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Your mission statement will be tested on Friday afternoon

5012814028_47282104e8_zI was walking to the shops when I noticed her standing in front of a car that was blocking traffic. She looked distraught. She pleaded for help from the only passerby.

I’ve nearly crashed my car. Could you please kill the spider on my windscreen.

There was a very big and ugly spider sitting inside the windscreen. Having ascertained that her shoe was the only weapon to hand I dispatched the spider.  It curled up onto the dashboard no longer a threat. She thanked me profusely, no doubt to recount the tale of the stranger who came to her rescue. Earlier that day I experienced being rescued myself. We discovered at the 11th hour that we needed an adapter for our telephone cable. No adapter, no connection.  At 5.05pm I rushed into a mobile phone shop only to be greeted by a departing customer.

They’re closed mate.

Not to be put off I started towards to the counter and was headed off by the manager.

Sorry sir we are closed unless it’s something really quick.

I explained my problem. He thought there was the very thing I needed in the store room. He said he’d be back soon. His staff were not impressed. I was making the shop untidy just as they were preparing to turn off the lights. No eye contact. No smiles. They busied themselves turning off computers and getting their coats. I tried to look apologetic. Finally the manager reappeared beaming.

Found it. It’s not in a box, so I won’t charge you. Have it sir.

It wasn’t quick. He didn’t need to find it. He made no money on that encounter. But he gained a huge amount of good will and the next time I need a phone, which will be soon I’ll seek him out and recommend the shop to my friends. The person with the urgent problem really tests our claim to be involved in our work to help people even when it isn’t convenient and we want to be elsewhere. We sometimes think of ‘innovation’ as something new that we need to do to win loyalty. Occasionally the opportunity presents itself as the last person to come through the door late on Friday afternoon. Again I agree with Bernadette, real progress only happens when we understand the business we are in and we have some insight into how we make a difference in the lives of the people we serve.

Picture by samwebster

No budget required to make a difference

3386629036_0b929ebb7f_zI said good bye to my patients and colleagues this week. Next week I move to a new job in a new city. It is always surprising what people say to you when they think they might not see you again for a long while.

They don’t recall the grand gestures or the major projects. Instead they talk about the little things that made an impression. Things that made them smile sometimes at your expense. Things that made you human in their eyes.

But perhaps that’s a lesson I should have learned on the 26th Jan 1986. It was a bitterly cold Australia day in Dublin. I was invited to celebrate with my Australian flat mates. As I stood there mouthing the words to Waltzing Matilda on a stage in St. Stephens Green I caught the eye of this gorgeous creature who seemed to be thinking the same thing. These people are mad! And if this is what Australians are like- then that’s where we want to be.

As we left the Green and headed home I unwittingly did something that became the defining moment in our relationship- I offered the girl my gloves. The rest as they say is history and frankly I had no chance once she made up her mind I was the man for her. And now almost 30 years later we are proud to call Australia home.

As you consider how to make a difference – perhaps it’s the little things that you can do that will have the greatest impact. The things that people will recall when their association with you, your team, your organisation or your business ends. Practice random acts of kindness, you don’t need permission, a budget or a committee to do that.

Picture by Ed Yourdon

Implications of the uberization of medicine

5895298746_107c22521b_zAn article published in Body Week predicts that primary care clinics will close:

Doctor visits are so 2014

The author imples that people are now demanding convenience above all and primary care is not convenient. This calls to mind the days when I did home visits in the UK. I’m told some practices still do. I remember making arrangements to visit some of our older patients, who were too frail to come to the clinic but insisted that my visit had to be timed in such a way that I got there before or after their weekly trip to the shopping centre or hairdresser.

The opportunity cost of these visit was vast. Of course the patient loved it. But as I drove around town looking for somewhere to park, negotiated the traffic with a sandwich on my lap and then tried to get back in time for the afternoon clinic I often wondered if the practice of making these visits would be sustainable in the long term given that if I had been working at the clinic over lunchtime I could have consulted with half a dozen patients in the time spent on the road.

