovators have something to offer the airline industry. An industry that remains the leader in safety but not in customer service.

Picture by Alex Avriette