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Do you take the shortest route to add value?

Every thriving business adds value. If it didn’t it would not exist. Healthcare shares many points of difference with any other service but none is more remarkable than the  ability to forge connections via the physical examination. It meets our fundamental need when we are ill.

Treatment that uses direct touch can have a depth and potency that can have a great therapeutic impact, which provides some explanation for why so many people are seeking out their own “professional touchers” or are filling the waiting rooms of physicians, waiting for the doctor to find the cause of the pain and make them better. In the process, they are touched. When the patient is assured that the work of the professional toucher is free from infringement, that sexual contact is clearly out of bounds, and that the patient can say “no” to any intervention the body-work practitioner proposes, then the patient can have the experience of trust and physical touch in the context of a controlled respectful relationship. Sharon K Farber

If you are a healthcare professional in what proportion of cases don’t  you perform a physical exam? Why?

Picture by Army Medicine

What was the journey like?

Do you know what your customer, client or patient’s journey to your office, clinic or shop was like? How did they get there? How long did it take? Who travelled with them? What did it cost? If they drove where did they park? Did you take any of that into account in your dealings with them today? Does it matter?

If you’re lying on a table waiting for radiation, you can’t just jump up and plug your meter,” she wrote to the city. “As someone who has gone through and survived cancer, I can’t tell you the anxiety experienced at finding a parking ticket on my vehicle. Nancy Piling

That patient’s experience was impacted by factors that had nothing to do with the professional care she was receiving. But…..

Picture by lagaleriade arcotangente  

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

Picture by Carlos Ebert

I am Joe and I get what I want

As I surveyed the new intake of medical students one student found his way to the front of the room.

Are you the associate dean?

When I confirmed he went on:

My name is Joe ( Not his real name- to spare his blushes). You need to know that I get what I want.

Now two years later here was Dr. Joe graduating, resplendent in his academic gown. He has his wish which I hope is for a lifetime of selfless service to people in distress. So when he is called to the patient in bed 9, on the wards tonight and he is told:

I’m Mr. Smith, and you need to know I get what I want. Tell your boss to come to my room at 11am, I’ll be ready for him then and by the way I’m not happy taking those pill, please take them away.

Joe will know he has got his wish.

Picture by KC

Who taught you how to complain?

When during your training or your induction did anyone teach you how and when to express yourself when something did not meet with your expectations? Your parent might have said:

I know you’re angry darling but we don’t scratch and bite

How do your customers, clients, patients know how to complain? How did you learn to respond? Who models that behaviour for you? What is the approach to giving or receiving negative feedback where you work?

Picture by Paco Trinidad Photo

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

The most valuable lesson learned on my first day as a doctor

Picture by JD Lasica

Much of what’s wrong with healthcare is in the consulting room

It’s not that complicated. Not really. So where do you look for pathology? Inspection, palpation, percussion and auscultation. How does it look, how does it feel, how does it sound and what do you hear when you know where to listen closely. I’m talking about healthcare. Take a helicopter ride through your business.

Access

What is the route to your service? Where is the delay? How long do people wait in the waiting room? How do you know? What do you know about the people who use your service even before they are seated in your waiting room?

Greeting

What happens when people call or arrive in person? What message is conveyed?

Welcome we’ll do our best to help you today OR you are lucky we are ‘fitting you in’.

Just stand there- I’m dealing with someone on the phone.

We have no time- go complain to the manager/politician/ bureaucrat-consider yourself drafted to the cause.

Hold the line. We are dealing with something far more important but your call is really important to us so just listen to how good we are as conveyed by our prerecorded message.

Associated with that is what is perceived about your attitude that is not verbalised?

Look at ALL these posters and the many ways you can be helping yourself instead of wasting our time.

People vomit and pee while they wait so the seats have to be cleaned with detergent. Plastic is the best option.

If you want a drink go buy one at a cafe.

We rely on donations for our toys and magazines- we don’t have to provide anything OK? Now if you don’t like the stuff just watch Dr. Phil.

What do you mean you have been waiting a couple of hours? This isn’t McDonalds now take a ticket, sit down, shut up and wait. And turn off your phone so you can hear the old lady at the desk who has an embarrassing problem.

Communication

How long is the meeting with the provider? How does that meeting unfold? What is conveyed during the meeting?

Welcome- I’m so sorry you are not well. Tell me what happened? OR I haven’t got long what do you want exactly, spit it out be quick about it I need to get on with the next guy. Didn’t you see the queue out there?

I’m the important one around here- you are lucky I’ve chosen to be here today. Let me tell you about my holiday, my kids, my new car. It’s fascinating really!

Room 5. Quickly. Never mind my name.

Test/ Referral and Prescription

What action is taken at the consult and are you confident that is the best possible action?

I don’t have time for talk- have this test and take another day off to see me next week.

I don’t have time for you to take off your umpteen layers- go have a scan.

The rep told me this works- I only have to write a script.

If you want to get better take my medicine/advice/ referral or get lost.

What medicine do you want? How do you spell that? Tell me slowly I’m writing it down on your script.

Outcome

What proportion of people takes your advice/medicine/test? How many people stopped smoking? How many were triggered to lose weight? How many are addicted to prescribed medicines? How many were prescribed treatment or tests that were not indicated? Where’s your data? What are your plans for dealing with this?

Team

To what extent can you say that when people transition to another healthcare professional either on site or elsewhere that the relevant information follows them? Is everyone on the same page with the same patient?

