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Denying people the feeling that someone cares

The conversation I overheard in my practice many years ago went something like this:

Jean, I’m sorry there are no appointments available until Friday. Has he got a fever? Try him with some paracetamol today and I’ll book him in for Friday afternoon. There’s a lot of this flu like thing going around school. Ok, see you Friday.

A receptionist was triaging my patients! Medical qualifications = nil. She looked up with a pained expression, she was carrying more responsibility than I paid her for. And yet it has long been recognised that:

Little difference was observed between the symptoms reported by patients to the physicians as compared to those received by the receptionist staff. Physicians are more likely to use the telephone contact to treat the patient’s complaint with home care advice or a prescription. Receptionists are more likely to use the telephone contact for scheduling an office visit. Fischer and Smith.

What we also don’t acknowledge is that receptionists take calls from their friends, neighbours and relatives. The callers may be worried, unwell, confused, frustrated, angry, grieving, embarrassed, lonely, sad, suicidal, dying or just simply unable to cope. We place them in a front line role in a system that is often over subscribed, under staffed and the first port of call for anyone who thinks they need medical attention. Sometimes receptionists undertake tasks that should be the preserve of someone with other qualifications! We expect the receptionist to be polite, courteous, discrete, sensitive, thoughtful, obliging and intuitive. If she, and it’s usually a she, gets it wrong the practice faces complaint or litigation and a very bad press. Employers have recognised the challenge inherent in the role, but in many parts of the world those who under take this work have no formal qualifications or appropriate training. This issue has received research attention but there are challenges to developing innovations to help reception staff to prioritise patients.

Where contamination of the study population is an early complication, no current gold standard exists to define safe triaging, contextual differences between practices lead to inter-practice variation, and proxy outcomes (improvement in receptionist response to written scenarios of varying urgency) are used. Hall et al
Can we really guide someone who isn’t a doctor, or have any medical qualification, to make appropriate decisions based on a telephone conversation about potential medical emergencies?  There was a recent report of a disastrous failure to appropriately sign post the parents of a very sick child which involved ‘suitably qualified’ people working to nationally accredited algorithms. The issue at heart is that there is a greater demand for access to medical practitioners than supply. In response to demand policy makers have promoted ways to limit or control access to that expertise. The temptation is to innovate for alternatives that don’t involve the doctor. Those who advocate for this approach may be failing to recognise that people in distress aren’t simply disordered machinery in need of a technical fix. They can’t be rescheduled like a car service. That doesn’t mean they need to see the doctor straight away but they do need to feel they have had that experience sooner rather later. People are hard wired to feel better after contact with a doctor- it’s fundamental to how medicine works. That was what we decided back then so we relieved our reception staff from having to determine who was ‘not urgent for today’ when our schedules were full- instead we, the doctors, spoke to the patient by telephone and if we were not absolutely sure we had enough information we saw the patient and we still reduced our workload by 40%. Innovating to ration access to the healer is a bad idea if only because we are deny people the feeling that someone cares. The cost of that loss of connection is a failure to fulfill our purpose in people’s lives.

 

Semiotics and the placebo

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

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

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

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

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

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

‘Dear Patient’, You Matter To Us.

Research reveals that a US civilian is expected to spend 72.35 years in the community, 59.5 days in short-stay hospitals, and 2.28 years in nursing homes throughout his or her lifetime. The probability of receiving care from a primary care physician is 100%.  It is conceivable that an individual may never need specialist services but it is inconceivable that an individual will never need to attend a primary care practitioner.

It is therefore a priority to ensure that the impact of contact with primary care practitioners is optimised. Two recent studies meet the criteria for lean innovations- low cost, agile, intuitive and creative solutions to common problems. The first of these was published in the British Journal of General Practice . The authors set out to increase the attendance rate for adolescents to general practitioners. Simply writing to young people as they reached the age of 16, assuring them of their privacy was enough to boost attendance rates. The results were remarkable. The authors, Aarseth et al conclude:

The proportion of adolescents in contact with a GP increased from 59% in the control group to 69% in the intervention group (P<0.001). For the males, the increase was from 54% to 72% (P<0.001). An information letter about health problems and health rights (such as the protection of the adolescent’s privacy) seems to enhance the accessibility and utilisation of GPs, as measured by contact rate, particularly for males.

The second study, also involved writing to patients and was published as part of a PhD thesis.