Now it seems that people want the ‘Uber of healthcare’. Change is already a foot we are advised:

Instead of waiting weeks to see your doctor when you have a cold, you can now go to your local drugstore, see a nurse, pick up your medications and be home in an hour.

It is assumed that it is appropriate for anyone with a ‘cold’ to make do with this version of healthcare. Perhaps it is.  However a ‘cold’ is a diagnosis. Symptoms are a different matter. Is it safe for anyone who experiences a persistent dry cough and a temperature to simply buy a cough linctus? At what point can a cough and temperature be labelled a ‘cold’ ( i.e. minor self limiting condition) and not ‘pneumonia’ (potentially life threatening)? Those who cannot afford the ‘uber service’- a suitably qualified and experienced health professional at their beck and call- may have to make do with something much less satisfactory. Perhaps the alternative is a video consult.

If you have a problem that might not necessarily require a healthcare professional to be physically present—say, for example, you are having an acne flare-up or you want to know why you get nauseous when you eat cheese—you can opt for a video consultation for $50.

Perhaps the answer is avoid cheese and $50 is a substantial sum for the parents of many teenagers I consult in my practice. Their visits are covered by a government fee and they do not incur out of pocket expenses. It may certainly be inconvenient to drag your teenager to the clinic after school and to occasionally wait for a few minutes before it’s your turn. However if doctors could make a substantially better living consulting those who can afford it on line then they will be less available to those who may have a greater need but cannot pay. In the drive to make healthcare more convenient we could introduce both inequity and risk. Those who design such reform need to understand the business of doctoring and not just the profit margin. General practitioners in Australia have already expressed the view that there are limited circumstances in which a video consult is appropriate.

There is a market for on-demand medicine, facilitated by technology,  however the potential downside includes:

1. Soaking up capacity to provide services to those who cannot afford it.

2. Risk to those who may not receive the correct diagnosis.

3. Worse outcomes for those who are most vulnerable in society.

4. Generating demand for advise about conditions that are better managed without recourse to health professional time.

We should certainly respond better to the needs of people who daily attend general practitioners. However we risk throwing the baby out with the bath water if we do not consider why people need these services. There is great scope to do more good but introduce the profit motive as primary and someone will lose out. Better not those who already have little or nothing.

Picture by Gareth Williams

Staff needs should drive improvements

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I sometimes go to the bank on a Saturday. It’s the only day when I can afford to take the time to pack a picnic and wait in the long queue with everyone else who can’t make it there during the week. This week I sold some unwanted furniture and decided I didn’t want to leave the money in cash. So I made my way to the shopping centre and then to the back of the queue and waited with parents who were trying, feebly I thought, to keep their bored kids taking all the leaflets out of their holders. The attraction I’m sure wasn’t the apparently lowest ever interest rates.

Then, and I could have sworn she simply apparated Harry Potter style, a teller sidled up and asked what business I had at the bank. I explained my need to deposit money so she led me quietly outside to the ATM. As if talking to someone very old and deaf she explained that I did not need to queue to deposit money. It can all be done via an ATM. She talked me through the process, waited till I collected my receipt and then smiling kindly waived me off to my next destination. This got me wondering how many patients feel the same way about taking the time to visit a clinic. Waiting in line even when their need is not urgent and when it may be possible for them to get what they need without the inconvenience of attending in person.

The secret to dealing with the problem is to reframe it as staff’s problem. I hope the bank teller is rewarded for assisting me, for taking the time to make some Saturday excursions to the bank unnecessary, perhaps even getting a high-five from her manager. She certainly needs to make a habit of what she just did. I bet even bank tellers prefer to have their exploits celebrated by bloggers than deal with grumpy people who have waited an hour on a hot Saturday morning.

The issue of improving customer service can be reframed as something to be tackled in response to staff needs. Only then will it be a sufficient priority for front line staff to act in response to a trigger- such as ‘there are now more than five people queuing at the counter’. It’s time for someone to see if we can send some people on their way sooner rather than later.

That was quite different from my experience with Rain man’s favorite airline. My flight to Sydney was diverted to Melbourne three months ago. The ground staff gave me a note to send to their customer service people to refund me for the flight to Sydney early the next morning. Three months later and despite following instructions the money wasn’t credited to my account. Eventually I found the number for customer service and after waiting what seemed a very long time spoke to a human being. She assured me I was given the wrong information.

