better health by designLearn More

The failure to communicate is costing us billions

377593632_1fef556790_z

The Weekend Australian headline today, Sunday 24th April 2016 declared that

Healthcare waste costs $20bn a year

According to the graph on the first page of the paper there were 105-110 General Practitioners (GPs) or specialists in 2004. Although the number of GPs per 100,000 population has remained static there are now more than 130 specialists per 100,000 people . Therefore the rising cost of waste in healthcare runs parallel to the increase in specialists in the population. The source is quoted as the Australian Commission on Safety and Quality in Health Care.

But there is nothing new about this story. This trend was demonstrated in previous decades. More primary care equals lower costs the formula isn’t complex. Reading the papers today we recall the late Barbara Starfield’s words:

Six mechanisms, alone and in combination, may account for the beneficial impact of primary care on population health. They are (1) greater access to needed services, (2) better quality of care, (3) a greater focus on prevention, (4) early management of health problems, (5) the cumulative effect of the main primary care delivery characteristics, and (6) the role of primary care in reducing unnecessary and potentially harmful specialist care.

The disappointing thing about the accompanying newspaper commentary was the suggestion that the solution is political. The journalistic analysis is that powerful lobby groups have managed to influence policy to the point where there is subsidised over servicing of the population. Specifically prostatectomies, colonoscopies, arthroscopies, cataract surgery, hysterectomies and CT scans.

In a country where general practice remains the gatekeeper to specialist services we need to figure out how we might be able to tackle the problem for the sake of the economy. The solution is to remain circumspect about another quick fix because we have learned that politics and the need to be popular with the electorate rarely delivers anything like a lasting solution.

In medicine people are referred or persuaded to have treatment or investigations and under the ‘big data’ is the story of ineffective consultations. One where either the patient is not examined or an adequate history taken, or where the risk and benefits are not explained to the patient in a way that informs the decision. After all if that were not the case which patient at very low risk would chose to have a colonoscopy?

What is the difference between managing a request for an antibiotic for a cold and managing a request for a CT scan for mechanical back pain? To those who are cynical about the chances of getting the message heard we might say wait. When there is sufficient pain the bureaucrats will beat a path to your door. There is no solution as effective as improving how we communicate with patients, anything else will paper over the hole, no the chasm, in the budget.

Picture by Christopher Blizzard.

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

Business R&D approaches may be the salvation of healthcare

9601469425_834bbd0548_z
There are lots of get rich quick ideas around. Just as there are lots of people who will tell you they can fix the healthcare system. But as the song goes:

There’s a guy works down the chip shop swears he’s Elvis
But he’s a liar and I’m not sure about you. KM

What really works requires knowledge of the business you want to fix, especially when you know what happens when the rubber hits the road, not a decade ago, not even five years ago but last Friday afternoon.

There are opportunities to improve every aspect of healthcare but that requires accepting one fundamental point:

People don’t really care whether their actions will please you or not.

People won’t change to please their doctor, their pharmacist, their mother or their government. They will adopt an intervention because it helps them do what they want to do for themselves. The opportunities lie in understanding how to work within these parameters. This is fundamental when it comes to business and people have made significant headway adopting this paradigm. Here are some ideas that demonstrate the power of knowing something about the needs and wants of the target audience:

  1.  Peerby from Amsterdam enables people to borrow expensive items from their neighbours, rather than splashing out on new products.
  2. Fortaleza Tour in Panama City is a walking tour set up by rehabilitated graduates of the Esperanza Social Venture Club — an organization dedicated to demobilizing Panama’s street gangs, integrating their members into society, and improving the area’s economy.
  3. Peru’s black vultures are well known locally for their natural aptitude for garbage location. In that country by fitting a flock of them with GoPros, the authorities collect real-time GPS data and enable the people to find the illegal dumps across the city of Lima.
  4. The UNPF is currently flying condoms, birth control pill and other medical supplies to the Upper East Region of Ghana using a fleet of long-flying drones.
  5. Many of the hosts on Airbnb are vacation property managers with multiple lettings. There are a number of startups offering management platforms and services that enable them to optimize their sub-letting business. Now, Parakeet is a platform that enables hosts to manage and monitor their property remotely via a cloud-based dashboard and keyless entrance system.

There are numerous examples of such out-of-the-box thinking. These innovations allow people to continue as before, to access equipment they hardly ever use but sometimes need, use their knowledge of a neighbourhood to make a living, use nature to monitor the environment, deploy technology to allow people to make personal choices and facilitate ownership of investment properties. The key aspect in each case is keen observation and insight.