The project ’10 Small Steps’ encompasses the development and evaluation of a general practice based RCT designed to improve ten lifestyle behaviours known to be associated with chronic diseases. The low-intensity intervention involved providing computer-tailored feedback, based on a health behaviour summary score, to more than 4500 adult patients recruited through 21 general practitioners in Brisbane, Australia. Participants were followed-up at 3 and 12 months. The intervention was effective in improving the health behaviour score. These findings demonstrate the potential for a low-intensity intervention to improve the adoption and maintenance of health behaviours in a primary care population and for general practice as a conduit for the primary prevention of non-communicable diseases.

These studies exemplify the scope for significant health gains through low cost interventions developed, administered and evaluated in primary care.

Innovating locally

The foreign-looking chap in the baseball cap, the one wearing a pair of torn jeans and a singlet, the one on the mobile phone, sporting a dragon tatoo on this forearm might be a famous musician and the only son of a bedridden widow. But you’ve decided he is  probably a drug addict and treat him with suspicion and hostility. On the other hand the smartly dressed, attractive white woman carrying the brief case might be a drug dealer and you greet her with a welcoming smile. I was born of an ethnicity that wherever I have lived or worked people I meet for the first time assume things about me that are false, even laughable. Before I open my mouth, my students are invited to guess the nationality on my passport, the city where I was born and my first language. They mostly get it wrong. Therefore I do people the courtesy of not making assumptions. Often in medicine the doctor is the only person who will treat some people with respect in a day when they have to contend with lots of challenging behaviours, whether because of their appearance, their accent, their culture, the clothes they wear, their disability or their needs.

I should not have been surprised by research that suggests that doctors know very little about their patients. And least surprising was the finding:

Physicians were poorer judges of patients’ beliefs when patients were African-American (desire for partnership) (p=0.013), Hispanic (meaning) (p=0.075), or of a different race (sense of control) (p=0.024).

Street and Haidet

Could a doctor pick out a patient’s partner, whom they have never met from a police line up? Would they know what car that person drove? Would they have any idea what their patient had for breakfast? Where that person is planning to go on holiday ? What they wanted to be when they grew up? In many cases it doesn’t matter but as innovators we feel we are able to develop interventions that will make it more likely that those very people will comply with our prescriptions, give up smoking, eat more vegetables, wear a condom and monitor their chronic condition. Not all at once of course!

Technology now allows us to take a bird’s eye view of our practices. We record key parameters for people who attend our clinics- for example blood pressure, cholesterol and glycosylated haemoglobin and can link that to geographical data- demonstrating where our poorly controlled diabetics live. We might like to guess before we are presented with the data- I bet we would be way off the mark.

Then we can see if there is public transport to bring those people to the clinic. Where they buy their food. Whether there are open spaces and leisure centres within reach.  Could those people easily attend an optician or a podiatrist? Only then should we contemplate something locally that will make it more likely to improve outcomes. But only after we check our assumptions with the people for whom the innovation would be designed. This work has a local flavour- ineffective innovations are designed on a ‘one-size fits all’ model as if everyone lives in an affluent middle class neighbourhood and seek care at the convenience of the healthcare provider. To quote Idris Moottee:

The customer is King, Queen and Jack. Any innovation efforts will fail eventually if the end user is not driven to use your new product or service. Most consumers are intelligent and can contribute so much to the process. It is true that people can not always voice their needs and desires in a way that makes sense, but our job is find creative ways to understand their attitudes, values and behaviors and figure out how to include them in your innovation process.

Meanwhile my friend Alan Leeb noticed that people are wedded to their mobile phones and are likely to respond to an SMS from his practice. So now each time his nurse administers a vaccine, the practice sends them an SMS asking if they had any sort of adverse reaction. The practice is now able to monitor reactions to vaccines in real time, that means if there are severe reactions his practice will know within 24-48 hours, probably faster than any other agency. This information might just help to save lives in his practice but perhaps in yours too.

Testing assumptions before innovating

Successful innovations are based on addressing ‘real’ problems. They are not founded on assumptions that haven’t been tested. All too often we are presented with ideas that don’t really address the problem from the perspective of the end user. Usually these innovations are designed to solve someone else’s problem and then foisted on an unsuspecting end user. The result is the creation of yet another problem and worse of all wasted resources at a time when economies are under strain.  There is another way. In a very generous contribution with a more sensible approach Julius Parrisius offers this brilliant slide deck. It involves actually finding out what the ‘client’ aka end user needs from you to get through their day, what they find challenging about the problem in question and what’s on their wish list.

