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What’s your vibe?

Do the people who seek your help sense that you are distinctive in some way? How? Is there anything remarkable about you? Your blue shirts? Your leather boots? Something that they immediately recognize as your ‘trademark’. According to Dana Lynch image consultant, your style matters for three reasons:

  1. People for impressions of you within a mere 3 seconds!

2. Your style makes you memorable.

3. Your style allows you to express who you are, which ultimately leads to an improved self-image and confidence.

If you are a doctor your patients will likely decide within seconds if they are going to take your advice.

Picture by Ronald Menti

How many senses do you engage?

How many of the five senses are engaged in your office? Sure people see things, hear things and touch things but are their other senses stimulated?  Do they associate your office with a smell or a taste? What is it? If you are  a doctor it’s not likely to be something pleasant. But if you are and have done something about it then Elizabeth Ely sounds like she would approve:

Just what is it about medical disinfectant? It just smells so, well, medical. So like it’s covering up sick, and bringing you along with it, pulling you under its odourous spell.

Picture by Your Best Digs

How do you explain?

In any meeting where you are the expert how do you explain technical details? As a doctor how do you explain viral illness? Warts? Heart disease? Cancer? How do you know the other person ‘gets it’? Do you say the same thing every time? Do you use pictures? Sounds? Have you practiced the script as much as you practice other aspects of your art? Why or why not?

Andrew McDonald wrote in the BMJ:

The development of such a language, securely founded in shared meanings, would be a good first step towards better communication between professionals and patients. It would not, of course, deliver the goal of full participation in decision making, but that goal will remain elusive unless we begin by understanding one another.

Picture by Marco Verch

How do you end your meetings?

We know how to start a meeting- we stand up, shake hands, say hello, smile. But what’s the best way to end a meeting? It matters for one reason:

The peak–end rule is a psychological heuristic in which people judge an experience largely based on how they felt at its peak (i.e., its most intense point) and at its end, rather than based on the total sum or average of every moment of the experience. The effect occurs regardless of whether the experience is pleasant or unpleasant. Wikipedia

If you are a doctor this is all the more important because people generally don’t seek a meeting with you because all is well. They may be experiencing all sorts of unpleasant feelings. So how do you end that meeting? How do you know it’s working?

Picture by Peter Lee

How does your skill at communicating manifest in your interactions?

It is assumed that doctors have to be specialists in communication. People will tell doctors things they may not confide in anyone else- much less a total stranger. That is part of the equity in the business of doctoring. So if you are a doctor, how does that manifest in your interactions with the people who seek your help? Is it reflected in your greetings? In your body language? In your eye contact? In the way you phrase your questions? In the way you terminate your meetings?

Picture by Paul Moody

When did your doctor last ‘do nothing’?

When was the last time your doctor, or you, if you were the doctor, ‘do nothing’ in the consultation? We don’t feel we have received or delivered value in the consultation unless we prescribe something, order a test or make a referral. But what does that tell us about the business of doctoring or the attitude to medicine?

Picture by AnaC

 

Why medical tests can be misleading

If you have had to consult a healthcare practitioner there will almost certainly have been an occasion when you were advised to have a test or X-ray. But to what extent could you have been misled by the results of that test? Well it depends. The issue may seem complex but the science need not be inaccessible.

Purpose: To conduct a video vignette survey of medical students and doctors investigating test ordering for patients presenting with self-limiting or minor illness.

Methods: Participants were shown six video vignettes of common self-limiting illnesses and invited to devise investigation and management plans for the patients’ current presentation. The number of tests ordered was compared with those recommended by an expert panel. A Theory of Planned Behaviour Questionnaire explored participants’ beliefs and attitudes about ordering tests in the context of self-limiting illness.

Results: Participants (n=61) were recruited from across Australia. All participants ordered at least one test that was not recommended by the experts in most cases. Presentations that focused mainly on symptoms (eg, in cases with bowel habit disturbance and fatigue) resulted in more tests being ordered. A test not recommended by experts was ordered on 54.9% of occasions. With regard to attitudes to test ordering, junior doctors were strongly influenced by social norms. The number of questionable tests ordered in this survey of 366 consultations has a projected cost of $17 000.