All of this matters. All of it. Some of you can fix tomorrow. No need to wait for another round of healthcare reform. No one said it was easy. And whatever their business the best don’t compromise.  A lot of what can be fixed in healthcare takes place behind the closed doors of the consulting room.

Picture by Daniele Oberti

The welcome rise of alternative providers

Two weeks ago an 80-year-old waited without food or drink for 14 hours in a Dublin city emergency department having fallen in her local supermarket. She was black and blue from head to toe a response to the call of gravity when she was launched off a faulty escalator. She was ‘triaged’ and seated next to drunken revelers who also managed to injure themselves on that fateful evening. She was seen for all of 10 minutes by a medical student and then briefly by a doctor who recorded that her visual acuity couldn’t be assessed because she didn’t have her glasses. With that, she was sent home with her granddaughter and asked to return a couple of days later when she again waited another 9 hours for a five-minute consultation presumably so that the doctor could make sure she hadn’t really injured herself and wasn’t going to sue the hospital as well as the supermarket.  I know this person and read the discharge summary even though her daughter and I live on the other side of the world. As far as we know the provider believes we should be thankful because they are very busy and at least ‘someone’ saw her.

What’s it like to be your patient?

  1. How long do your patients wait?
  2. How are they greeted on arrival and how do they feel about waiting?
  3. What do they do while they wait?
  4. How long do they see you on average?
  5. What do they expect from the visit?
  6. Why do you order tests? What difference do these tests make to the outcome?
  7. Why do you prescribe those drugs? How many people take them as prescribed?
  8. Why do you ask them to return for a review appointment?
  9. Why do your refer them to someone else?
  10. What do they tell their family about your service?

No business would survive without a handle on this information. Arguably some sectors of the business of healthcare only survive because of a monopoly.

A newer take on the organizational environment is the “Red Queen” theory, which highlights the relative nature of progress. The theory is borrowed from ecology’s Red Queen hypothesis that successful adaptation in one species is tantamount to a worsening environment for others, which must adapt in turn to cope with the new conditions. The theory’s name is inspired by the character in Lewis Carroll’s Through the Looking Glass who seems to be running but is staying on the same spot. In a 1996 paper, William Barnett describes Red Queen competition among organizations as a process of mutual learning. A company is forced by direct competition to improve its performance, in turn increasing the pressure on its rivals, thus creating a virtuous circle of learning and competition. Stanford Business

Certainly, the 80-year-old had no option but to go to a state hospital emergency department because there was a very real possibility that she had fractured something coming off that escalator. The hospital manager might say in her defense that they have no option but to offer the service as described, but where is the data to demonstrate that it is the lack of options rather than a lack of interest or talent in managing one of the most important services the state is charged by taxpayers to provide? The monopoly may be around a little longer when it comes to life-saving treatments but what about primary care? If this 80-year-old can wait 14 hours to be seen by a medical student there may be real scope for the service to be provided by someone who is qualified, will see her much sooner and offer her a cup of tea while she waits for the X-rays to be reported. What about the scope to provide better than what you offer?

Picture by Toms Baugis

Why general practitioners are crucial to the economy

The odds of experiencing an event that will descend you briefly into your own private hell are significant.

These odds are much greater than the odds of getting something that requires heroic intervention:

Good news = You are more likely to catch a cold, sprain an ankle or have a runny nose than suffer anything more serious.

Bad news = What happens if you get one of the aforementioned ‘minor illnesses’.  I am living with fractured ribs this week. This is what happens:

  • You are told there is no treatment and no definite recovery period.
  • You can’t tie your own shoe laces, take off your socks or dry your back after a shower.
  • You can’t push open doors.
  • You can’t get out of, our turn over, in bed.
  • You dare not sneeze or pick anything off the ground.
  • You get persistent headaches because of paravertebral muscle strain.

The pain will get worse before it gets better. So at first you might go to the emergency department (ED) because your family will insist. At the ED you will be X-rayed. You will be prescribed analgesia and advised to take time off.  A day or two later in increasing pain you will toy with the idea of going back to hospital just in case they’ve missed something.  The codeine will cause constipation making things worse. Some doctors will advise you to take tramol others will advise against it. A specialist might recommend intercostal nerve blocks (anything looks like a nail when you are armed with a hammer). The cost of getting medical attention will mount. What you will need the most is symptom relief and a greater sense of control. Your only hope is a good GP.

In desperation you might consult YouTube for any useful hints on how to recover. This person has clearly never experienced rib fractures. I hope no medical student thinks this is how to approach the examination of anyone with this condition. On the other hand this person clearly has.

Health economists tell us that the increased costs in the healthcare system are due to unnecessary tests and treatments.

On average, a 50-year-old now is seeing doctors more often, having more tests and operations, and taking more prescription drugs, than a 50-year-old did ten years ago

You are at greater risk of ‘minor illness’ than any other illness. Yet we know that is when we are likely to request tests and treatments in the vain hope it will hasten the recovery. Good GPs  reduce this morbidity as well as the cost of caring for people when time is the only treatment.

This week we launched the Journal of Health Design. The scope of our journal is to support researchers who are developing innovations inspired by the patient experience of healthcare. This was also the week that the Royal Australian College of General Practitioners supported our team to conduct research that aims at supporting GPs in consultations with people with viral infections when antibiotics are not indicated.

Picture by Matt Pelletier