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How do you prepare for work?

I don’t know him personally but I don’t imagine that Michael Phelps dives into a pool when he isn’t ready to race. Similarly Usain Bolt might look like he jumped off the viewing stands and popped himself on the starting blocks but in truth his mind and his body are ready to make him the fastest man on dry land. However when we arrive at work we might still be thinking about the argument at home, the traffic jam or the news. We might arrive a bit disheveled, a bit breathless or a tad tired. We might not hear the first few things we are told or notice more than we can take in at a glance of our first customer client or patient. However to perform at our peak we might consider what might get us in the zone so that our performance is not in question.

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Are you worried they’ll never stop talking?

It’s a busy day at work and the next customer, client or patient settles in to tell you something. Are you secretly asking yourself:

 How long will this take?

Will it pay off allowing them to take a couple of minutes to speak about whatever’s on their mind? Have you tried it and timed how long before they stop?

Studies have even shown that participants are willing to give up between 17% and 25% of the monetary reward offered for talking about others in order to feel the intrinsic rewards of talking about themselves. And outside of the lab, 40% of our everyday speech is devoted to telling other people how we feel or what we think. That’s almost half! Belle Beth Cooper

So if you want to do something special for your client, customer or patient give them a chance to say what they want- you might be surprised that it doesn’t take that long and pays enormous dividends.

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Could you do better?

Do you think your work could be better? How? If you think it could be improved what are you waiting for?

The intense debate about how to move forward is a sign that overtreatment matters,” Brownlee says. “We want everyone involved and sharing their expertise on potential solutions. There is room for many political ideologies and beliefs about how to pay for healthcare. The crucial step right now is to get the medical community mobilized around the idea that overtreatment harms patients

BMJ Jeanne Lenzer

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Are you sure they can help?

One of the key roles in healthcare is to refer people to other sources of help. The list of therapists, specialists and clinics is as long as any phone directory. However off loading someone elsewhere is hardly worthwhile if it’s a waste of time and money.

The goal should always be the initiation of a discussion about a patient’s needs and the beginning of a triaging process to address these, rather than problem identification being an end‐goal itself. Gemma Skaczkowski

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Are you persuasive?

If your job involves advising- are you a credible source of advice? How do you know?  What can you do to make yourself a more influential? Apart from giving credible advice is there something you can do to make your advice more likely to persuade?

There’s a critical insight in all this for those of us who want to learn to be more influential. The best persuaders become the best through pre-suasion – the process of arranging for recipients to be receptive to a message before they encounter it. To persuade optimally, then, it’s necessary to pre-suade optimally. But how?

In part, the answer involves an essential but poorly appreciated tenet of all communication: what we present first changes the way people experience what we present to them next.
Robert B. Cialdini, Pre-Suasion: A Revolutionary Way to Influence and Persuade

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How do you frame your solutions?

How do you frame a suggested solution to someone’s problem? Do you mention the possibility that your suggestion won’t help? If you are a doctor do you speak of the number need to treat? We know that not everyone is helped by a medicine or intervention — some benefit, some are harmed, and some are unaffected. One of the commonest reasons that patients consult doctors are for sore throat. How many people with a sore throat should be treated for one person to be free of the sore throat at day 3 of their illness? At day 7 of the illness?

Protecting individuals with sore throat against suppurative and non-suppurative complications in modern Western society can only be achieved by treating many with antibiotics, most of whom will derive no benefit. Cochrane Primary care

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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.

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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?

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Why the data suggests people don’t get the latest medicine

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It sometimes seems ‘obvious’ why things go ‘wrong’ in practice. For example, the proportion of people with diabetes prescribed a cholesterol reducing drug is low…. because? You might have your favorite answer at the ready. Others certainly do and will climb their hobby horse with little or no encouragement. ‘Prescribers don’t accept the guidelines‘, ‘patients don’t take their medicines‘, ‘people can’t afford the drugs‘ or ‘doctors don’t monitor patients‘. The truth may encompass any or all of these.

Let’s do the maths with reference to Glasziou and Haynes.

Let’s assume 80% is true in each of the following points:

1. Doctors are aware of the guidelines.
2. Doctors accept the evidence underlying these guidelines.
3. Doctors remember to apply the guidelines when the relevant patients present.
4. It is possible to do something practical to comply with the guidelines.
5. Doctors act to prescribe the relevant treatment.
6. Doctors and patients agree on the need for that treatment.
7. Patients comply with the treatment.

If these statements are true 80% of the time then 21% of people with the relevant problem will be managed according to the guidelines (0.8x 0.8x 0.8x 0.8x 0.8x 0.8x 0.8= 0.21). Experience tells us that in many, if not most, conditions only 1 in 5 people will be managed as per research evidence.

A quick review of the literature confirms this.

1. Only 17% of patients with diabetes were screened for sexual dysfunction despite it being a common complication of this condition.

2. A primary care study has shown that despite an active education program over two years the proportion of treated patients whose blood pressure was controlled to < 160/90 mm Hg remained at only 33%.

3. When examining the referral origin of all Colorectal cancer patients diagnosed in one study only 24% had been referred on a pathway that was consistent with national guidelines.

A video summary appears here:

 

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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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