This is needed in healthcare, local solutions that can be scaled to improve outcomes without imposing burdens on patients or practitioners. Nobody is as well placed to make these advances than those who already deliver and or avail of the services.

Picture by Cris

Observations of healthcare workers may be better than big data

Apparently when a message is put alongside a cardboard cut-out of a person it is more likely to be noticed and actioned. How the message is relayed to the ‘customer’ matters. This has implications for the sort of results we seek in health care. I am sure the reader could think of many ways this observation can be deployed to improve outcomes in healthcare, just as retail and law enforcement organisations use the concept to communicate with their customers. For example, would you consider having a full sized cardboard representation of a doctor in your practice encouraging people to have their children immunized? Richard Wortley offers some other interesting insights and strategies for behaviour change albeit in the context of law enforcement. What healthcare needs is interventions and ideas, whatever their provenance.

The observations and insights of your staff and colleagues are often, if not always, more valid than so-called ‘big data’. Big data sets are often used for some other purpose (e.g. healthcare administration) and then extrapolated to understand why people are referred inappropriately or prescribed the wrong drugs. More often than not without reference to the people who collected the data in the first place. It is even more fashionable to ‘link’ this data to other information collected for yet another purpose ( e.g. cancer registry). The results may lead to dubious conclusions and wide-ranging policy changes endorsed by a professor or two who have never been on the shop floor, or at least not recently.

‘Big data’ may be easy to collect, despite the limitations of its validity, it offers substantial numbers for a statistician to ‘crunch’. National conferences are now themed on ‘big data’, there are substantial grants available to those who choose this ‘methodology’ for their research endeavours. Meanwhile, the local and contextualized reflections and observations of those delivering health care are seldom accorded the same credibility. The desire for a fast and cheap solution to the increasing cost of healthcare drives funders to throw dollars at anyone who promises a quick-fix and can cite a p-value.

Here the business literature may be relevant:

The study identified a number of factors that influence the success or inhibit progress in terms of performance and sustainable improvement. The findings identify what companies perceive to be inhibitors and enablers for sustainability, within 21 companies who have conducted process improvement (PI) activities using a common intervention approach…..The general and cultural nature of the identified enablers indicates that managers perceive progressing PI activities are reliant on a change of culture within their organisations in parallel with “up‐skilling” the technical knowledge of employees for change to be successfully enacted. The lack of specific processes to change culture, identified in the enablers, also indicates that managers do not know what to do to change their cultures or how best to deal with the inherently challenging and demanding nature of process improvement with shop floor operators. Rich and Bateman

Sounds like healthcare. Perhaps the methodologies deployed in successful care studies hint at a better approach. No big database was dissected in this example which resulted in sustained business performance in an Australian company:

Using data collected through in-depth interviews, the case study describes how the company progressed from an earlier initiative based on quality control to the present initiatives that emphasize customer focus, product development, and innovation. Several important insights are drawn from the case study, including the importance of aligning the quality programmes or initiatives with a clear strategic focus. Prajogo and Sohal

Stand by for the launch of a new academic forum which will focus on the patient experience as the driver of innovation.

Picture by Aranami

 

Address the patient’s greatest fears ASAP

5418964298_f559aa973b_z

I think my son has meningitis.

I glanced at the boy who was now walking across the room to look more closely at a poster on antenatal care.

I don’t think so was my first thought, followed by thank you for telling me exactly what you are worried about. It’s not always that easy. Often the ‘hidden agenda’ remains just that- hidden. The longer it remains unchallenged the greater its hold. Then it’s much less easily to address head on. Sometimes you get a sense of it from the smell of fear as it comes into the room. Occasionally it’s hidden in a request for curious tests:

Could you check my vitamin levels?

My favorite is those who come for ‘check ups’ and are seemingly asymptomatic. I recommend the paper by Sabina Hunziker and colleagues. They studied 66 cases of people who explicitly requested a ‘check up’. All consults were video recorded and analysed for information about spontaneously mentioned symptoms and reasons for the clinic consultation (“open agendas”) and for clues to hidden patient agendas using the Roter interaction analysis system (RIAS).In RIAS, a cue denotes an element in patient-provider communications that is not explicitly expressed verbally. It includes vague indications of emotions such as anxiety or embarrassment that patients might find difficult to express openly and that prevent the patient from being completely forthcoming about his or her reasons for requesting a consultation. All 66 patients initially declared to be asymptomatic but this was ultimately the case in only 7 out of 66 patients.