Conclusions: This study suggests that there is some evidence of questionable test ordering by these participants with significant implications for costs to the health system. Further research is needed to explore the extent and reasons for test ordering by junior doctors across a range of clinical settings. D’Souza et al

I summarise the issue in this video:

Picture by Erich Ferdinand

The healthcare experience must change

The person who believes they have a problem must be fully involved in the options offered for treatment if healthcare is to result in the best outcomes. Research and experience suggests that may not always be the case:

OBJECTIVE: To evaluate hospitalized patients’ understanding of their plan of care.

PATIENTS AND METHODS: Interviews of a cross-sectional sample of hospitalized patients and their physicians were conducted from June 6 through June 26, 2008. Patients were asked whether they knew the name of the physician and nurse responsible for their care and specific questions about 6 aspects of the plan of care for the day (primary diagnosis, planned tests, planned procedures, medication changes, physician services consulted, and the expected length of stay). Physicians were interviewed and asked about the plan of care in the same fashion as for the patients. Two board-certified internists reviewed responses and rated patient-physician agreement on each aspect of the plan of care as none, partial, or complete agreement.

RESULTS: Of 250 eligible patients, 241 (96%) agreed to be interviewed. A total of 233 (97%) of 241 physicians completed the interview, although sample sizes vary because of missing data elements. Of 239 patients, 77 (32%) correctly named at least 1 of their hospital physicians, and 143 patients (60%) correctly named their nurses. For each aspect of care, patients and physicians lacked agreement on the plan of care in a large number of instances. Specifically, there was no agreement between patients and physicians on planned tests or procedures for the day in 87 (38%) of 229 instances and in 22 (10%) of 220 instances. Complete agreement on the anticipated length of stay occurred in only 85 (39%) of 218 instances.

CONCLUSION: A substantial portion of hospitalized patients do not understand their plan of care. Patients’ limited understanding of their plan of care may adversely affect their ability to provide informed consent for hospital treatments and to assume their own care after discharge. O’Leary et al

Here is my summary of this topic:

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The future arriving at an unprecedented speed

  •   As a general practitioner you must show a commitment to patient-centred medicine, displaying a non-judgmental attitude, promoting equality and valuing diversity
  •   Clear, sensitive and effective communication with your patient and their advocates is essential for a successful consultation
  •   The epidemiology of new illness presenting in general practice requires a normality-orientated approach, reducing medicalisation and promoting self-care
  •   Negotiating management plans with the patient involves balancing the patient’s values and preferences with the best available evidence and relevant ethical and legal principles
  •   As a general practitioner you must manage complexity, uncertainty and continuity of care within the time-restricted setting of a consultation
  •   The increasing availability of digital technology brings opportunities for easier sharing of information and different formats of consulting, as well as raising concerns around information security. RCGP

The summary suggests that the consultation will survive. However the rate of change in every other service is such that the notion of ‘negotiating’ seem quaint as more choices are made directly available to the consumer. Healthcare providers need to be part of the solution as was suggested in this research:

Communications technologies are variably utilised in healthcare. Policymakers globally have espoused the potential benefits of alternatives to face-to-face consultations, but research is in its infancy. The aim of this essay is to provide thinking tools for policymakers, practitioners and researchers who are involved in planning, implementing and evaluating alternative forms of consultation in primary care.

We draw on preparations for a focussed ethnographic study being conducted in eight general practice settings in the UK, knowledge of the literature, qualitative social science and Cochrane reviews. In this essay we consider different types of patients, and also reflect on how the work, practice and professional identities of different members of staff in primary care might be affected.

Elements of practice are inevitably lost when consultations are no longer face-to-face, and we know little about the impact on core aspects of the primary care relationship. Resistance to change is normal and concerns about the introduction of alternative methods of consultation are often expressed using proxy reasons; for example, concerns about patient safety. Any planning or research in the field of new technologies should be attuned to the potential for unintended consequences.

Implementation of alternatives to the face-to-face consultation is more likely to succeed if approached as co-designed initiatives that start with the least controversial and most promising changes for the practice. Researchers and evaluators should explore actual experiences of the different consultation types amongst patients and the primary care team rather than hypothetical perspectives.

Here is my perspective on the challenge:

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It’s not the gizmo it’s the operator who matters

Picture by Tyler