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The simplest way to create a powerful first impression with your patients


The probability that your family doctor will need to make heroic efforts at your next visit is very low. That’s because you are most likely to go with a minor self limiting illness and the best she will be able to do is reassure you that the rash, cough, discharge or fever will resolve in a few days. She might recommend paracetamol, rest or exercise and above all apply judicious tincture of time. You will leave the room feeling better or decide that you have wasted time. Either way it will influence how you feel about going back to see that doctor and inform your opinion about whether it was worth the dollars you, the funder and or the government invested in that visit.

A desk, chair and a couch furnish most consulting rooms. How that furniture is arranged may have an impact on how you feel about being in that space. We know that posture, eye contact and verbal communication matters. However we might also consider that where we sit in a room, and what we sit on also influences the interaction. This is true of boardrooms but it also applies when there are only two at a desk. There are three factors in raising perceived status and power using chairs: the size of the chair and its accessories, the height of the chair from the floor and the location of the chair relative to the other person. Executive chairs, the kind the doctor might sit on are bought because they are perceived to convey authority. ( OK, may be also because they are comfortable). But nonetheless they create an impression:

The height of the back of the chair raises or lowers a person’s status…the senior executive has a high backed leather chair and his visitor’s chair has a lower back.

Therefore from the moment the person enters the room they glean the impression that they are less important than the person in another spot. Unlike the situation where the seating arrangements make the person feel valued.

Picture by Cacau & Xande

First impressions are the love-at-first-sight of the business world.

If you are a doctor have you ever considered letting the patient have the high back leather chair? How doctors position themselves physically relative to the patient matters. There is some evidence in the literature but there’s nothing better than trying it yourself.

Patients commonly perceive that a provider has spent more time at their bedside when the provider sits rather than stands. Swayden et al

The perception that the doctor is spending more time is important because in some cases there isn’t more time available.  There is not much doctors can do in the short term about healthcare policy or resourcing. However just by changing the seating arrangements in the consulting room they can convey to patients that they matter. That’s before they even begin the consult. I’ve tried it, I think it works.

Picture by banlon1964

Are you borrowing money to pay for someone else’s healthcare?


I didn’t think I could have heard her right.

Oh yes doctor $2000. The vet lets me pay it back in instalments. He did the same a couple of years ago. He is very kind.

This old lady had visited me umpteen times. I knew she didn’t have a lot of money and that on occasion she would go without her pills because things were tight. She tried to make ends meet by working as chef at a greasy spoon. Her boss was a bit of a bully and often refused to pay her overtime. I had seen her through oesophagitis, osteoporosis and breast cancer. Each time she couldn’t afford to expedite the investigations and insisted on waiting months to be seen as a ‘public’ patient. But that weekend her dog had been paralysed and the vet had been authorised to carry out emergency surgery. Something she would be paying for months into the future.

Australia has one of the highest rates of pet ownership in the world. The pet care industry in Australia is estimated to be worth $8.0 billion annually. 39% of households own a dog. In fact 50% of Aussies live in a household with at least one cat and or dog in it, whereas only 35% share their household with at least one child under 16.  Companionship is the driving reason behind pet ownership. Australians are showering pets with gourmet food, protecting them with insurance and pampering them with reflexology, acupuncture and hydrotherapy. Pet food has been compared to baby food in terms of resilient market performance. I notice that one of the major supermarket chains has half an isle now stocking chilled pet food.

Most pet owners consider their pets to be members of the family and this has a powerful impact on how and what people buy. Julie Power

This trend has taken medicine by surprise. It may be prudent to enquire if your patient has a pet and if that pet is well. This is especially the case for pensioners whose dog or cat may be the only company they have. The impact of pet ownership on health continues to be debated. On the one hand it is considered to be beneficial, for reasons unknown. On the other hand being responsible for a pet may negate all the benefits. It is stressful worrying about the dog barking and annoying neighbours or damaging property.

Health care practitioners might ponder the impact of these surrogate family members on the lives of people. For pensioners in particular:

High levels of grief may also be experienced in the event of a pet’s death. Other aspects include cost, time, and behavioural problems that may lead to further stress, anxiety and loneliness. Bradley Smith

It is helpful to know if the person who is consulting you smokes tobacco or drinks alcohol. We think nothing of asking other intimate details. However we often fail to ask if the person has a pet. It might explain a lot.

Picture by Malcolm Payne

How are you today?

4704953402_631194c066_zAustralians do a lot of flying. That’s what comes of  living mainly in coastal cities on the edge of a huge land mass. So we spend a lot of time watching cabin crew run through safety procedures. I’m wondering if that’s something we should do before we consult our patients or clients. Here are three things you might ask yourself during consultations this week:

1. Am I fully with this person in the room just now?

2. What do I know about this person and the impact of their problem?

3. What happens if whatever it is that’s bothering them doesn’t improve or gets worse?

I sometimes wonder if I could be replaced by someone who hasn’t spent 6 years at medical school, four years training and then more years than I care to count ‘practicing’. The answer depends on the extent to which I am able to reach beyond myself on the day the question is posed. On the best days I can pick up on subtle cues. When it’s not so good it’s because I’m not all there.