Back to the boy with ‘meningitis’. He had a fever and aches and pains. However according to Dr. Google, who mum consulted just before rushing to the surgery, if the child had ‘cold hands’ one of the possibilities is that the child has meningitis.

I examined the child thoroughly and found that he had a mild pyrexia and signs of an upper respiratory tract infection. He was awake, alert and clearly interested in his surroundings. He was persuaded to smile and had no signs of septicemia. As this is a common fear in anxious parents I am prepared with standard advice that might be helpful and outline the way meningitis presents. Something I have encountered in practice.

There are many other fears that are presented in an urgent consult. In 99.99% of cases, they are unfounded. However the opportunity to allay the patient’s fears is also an opportunity to forge a bond that may be of enormous assistance when those fears prove to be well-founded. It may be worth considering how you will respond to patient fears of the many monsters that appear in the dead of night; cancer, heart attack, Kawasaki’s disease and meningitis in particular. Bearing in mind these monsters do occasionally present in the most atypical fashion.

Picture by Pimthida

 

How improving the experience of hospital death can help redesign healthcare

 

The residents always approached my father as if he was a person and there weren’t any divisions between them. They didn’t come in and say, “I’m Doctor so and so.” There wasn’t any kind of separation or aloofness. They would sit right on his bed, hold his hand, talk about their families, his family, golf, and sports. From Steinhauser et al.

The chances are when the times comes you will die in hospital. It may be sudden or it may be expected and either you will die a good death or the experience for you and those who are left to grieve will make a bad situation worse. Charles Garfield put it like this:

A good death is no oxymoron. It’s within everyone’s realm of possibility. We need only realize its potential and prepare ourselves to meet it mindfully, with compassion and courage

John Costello concluded his research on patient experiences of death as follows:

The findings also challenge practitioners to focus attention on death as a process, and to prioritize patients’ needs above those of the organization. Moreover, there is the need for guidelines to be developed enabling patients to have a role in shaping events at the end of their lives. John Costello

Therefore, the needs of the ‘organisation’ may impact adversely on the experience of death. These might include the need to adhere to routines such as ward rounds, meal and medication time on open wards which may make it difficult to cater to the needs of the family when the patient dies.

A good place to start with innovation is to consider what, how and when things go wrong. Costello’s interviews with nurses identified several determinants of a bad death:

  • Sudden, unexpected or traumatic deaths especially soon after admission
  • Death other than on the ward
  • Family not aware of impending death or family conflict a major feature
  • Lack of dignity or respect
  • Diagnosis uncertain

Therefore, the key features are the circumstances surrounding the death. The consequences are far from trivial:

Dying patients with unresolved physical and psychological problems, such as pain, nausea, vomiting or spiritual distress, and who were unresponsive to treatment or nursing care, were invariably regarded as experiencing bad death. John Costello

This begs the question why not prepare for death in every hospital admission especially where death is a less than distant possibility. The majority of hospital deaths occur in those over 75 years of age. How is the team prepared if there is a death on the ward expected or otherwise, whether it’s convenient to the routines or not?

Achieving seven goals appear to mark a ‘good’ death:

  1. The patient should be physically, psycho-socially, and spiritually pain-free
  2. Recognize and resolve interpersonal conflicts.
  3. Satisfy any remaining wishes that are consistent with their present condition.
  4. Review their life to find meaning.
  5. Hand over control to a trusted person, someone committed to helping them have the kind of death they desire.
  6. Be protected from needless procedures that serve to only dehumanize and demean without much or any benefit.
  7. Decide how social and how alert they want to be.

Many of these goals are in the purview of the doctor and her prescription pad, others require all those involved to help prepare for an event that will impact on everyone associated with the patient. Healthcare is now a team effort and nowhere more than at the end of life.

When physical symptoms are properly palliated, patients and families may have the opportunity to address the critical psychosocial and spiritual issues they face at the end of life. Steinhauser et al

The point is if we prepare every hospitalised patient who may conceivably deteriorate and die as if we were preparing them and our units for that experience we will treat all patients with greater dignity. That’s the foundation of good outcomes for healthcare staff and the dying.