The issue in healthcare is that many value propositions are hard to pin down, either because the circumstance are relatively uncommon or because people don’t want to talk about them. They include people presenting/ experiencing:

  • Cancer symptoms- especially the kind that involve embarrassing symptoms- diarrhoea or offensive discharging from unmentionable orifices.
  • Psychosexual problems
  • Sexually transmitted disease
  • Substance abuse
  • Death and dying

Sure you can organise focus groups with a handful of ‘representative stakeholders’ but are you really going to get to the truth? The whole truth? There isn’t really a better way then observing the interaction between practitioner and patient. The challenge is that no one wants you or your video camera in the room while they confess their problem and the care professional doesn’t care for this either. Ethics committees tend to agree. What’s more this preliminary, hypotheses generating research is seldom funded by anyone and sounds daunting- much more so than calling up a friendly ‘stakeholder’ from your list and taking it for granted that they know what they are talking about. So you enlist the ‘support’ of your token end user on one of your ‘project steering groups’ and then hope and pray that they haven’t misled you. Unfortunately it can persuade grant committees that you have done your homework. They won’t find out until they read the press following a launch of your baby and discover that other end users don’t agree. Then you…start again, if anyone still trusts you.

The other issue is that you may also uncover evidence that could land the professional end user into some difficulty-failure to provide evidence based practice with actual patients cannot be overlooked if it is likely to put people at risk in the future. You have a responsibility to protect people- notwithstanding your role as innovator. So, where to from here? How do you get behind closed doors without interrupting the business at hand and while also allowing the practitioner to demonstrate their ‘pain’ with this problem/ issue? Our team has done well deploying simulations. It has allows us to generate and even test hypotheses in an environment in which people have not been put at risk and also relatively quickly allowed us to duck blind alleys before we were committed to them. The key is to accept that the rubber always hit the road when the person with the problem seeks help- in our setting that is usually when they present to a general practitioner /primary care physician/ family doctor and therefore the stage, the props and the actors are already defined- all we have to do is produce enough of the script to let the cast develop the plot- the rest is done by the participants and the truth will out.

Innovating for exemplar conditions

Colorectal Cancer (CRC) impacts on every part of the healthcare system. If a solution can be found to the challenges associated with CRC then they can probably be found for dealing with many other chronic and complex conditions.

  • CRC is one of the commonest malignancies in the developed world and often presents too late for curative treatment.
  • It may be related to a poor diet and is associated with obesity. The incidence is rising.
  • The vast majority of CRCs present with embarrassing symptoms.
  • Such symptoms are common and are also features of benign disease. People find it difficult to decide when they should see a doctor.
  • They often choose to consult other than a medical practitioner and there is evidence for procrastination and for inconsistent advice from the other healthcare providers.
  • [We need tools to assist those healthcare providers to signpost people to a doctor. Such tools need to fit seamlessly into their way of working]
  • The investigation of lower bowel symptoms are invasive and involve unpleasant intimate examinations.
  • Men are more likely to delay consulting a doctor than women.
  • [We need to understand why that is and what we might be able to do about it.]
  • Eventually anyone who develops CRC has to visit a doctor occasionally as an emergency. Symptoms may not correlate to the severity of the disease.
  • Those at highest risk of cancer are older people with lots of other problems.
  • They are all referred to a surgeon. Sometimes the diagnosis is delayed longer than it need be.
  • The treatment of CRC may include surgery, chemotherapy and or radiotherapy. Most people survive.
  • In a typical group of people treated for CRC a large proportion will develop long term side effects.
  • After treatment most patients will attend a specialist clinic briefly once a year, they will have unmet needs.
  • All patients will visit their GP/Family physician/Primary Care Practitioner more often than that mainly about their other problems.
  • We know the sorts of problems they present to their GP.
  • We also know that there are many problems or concerns that the patient does not voice to their GP and that treatment for CRC diminishes quality of life.
  • Primary Care Practitioners have the skills and resources to help people in these circumstances although they might need some additional guidance.
  • [We need a tool to help patients focus on these side effects and help them present this information to their GP.]
  • We need a tool that does not require fundamental reform of the healthcare system.

[A team of PhD students is working to fill in the blanks- their expertise will give us the capacity to focus on other such conditions]
In developing this program for innovation they worked with people who have been closely affected by this condition. They worked quickly, economically, creatively and in partnership with the healthcare practitioners involved in responding to the needs of patients and their families. Their work is beginning to be published.