You must claim the money from your insurer.

Nope. No can do. Your staff told me to send you the invoice and I will call you every hour until you credit my account. What your staff are telling your customers in these circumstances is not my issue.

That’s all it took. I got the money refunded before the second call. No good will generated despite, eventually, doing the right thing. It was much easier to hide behind the anonymity at a call centre. Little motivation, despite the ability, so not triggered to act to when the customer calls. How often does this happen in medicine? How often are front line staff put in the position of fending off demands from the customers even when the customer is acting in accordance with information received? This does untold damage to the brand. Our time is at least as important as those who provide services. We scarcely put up with shoddy service in other aspects of life. Why should medicine be a special case?

Picture by A. Currell

Least qualified and potentially most influential

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People spend more time in one part of the health professional’s office than anywhere else. Waiting times for a 10 minute appointment can be 40 minutes and, unfortunately, longer at some clinics. Patients may even interact with receptionist longer than with their health practitioner. The receptionist will make the appointment, greet on arrival, take details, offer a seat, let the medical team know if the patients condition warrants urgent attention and check the patient out at departure. Yet the word most often uttered by reception staff is:

Sorry. Sorry about the wait. Sorry we have no appointments. Sorry we’re running late.

I agree with Bernadette’s view of the use of this word. Receptionists are in a privileged position to tell the team when they are failing in their mission. But more importantly they can express empathy, notice emergencies, reduce risk (e.g. the child with chicken pox running around a waiting room full of soon-to-be mums), explain when expectations are not met, defuse complaints, maintain a sense of calm when the practice is hectic, embody discretion and confidentiality. Receptionists can underline messages, endorse what the team has to offer or in the moment the patient comes into contact with the practice destroy, or severely compromise the scope to achieve any of this.

The receptionist will be the first to hear if the patient is satisfied and also the first to know if the patient is unhappy. She, and it’s usually a she, will have the least qualifications of anyone in the building and be the lowest paid. Yet she will hear much of what the health professional is told before the patient enters the consulting room. She may have been recruited after a brief interview by the practice manager. Yet this is the face of the practice. This is the person who sets the tone of the patient’s experience and the person who is very well placed to trigger health behaviours in much the same way that front end staff in other businesses are able to influence customer choice.

The receptionist can light up a room by her presence. She can engender calm when the practice is at capacity, she can embody a sense of caring and compassion and promote health in her discussions with patients at the various points at which she interacts with them. Opportunities to trigger health behaviours scarcely have this potential and yet are rarely embraced by innovators.

Picture by Evan Bench

The value of rituals to innovators

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

Review

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

The greeting

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

The pregnant pause

Patient: Not so good doctor……..

The context

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

The examination

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

The decision and the check

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

Safety netting

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

Administration

Note writing, charging etc.

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

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

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

Picture by Laura4smith

Innovate to enable rather than motivate

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A perennial issue is how to trigger behaviours that are likely to result in good outcomes for the individual. Smoking cessation, regular exercise, more fruit and vegetables, less alcohol….the list is long. There is no magic bullet. Again I make reference to BJ Fogg who offers the most easily digestible way to ponder the question. He promotes the philosophy that innovation is about making it easier for people to do what they already want to do and then triggering that behaviour until it becomes a habit. There are four scenarios:

High motivation and easy to do

An individual in pain will need very little to trigger the relevant behaviour- i.e. take the pill that is stocked in the cupboard.  It might be enough to suggest:

Why don’t you take something for that headache?