Picture by Alyssa L. Miller

Don’t trust data out of context

5331111591_5352e900cd_zIn the drive to solve healthcare problems, it’s tempting to tinker with the essence of what medicine has to offer. When we are trying to give patients answers we often fall back on what we can measure, like blood pressure, cholesterol levels and so on. It’s easy to offer people a number that is a barometer for their health. However it’s just as important to understand our patients and the context in which they seek help. What worries them about their current situation or problem? Can they earn a living whilst they have this problem? How are they coping?

If we rely too much on big data we are failing to recognise the role that the practitioner plays in facilitating the recovery from disease. A fundamental truth is that technical medicine- surgery and drugs have very little to offer most people who seek help. There is plenty of evidence that such interventions may even be harmful. There is no occasion when technical assistance alone will make any difference to a person’s distress. That is not to say that there is no place for surgery or powerful drugs. In most circumstances though it is the interaction between an interested practitioner, who gives their undivided attention, who enables the patient to understand and acknowledge the source of their distress that makes all the difference. The best medicine helps patients to find the resources within themselves to improve their circumstances or alter an unhelpful perspective on a difficult situation. Innovations that enable the patient and the practitioner to arrive at this point sooner rather than later are most likely to make a difference to patients.

Not everything that a healer offers can be replaced by facts and figures, or enhanced by gadgets or gizmos. In fact the true value of the encounter between doctor and patient cannot be audited. Failure to factor this truth into our attempts to innovate will lead to sterile and inevitably harmful efforts to improve the outcomes in healthcare. This is especially true when those innovations are a distraction to either the doctor, the patient or both. How are your attempts to solve problems disrupting the business at hand?

Picture by Lara Lima

There is no curriculum for kindness

For months, my wife had been worried about the mole. I couldn’t see anything wrong with it but then it was on my back and I was peering at it through a mirror. In the end, she put the job of getting it examined by a doctor into my diary and it became ‘urgent and important’.

I decided I’d ask my colleague in the office next door if he could recommend a dermatologist.

Do you want me to take a look?

I hated to impose, it seemed hardly worth wasting a surgeon’s time looking at something I was convinced was benign.

Without a second thought, he bounced out of his chair and headed to his car appearing a moment later with a head-mounted magnifier.

It looks benign. However I have three rules with these things. We remove it if your wife is worried about it, if you are worried about it or if I’m worried about it. It’s a five-minute job. We can’t be sure until it’s sent to the lab. But you know that.

He smiled kindly. It was a small courtesy to a colleague,  but a telling example of how a man you had been a surgeon all his life could still be spontaneously kind. His rule made excellent sense. This behaviour is not in any medical textbook. It’s not recognised as an ‘innovation’ that can improve outcomes. It’s just plain old-fashioned, good-natured thoughtfulness. It doesn’t require a grant or a special piece of equipment or anyone’s approval. It makes all the difference to all of us every day. It’s the sort of thing that speaks of vocation. I’m grateful that my colleague works with me, he is a wonderful communicator and that matters when you are training future doctors.

Picture by British Red Cross

Why understanding the patient’s worldview matters

4162021447_2d1bc7c61a_zDad followed me into the consulting room speaking on his mobile phone. Grandmother was carrying the child and walking in his wake. At first, I was a bit irritated that the man was speaking on the phone even as he was seeking my advice but then I heard what he was saying and realised I understood the foreign words:

I’ll call you back in 10 mins, I’m with the doctor now, don’t worry.

It wasn’t what he was saying it was how the words were phrased. It was clear that the caller was someone with whom he shared intimacy. It was like overhearing a private conversation in their home.  The child, who was 2 years old was handed to her father. She turned to look at me suspiciously. Then burst into tears and made to jump back into grandmother’s arms. Then quietened again as long as I kept my distance.

The history was typical of a respiratory tract infection, the child woke with a fever, was coughing and had a runny nose. There were no signs to speak of other than a fever and inflamed upper airway. I asked questions which dad relayed to Grandmother. She provided answers and he translated.

I’m not sure when it was that it became apparent to them that I understood their exchanges.I hadn’t spoken the language in 30 years but I understand it perfectly. Dad relaxed visibly.

The concerns came pouring out- she’d had a sleepless night. Mum was at home worried. Because the child had a fever dad thought she needed antibiotics. As head of the household whatever was approved by him would be accepted by the extended family waiting anxiously at home. The fact that he and not mum was there underlined their concern. The untimely phone call made sense. He told me it  was always hoped that he would become a dentist but things hadn’t worked out and now he owned a shop. The family knew he was interested in medicine and so they deferred to him in what should be done when someone was sick.