There are lots of reasons why that might happen. Maslow’s hierarchy of needs explains it succinctly. Hunger, fatigue or boredom are not conducive to caring. Yet we have, and in some cases still expect, our health care staff to function despite those feelings. Roger Neighbour developed a wonderful model for the consultation in primary care. This remains the only guide that specifically includes ‘housekeeping’ as an essential step:

Neighbour acknowledges the need for the practitioner to take care of their own feelings, particularly those brought about by a consultation. If not, the emotions, possibly negative, engendered by one consultation, may spill over into the next.

Perhaps we could take it one step further and determine if someone is fit to work as a health professional on a specific day and especially if they are far too grumpy to care. Many have witnessed objectionable, rude and insensitive behaviour from those who should know better. It was once accepted as the senior doctor’s right to be ill tempered. It may still be. If it is then it should be no longer because anger clouds effective communication. And effective communication is vital to the art of medicine. We aren’t always at our best. Being aware when we aren’t is a first step to ‘safety netting’ as Neighbour put it.

Cancelling the flight because the pilot has a cold isn’t always an option. However replacing the pilot may be wise if she has lost interest in flying the plane. It matters how we look as health practitioners but perhaps it matters even more what we are thinking, and therefore feeling, as the patient enters the room. For those with an interest in innovation, here is the first and perhaps vital focus for improving the quality of the experience for the consumer.

Picture by Ryan Hyde

‘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.

The most successful health innovation ever

What medical innovation is:

1. Available worldwide
2. More likely to yield a diagnosis than an X-ray
3. Cheaper than the cheapest stethoscope
4. Requires less training to operate than a tendon hammer?

Answer: A tongue depressor

Why? Because when deployed within the context of a medical consultation- when the practitioner gives the patient their undivided attention, the tongue depressor forges a relationship that may lead the patient to express their deepest concerns. In what other social context can you shove a piece of wood into someones open mouth and get them to say ahhh? A few years ago I consulted a fifty year old mother of five, working as a supermarket check out assistant complaining of a sore throat. We talked about how awful she felt and how she was struggling to cope with her job, how she gets frequent bouts of tonsillitis and how she was afraid her boss would sack her. She had a mildly red throat and I thought I could feel a couple of tender lymphnodes in her neck but her temperature was normal and I remember thinking I’d seen worse earlier that day. Then as I turned around to write a prescription she burst into tears and said-

‘There’s something else I need to tell you doctor. I’m now working as a prostitute because for the first time in ten years I haven’t been able to afford my kids school books.’

That was not what I expected to hear, or anything they told me at medical school could result from examining a throat. That consultation took a very different direction, she was screened for other infections and was fortunately negative. We then talked about her dilemma and she decided there may be better ways to furnish her kids with what they needed for school.

There is very little evidence that the appearance of the throat aids the diagnosis in most cases- even a viral sore throat can mimic a bacterial infection. In any case in developed economies penicillin does not help the patients recover much quicker. However, anyone with a sore throat who consults a doctor expects to be examined. Besides why do people seek medical advice about pharyngitis? It is common knowledge that in most cases a couple of paracetamol, fluids and rest is the only effective treatment. In many cases people are expressing concern about some other aspect of their life when they present with minor self limiting illness. What people say, if you are receptive is

‘I’m unhappy, I’m worried, I’m bored, I’m feeling guilty, I’m tired or I’m not coping and this discomfort is the last straw.’

That’s one of the myriad of reasons that general practice is the most challenging medical specialty, nothing is necessarily what it seems at first glance.

Innovations don’t need to be high tech or expensive- a tongue depressor costs 13 cents. That doesn’t mean that in the right hands such simple equipment is not extraordinarily powerful. There are tools we seldom do without- a stethoscope is vital and not only because of what we can hear when we put it to the chest.

Instruments of measurement vs. instruments of connection

9597562683_0f1bb9156a_zMany health innovators argue that future advances in health care will come from technological solutions. Things we can measure and quantify. Governments and health care providers are holding their breaths for a magic bullet that can easily, measure and thus fix everything.

People who advocate for technological health solutions think that it’s possible for doctors to routinely consult patients without touching them, or even looking them in the eye.

Stakeholders imagine that that health practitioners spend time with their patients simply to gather and process data. We imagine a future when a patient’s wearable device will be handed over to the doctor, who will have everything he needs to know and more, in order to treat any ill.

That is not to say that we should not innovate, or that technology will not enhance the encounter between patient and healer. However we do need to think about how those innovations will become part of that powerful ritual known as the medical consultation. Technology, high tech or low tech, needs to be incorporated in a way that responds to the person in distress. It should be seen as a means to an end, and not an end in itself. If information was all that was required to get people to adopt healthy choices then why do we make so many decisions that defy logic?

Science has identified that people act on impulse, are moved by emotion, or commit themselves to decisions because it makes them feel good even if they know it’s doing them harm.

The reality is that not everything that matters can be measured. Patients don’t just come to doctors to be fixed. As health care practitioners we mustn’t lose sight of the fact that what patients need as much, (if not more) than, instruments of measurement are instruments of connection.

Picture by Alberto Varela