There are many such scenarios ranging from the life threatening to the debilitating.  The symptoms may be enough to trigger the behaviour and act as a ‘signal’ for the patient. Unfortunately many chronic and even life limiting conditions are asymptomatic until complications ensue and the patient may not be motivated simply by knowing they have diabetes or similar with potentially serious complications. The motivation may also wane in time- as happens in the case of many acute infections where as the symptoms abate the motivation to persist with antibiotics drops. The longer the duration of the treatment the less likely that the patient will complete the course.  In the case of life long treatments for asymptomatic conditions the probability is low. On the other hand when a patient has perceived that they can do the needful, for example when someone has sourced advice on how to stop smoking, and is motivated to do so, then a simple ‘trigger’ is enough in many cases. Here is some empirical evidence. Health practitioners can provide such triggers- the results will depend on the extent to which motivation and ability are also aligned. Pharmacists may be able to trigger a medical consultation simply by advising it. Perhaps this is the most fruitful avenue for innovation at a time when people are becoming more enabled to self care.

High motivation but hard to do

Many people find it hard to give up bad habits. The mother whose child has suffered another asthma attack is motivated to stop smoking but may perceive it as difficult to achieve. The man who has gained weight in the last decade may feel that more effort is required than he is able to commit to dieting and exercise.  The teenager who has recently been in hospital may be advised to inject insulin and give up chocolate may soon quit the regimen. Unfortunately much effort is expended on developing programs to ‘enable’ patients to do ‘hard’ things in this context. It is critical that what needs to be done is made easier or perceived as easier. A  ‘facilitator’ trigger in this case would give access to something that is ‘affordable’ in terms of time and effort. Sadly this is also the stomping ground of charlatans who might trigger ‘quick cure’ schemes, things that promise more than they can possibly deliver to vulnerable (highly motivated and paying) individuals. Effective innovation comes from developing better, cheaper treatment regimens and then triggering them as in scenario one above. Often what is developed is not perceived as easier and the innovation fails.

Low motivation and easy to do

In this situation the patient is not motivated to do something from which they might benefit and is easily available. The influenza vaccine is offered at the requisite time each year. Uptake remains a cause for concern. The reasons for poor motivation need careful consideration- they may not be rational and the ‘spark’ trigger- something that will increase motivation to the point where action may be problematic or need a local solution. The challenge is always that motivation is hard to influence- people’s entrenched beliefs are difficult to shift. If the public believes there is a link between a vaccine and a serious illness, it will be challenging to trigger parents to bring their child for vaccination. Much effort is expended on ‘educating’ people who attend health practitioners. Motivation may increase to the point where it can be triggered but the amount of the effort expended by practitioners is governed by Fogg’s formula B=MAT. Practitioners may not behave consistently or effectively for a host of reasons and as has been shown through research this strategy has disappointing results.

Low motivation and hard to do

In many circumstances those who stand to gain the most are the least likely to act on health care advice. People in deprived communities often have fewer choices and have more to contend with then health practitioners are able to address. In these circumstances changing the environment in which people live may have more of an impact then attempting to trigger behaviours that are difficult if not impossible to attain by people with competing priorities. At an individual level a person may get to a point in their life where they are sufficiently motivated and can see a way to achieve a target behaviour. Until then they are unlikely to be triggered

Picture by Hamed Parham

What triggers health practitioners to act?

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There are four circumstances in which health practitioners might need to act, again with reference to BJ Fogg.

High motivation and easy to do

Imagine a patient who presents with a typical history of some potentially life limiting pathology. Health professionals are highly motivated to act, not least because failure to respond in these circumstances is the commonest reason for litigation. The presentation of the problem can itself trigger the behaviour one might conceive as appropriate. Think of:

  • Red light = stop
  • Green light = go

There are several such ‘signals‘ in medicine:

What the practitioner senses (sight, hearing, touch)

Abnormal physiological sign- abnormal blood pressure, erratic pulse, rapid breathing.

Sign of pathology- abnormal heart sound, a lump or bump.

What patient says

I’m bleeding, I can’t swallow, I’m going deaf, I can’t see

Did you spot the sign in the picture above? The problem with this scenario is that the signs of symptoms do not always evoke the necessary response. It may be too subtle, it may be presented when the doctor is distracted or it may not be recognised. Unfortunately in some instances the condition may be life threatening and therefore it is critical that the ‘signal’ is reliable. Much effort is expended in training health practitioners to be able to respond when required, unfortunately this effort is rarely maintained beyond the initial years of training.