He spoke to me in Gujarati. I struggled to respond in kind so I gave up and spoke in English. It didn’t compute to him I looked like him but sounded like a local. It was so much easier to explain the nature of the illness and the need for regular symptom management and what to do if the child didn’t respond. In a world where this family must feel out of place, this must have been a welcome moment of connection. What better time to feel understood than when you are frightened? In designing interventions to respond to the perceived pressure to prescribe or refer perhaps the most powerful is to connect with the patient’s worldview in a way that makes him feel seen and understood. To deal with the problem in the context in which it is presented.

Picture by Ronn

How do we stop the war over antibiotics next winter?

4250244436_dc5ae2dc86_z

She was quite insistent and becoming irate:

Look I am a busy woman. Every time I get these symptoms I come in and get antibiotics and it gets better. Whenever I wait it just gets worse. I don’t have time to mess about so can you just look at the previous notes and prescribe what I usually get?

She had an upper respiratory tract infection. Her throat was mildly inflamed and she had a runny nose. No pyrexia. She sat bolt upright and ready for an argument.

It doesn’t happen that way every time. The patient is usually prepared to allow her doctor to make the call but occasionally it’s not that easy. According to the literature, a third of the public still believe that antibiotics work against coughs and colds. We have seen quite clearly that offering a prescription with the advice to take the antibiotics if the symptoms don’t improve rapidly may help reduce the numbers who take antimicrobials unnecessarily. We know that in at least one study 38% of people may be prescribed an antibiotic this year.  More than one in ten will not complete the course.

How many take the drug as prescribed, e.g. three times a day? And why is it that younger people are less likely to complete the course all the while acknowledging that they understand the importance of taking the medicine as prescribedThe context in which people seek antibiotics may help to inform how doctors manage the call for antibiotics. The answer to the challenge thus far is to mount a public health campaign:

We could focus a ‘Do not recycle antibiotics’ message towards the higher educated, young women who are more likely to store and take antibiotics without advice. McNulty et al

An upper respiratory tract infection is an unpleasant experience. Having a ‘cold’ that lasts a few days may seem trivial to some healthcare practitioners or policy makers but to the patient, it is very far from trivial. In a brilliant paper describing work with 719 people, Longmier demonstrated that neither doctors nor patients can accurately predict how long an upper respiratory tract infection would last or how severe the symptoms are going to be. In an intriguing conclusion to their study they said:

Clinicians should not use their predictive assessments or their patients’ predictions when advising patients on the expected course of a URI (Upper Respiratory infection).

The average duration of symptoms  for URI is 7–10 days, with a minority of patients experiencing symptoms for more than 3 weeks. Antibiotics will do nothing to improve symptoms. Therefore, the problem can be framed quite differently. How you feel on the day you consult your GP is not a good predictor of how long you are going to be miserable with this ‘virus’. Your GP might tell you it’ll all be better in a week and that might sound okay alternatively she might say this will go on for two weeks or more and that might sound disastrous. In any case, she is not likely to be right.  So we go back to the scientists who suggest:

As we cannot accurately predict when the URI will end or how bad it will be, our best clinical tools for patients with URIs are empathy, reassurance and education on the self-limited, short-duration nature of viral upper respiratory tract infections. Longmier et al

To my patient my sympathetic demeanour and rehearsed speech about viruses was not satisfactory. What this patient wanted more than anything else was to be free from her symptoms. I was curious as to why but she was not in a mood to talk about it.  It seems that regular paracetamol in combination with chlorphenamine and phenylephrine may be helpful as are nasal decongestants.  Over the counter cough medicines are not. No doubt there is more literature on the topic of effective symptom relief however, no papers suggest that any treatment entirely rids the patient of symptoms immediately. The key question still remains- why do people insist on and or stop antibiotics before completing the course? If we could demonstrate that people stop antibiotics because their symptoms improve after regular use of effective symptom relief then such evidence may be helpful in any discussion with patients about antibiotics. We then reframe consultations on URIs to offering advice on symptom relief. We offer a solution more aligned to the context in which the patient is presenting. Let’s acknowledge that a cold is an unpleasant experience and not as seems to be suggested to the public a minor nuisance not worthy of our attention.

Picture by Marquette Laforest