Innovating in the too-hard box

Approximately one in a hundred people who consult a general practitioner is referred to a specialist. There isn’t an exact number because some GPs will refer more often, either because they have more patients who need referral or because they need the additional support themselves. Whatever the reasons the demand for specialist appointments is increasing; more people are diagnosed with cancer, dementia, diabetes and depression.  More people are surviving life limiting illnesses and joining long queues in outpatient clinics. At the same time there is enormous pressure to contain healthcare costs. So in the name of ‘safety, quality or efficiency’ healthcare providers are reigning in expensive healthcare interventions and access to specialists is on the list. That means there is a growing incentive to ‘prioritise’ those who are most likely to benefit from attending specialist clinics- those who are at highest risk of having a life threatening illness and especially those who are most likely to benefit from earlier treatment. There is pressure to ensure specialists are employed to serve new patients with serious illness and spending less time on matters that can be delegated to someone else.

In this context it is a feature of many healthcare systems that the specialist is requested to assist via a letter from his or her colleague in general practice. The GP is in fact the ‘gatekeeper’ to those services, this is especially true of those services that are subsidised or wholly funded by the tax payer. So what that letter says determines how quickly the patient will be seen because someone, often the specialist will schedule an appointment based on the contents of that letter. Of course it is still possible that a the doctor in the community might pick up the phone and call his specialist colleague if he was concerned that the patient needed urgent attention. Nobody really knows how often that happens. It is also possible that the patient may opt to see the specialist at a private clinic and, as would be the case in my country, be seen within a week.

In any case the ‘referral letter’ is an important element of the patient’s trajectory through the system and here are some inconvenient truths:

  • Doctors are not formally taught how to write referral letters and there is evidence that such letters can be improved.
  • The letter may be ‘triaged’ by a specialist, a nurse or a clerk.
  • Doctors don’t generally think there is anything wrong with their letters, or that their colleagues read those letters and everyone has a different idea about what they should contain.
  • We know specialist often say that GPs don’t write enough detail in their letters.
  • We also know that some people don’t think it’s worth spending time and effort focusing on referral letters because one day the process will be superceded by technology- it hasn’t happened yet and doesn’t look like it will happen soon.

Exploring, let alone improving referral letters is fraught with challenges:

  • GPs are not paid to do research and therefore are loath to spend precious consultation time recruiting and consenting patients for access to their records at a time when the patient might be facing bad news.
  • GPs are ambivalent about testing tools to improve their letter writing skills unless those tools are incorporated into their existing clinical software system.
  • Software developers won’t ‘waste’ time incorporating such innovations until they have proven value.
  • Doctors also argue that there is nothing wrong with their letters and that they record a lot of the relevant clinical details in their records. In fact, they don’t.
  • Specialists may be reticent to be involved in the research in case it sullies relationships.

Twelve years and several small or unfunded studies and some false starts later we are able to report on what we believe is the first randomised controlled trial examining the impact of GP referral letters on potential outcomes for patients. We were surprised by the results. The paper is in press and I look forward to sharing it with you soon. Suffice it to say that we still think it is an important issue, especially because most cancers are now diagnosed from people with symptoms who consult a generalist and because there are more, not less people in need of urgent specialist care. What’s more we have developed an innovation that just might work.

Innovating for multimorbidity

Most people who consult doctors in primary care have more than one problem. The proportion of people with so called multimorbidity is set to rise exponentially as the proportion of older people in many countries rises. The problem is that the length of consultations is limited and therefore the patient and practitioner are already at a disadvantage before they begin. Do you focus on the rash which the patient is anxious about today and which may be the beginnings of eczema, or the hypertension which isn’t at target despite therapy, how about the cigarette smoking and the aching hip and to what extent does the chemotherapy treatment in the past have a bearing on the fatigue that the patient has complained about in the previous consultation. In theory consultations can be extended for patient with greater need, assuming that the need is expressed. According to one team:

Approximately 9% of the patients had 1 or more unvoiced desire(s). Desires for referrals (16.5% of desiring patients) and physical therapy (8.2%) were least likely to be communicated. Patients with unexpressed desires tended to be young, undereducated, and unmarried and were less likely to trust their physician.

Bell et al JAMA 2001

The bottom line is that there is significant unmet need. In theory, in many countries the general practitioner has a longitudinal relationship with the patient and will eventually get around to some of these other issues.  Even in those countries that espouse the concept of  primary care as the first point of contact for people with the healthcare system, the reality is that people tend to consult more than one GP, either by choice or because they have no option and therefore continuity of care is theoretically possible but never actually achieved. The consequences include poor outcomes. It’s even worse in the specialist sector where regular turn over of junior staff means that people seldom see the same doctor from visit to visit.

Here is an opportunity for lean innovators to proactively screen people with a specific problem- for example all patients who have been treated for cancer attending a practice or by offering people an opportunity to have their needs met in another way– either by empowering self care or by enlisting the support of a nurse or allied health care provider. People in distress who are in contact with healthcare organisations cannot be left to fend for themselves or allowed to live under the impression that a diminished quality of life is the best that is now on offer.