High motivation but hard to do

This relates to patients who could be offered a treatment that the health practitioner knows might help but is hard to provide in the particular circumstances. Imagine traveling abroad and wishing to communicate with someone who doesn’t speak your language. Or wanting to donate money to a charity and not having access to the means to do it.

The triggers to act in these circumstance are what Fogg has dubbed  ‘facilitator triggers‘. Think of:

  • “Tip jars” at the cash register
  • “Add to cart”
  • ” Click on this link”

There are several such ‘facilitators’ in medicine:

  • In house referral cues
  • Desk top protocols for prescribing unfamiliar drugs
  • Charts with instructions from an expert

This trigger has to be available while the practitioner is consulting the patient. It has to be recognised as relevant to the patient concerned and it has to be reinforced by a good experience when it triggers the relevant action- usually a referral or prescription. The trigger both prompts and makes it easier to act.

Low motivation and easy to do

In these circumstances the practitioner is not motivated to do the action but it is easy to do and that behaviour is triggered by something that increases the motivation.

Think of littering.

In medicine this might include:

  • Prescribing an expensive drug when cheaper alternatives are available
  • Ordering unnecessary tests
  • Ignoring warnings of potential drug interactions

There are several ‘spark triggers‘ for such behaviours in healthcare.

What the patient, their family or an expert say or are perceived to say

I demand /recommend this test / prescription / referral.

How the practitioner is feeling or even the time of day

Tired people will behave irrationally or even irresponsibly (e.g. littering)

What the practitioner believes at the time
  • Promotional material from a pharmaceutical company- pens with company logos

In this case the focus is on removing these triggers or making it more difficult to act on the unhelpful trigger. Health care funders often seek solutions in this category. Occasionally a behaviour is desirable- e.g. referral to an NGO for support, in which case the trigger needs to be generated.

Low motivation and hard to do

When people believe they have nothing to gain from an action and they perceive that is it too difficult to respond the action cannot be triggered.

These circumstances are easy to recognise:

  • Being invited to donate a large sum to a cause that does not resonate with your interests / values
  • Spending time on an activity at great opportunity cost.

Several examples in healthcare include:

  • Offered to do research when there is little or nothing to gain from being involved personally
  • Being invited to specialise in a condition that rarely presents in practice.
  • Asked to employ someone who does not generate value to the business / clinic / institution

Often innovators are urged to find triggers for this category. In the first instance those who wish to promote these behaviours fail to recognise /accept that the practitioner is not motivated and underestimate the cost to that practitioner. One answer may lie in reframing the issue so that either motivation or ability are improved and the behaviour is then more likely to be triggered. Another answer is to accept that it is not possible to for practitioners to do everything we might want them to do.

Picture by Debs

Research to solve rather than explore

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To make an appreciable contribution to health research must address real world problems. The recurring dozen themes at primary care research conferences have hardly changed in decades. Many projects are exploratory and despite a plethora of peer reviewed publications hardly ever result in tangible solutions:

  1. Audits of compliance with guidelines.
  2. What goes wrong in a particular topic at a particular location in general practice.
  3. Exploring the needs of  minority groups of people who are poorly served by the health care system.
  4. Engaging doctors in getting people to eat less, drink less and exercise more.
  5. Getting doctors to do more of some things we want and less of other things they like.
  6. Working out what’s wrong with people who come to doctors more, or less, often than average.
  7. Defining the characteristics of  people who need to come to doctors sooner.
  8. Measuring what doctors do and how to incentivise them, financially, to do more.
  9. Surveying or interviewing doctors about their patients or their work.
  10. Getting health care professionals in different disciplines to work together under the leadership of a general practitioner.
  11. Working out what doctors’ databases tell us about their patients or their performance.
  12. Tools to research all of the above.