Innovation doesn’t always have to mean new

In a world of new gadgets and gizmos we have lost sight of the fact that medicine is a social construct and that there have been some extraordinarily successful doctors who never ordered an X-ray or prescribed penicillin. That does not mean to say that X-rays or antibiotics don’t make us better healers but if we lose sight of the reasons why people have always needed doctors then we face a very uncertain future. In the world of business it is recognised that people buy ( i.e. make decisions or commitments) based on how they feel about something, not just, and sometimes in spite of , the information available. Heart always trumps mind. How else do you explain so many of our questionable decisions in life? By corollary we need to invest in the experience we offer as health care providers, perhaps more than the devices we chose to purchase that keep us at arms length from the patient.

What that means for innovators is that we occasionally have to rediscover the ‘innovations’ that are already in our offices. Possibly the most celebrated research I led was a study that demonstrated that people trust you more when you are seen wearing a stethoscope. It followed on from research that confirmed other things we have ‘always known’- what you wear matters, how you greet your patients/ clients matters and if you seem distracted in the consultation then it detracts from the patient’s experience.

At medical school one of our tutors offered this advice:

Always stand to greet the patient, never sit down before the patient and always find a reason to touch the patient even if it is only to take their pulse.

Simple advice that speaks to the art of healing- because in the end that is what gives medicine its mandate to be involved with people in distress. We were reminded that for some of our patients, perhaps those who need us the most, the unemployed, the marginalised, the unfortunate  the doctor may be the only person in any authority who will greet them with respect that day. Therefore innovation begins and ends with a review of the basics- What is it like for your patients or clients? How are they welcomed to the service? Is your telephone message welcoming? Are your reception staff professional? Do you offer privacy at all times? Do you seem interested or concerned? Would you trust someone who presented themselves the way you do?  Would you feel better after a visit to your clinic? Do your staff need a new machine more than a better way to make people feel they care?

Innovating to save precious time

When I was at medical school Pendleton’s book on the consultation was required reading. Pendleton maintained that one of the tasks in the consultation was to consider ‘at-risk factors’. It’s one item on an otherwise long list of tasks to be completed. Today it is often the case  that a discussion of  those ‘at-risk factors’ take over the focus of the consultation. Doctors are urged, even rewarded for moving the agenda to- diet and exercise, responsible drinking, colorectal, breast and cervical screening, hypertension, safe sex….the list is endless. The impact of having the doctor’s agenda up front and central in the consult is what has been described as

High controlling behaviours.

Ong et al.

The resultant style of consultation is described thus:

It involves… asking many questions and interrupting frequently. This way the doctor keeps tight control over the interaction and does not let the patient speak at any length.

Recently medicolegal defense organisations have taken to issuing advice against this pointing out that when the patient does not feel they have been heard they are more likely to complain. Research has shown that patients don’t ask for much. They won’t take long to spit out the reason for their visit. In one study:

Mean spontaneous talking time was 92 seconds (SD 105 seconds; median 59 seconds;), and 78% (258) of patients had finished their initial statement in two minutes.

Langewitz et al.

Allowing the patient to speak first is a good start. Then how do we support practitioners to earn a living by also attending to those topics for which they must tick a funder’s check box? Tasks introduced by policy makers as if the primary care consultation was replete with redundant time. In some ways it’s like what happens when you buy a new television, it’s not long before the sales assistant wants to sell you insurance and other products- ‘just in case’ but really because their commission depends on it. What we need in medicine is to stop eating into the time it takes to explore a patient’s ideas, concerns and expectations, time needed to examine the patient and express empathy. We need cheap, agile, intuitive and creative solutions that will quickly offer the patient an indication of their risk from whatever the latest public health issue happens to be- smoking, influenza, prostate cancer…but also the benefits and why they might want to consider ‘taking the test’, accepting ‘the jab’, or changing the habit.  My colleague Oksana Burford invested three years testing one such innovation. What Oksana realised is that in the end it’s the patients choice and the key is to introduce the idea of change in a way that speaks to her but only when she is ready to hear the message.

The reasons why primary care is selected to relay public health messages is that people trust their health care provider and are more likely to comply if that practitioner recommends it. However that does not mean that we should assume the patient can only get the necessary information from one source. What the practitioner can do is sign post where that information can be found and effectively convey why the choice being recommended is better than the status quo. I recommend the food swap app– its downloaded free and saves a lot of time which can then be used to deal with the reason the person had come to see me in the first place. There is lots of room for innovation but it should meet the needs of the patient and the practitioner.