Perhaps the time has come to swap these for an alternative set of dozen themes focused more fully on generating tangible solutions:

  1. How to empower patients with specific needs to get what they require from identified healthcare providers.
  2. How to share decision making within the context of the limited benefits and significant risks of medical treatment.
  3. How to facilitate access to what the patient really needs. When and where they need it.
  4. How to trigger lifestyle behaviour change rather than deliver a medicalised means to achieve it.
  5. Establishing what can be achieved when health practitioners focus on what they are good at rather than become distracted by issues that are beyond their interest, training or expertise.
  6. How to signpost some people to more appropriate sources of advice other than their doctor.
  7. How to increase access to appropriate advice and support for those who are motivated to seek it.
  8. Defining the limits of what can be achieved by doctors working on any and every social ill.
  9. Designing and testing ways to promote the specific behaviours in healthcare professionals that are associated with the best outcomes in very precise circumstances.
  10. Working out what exactly needs to be done and by whom and when to get the patient with a defined need that which helps in a particular way. Then finding a way to trigger that behaviour in the most specific way in a particular context.
  11. Looking more closely at what doctors and patients do rather than just what is recorded and finding specific ways to trigger whatever benefits the patient in specific circumstances.
  12. Tools to meet the specific needs of patients and support healthcare providers in deploying them consistently.

The current research agenda aims to support the status quo. The times call for a radical review . Primary care, where ninety percent of healthcare is delivered needs to provide leadership about its role in making a real difference to people’s lives. This means acting on the evidence for the limited effectiveness for what we do today to design and test solutions for tomorrow. The focus should move away from trying to mimic researchers in the specialist medical sector and own the space that is primary care. In primary care what matters is what the patient thinks and needs and not on what the sector seeks to provide to sustain itself or maintain external and outmoded notions of  academic or clinical excellence.

Picture by Jiwa New York Public library.

Care is not delivered in a vacuum

3798267293_030d8688bd_zGeneral practitioners (GPs) are the most used health service providers in Australia. In 2010–11, an estimated 14.5 million people aged 15 years and over (82%) had seen a GP at least once in the previous year, with 11.8 million seeing a GP more than once.  At that time in 2011 that there were 43,400 general practitioners in Australia, 43% were women and they worked an average of 42 hours. An earlier census reported that the average age of a GP was 49.3 years with almost one in three older than 55 years. Yet studies seldom report the impact of this demography on the professional advice offered in practice. If it is relevant to tailor health care advice to the ideas and expectation of the patient or client than by corollary it is relevant to consider the personal experiences of the healthcare professional who offers a service. We know for example that lectures, guidelines and protocols aimed at doctors may have less influence on whether a patient receives evidence based care than staff room conversations, peer pressure, the views of opinion leaders or the impact of personal experience within an individuals circle of influence. In research on innovations delivered in the consultation, the clinician is a significant confounding variable. A fact that is rarely mentioned in the limitations of the study.

Primary care clinicians work in “communities of practice,” combining information from a wide range of sources into “mindlines” (internalised, collectively reinforced tacit guidelines), which they use to inform their practice. Gabbay and le May.

Consider for example a recent report that the diagnosis and treatment of malaria by doctors was derailed by the influences described above. What is also recognised is that when doctors become sick or treat their own families they don’t necessarily follow clinical guidelines. What then might make it more likely that doctors provide evidence based care for chronic and complex conditions? With one in three doctors over the age of 55 it is likely that many general practitioners, their partners, families and friends will experience the onset of chronic illness- diabetes, low back pain, depression, cancer etc. They are also going to be invited for screening- colorectal and breast cancer. Their attitudes and experiences may well predict how their patients will be treated. For example in a study in which doctors were asked their views on screening their patients for alcohol abuse, the authors, Anders Beich and colleagues did not report on the alcohol consumption of the participating doctors or their experience of alcoholism in their close family or friends. One participating practitioner was quoted as having said:

To me, just asking everybody about their drinking habits is in part comparable to if I had to do a rectal examination on all patients that came to see me.

Therefore the doctor is a key stakeholder in the process of health care not just by virtue of a professional role but also with respect to his or her personal history and prejudices. This has implications for diagnosis but also for treatment. Patients need to be seen and heard. When the doctors senses are impaired by personal history it is possible that their assessment of needs,  symptom severity or risk may be limited.  What may help innovators is empirical evidence that addressing this question in a defined setting may help deliver better outcomes for patients.

Picture by ReSurge International