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Do you advise or dictate?

What do you advise most people who seek your help? What will solve most of their problems? It was interesting to read an article this week suggesting that junk food may be associated with depression. In her commentary Megan Lee notes:

Depression has long been treated with medication and talking therapies – and they’re not going anywhere just yet. But we’re beginning to understand that increasing how much exercise we get and switching to a healthy diet can also play an important role in treating – and even preventing – depression.

For many of the most coveted outcomes in healthcare three things are paramount:

  1. Eat less
  2. Exercise more
  3. Don’t smoke

Simple focus. Not easily translated in practice because selling a healthy lifestyle is tricky:

Interviews with 130 mothers of lower social class provided the basis for studying their views on the desirability of general practitioner intervention in their lifestyle habits; the study used both quantitative (questionnaire) and qualitative (interview) techniques. The majority of women were in favour of counselling on specific topics by the general practitioner but the qualitative data also revealed that most respondents expected the issues to be relevant to their presenting problem. Moreover they were keen to assert their right to accept or reject the advice given. Stott and Pill

Picture by Fit Approach

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

Doctor now that my ears are older I can hear you so much better

He was much more willing to listen than the twenty nine year old who was only interested in his sprained ankle. The attitude that millennials consider themselves invincible might explain it. Dave on the other hand wanted a certificate for work. Bit of a headache that morning. Didn’t go to work.

So, we got talking. He coaches a local football team. Now 50 can’t keep up with the young blokes on the field. Can still drink ten pints of beer on Saturday night at the club but most other nights happy to settle for two and some nights doesn’t drink at all. He snores. His trouser size gone up to 36 for the first time ever. Feels too stiff and breathless to do any real exercise. His blood pressure is borderline though be feels well enough.

Just under 1 million Australians were born between 1962 and 1966. Even though birthdays at each decade are usually marked by a special celebration, those for 50 are often unusually large. Being fifty is a bid deal.

It is in their 50’s, for example, that most people first think of their lives in terms of how much time is left rather than how much has passed. This decade more than any other brings a major reappraisal of the direction one’s life has taken, of priorities, and, most particularly, how best to use the years that remain. NY Times

  • 50 year olds are now officially “middle aged” technically ‘Generation X’.
  • Retirement benefits are only going to be available when they reach 67 and the money may have to last another 20-30 years.
  • At 50, many couples still have kids in the nest, with educations to be financed, teaching them to drive with attendant expenses , and, perhaps, weddings and helping with house purchase.
  • They may have parents in their 70s and 80s. They are watching mum and dad and their worries about healthcare and long term care expenses.
  • At 50 the majority of people are over weight or obese, the risk of hypertension begins to rise at this age, some men suffer erection dissatisfaction, many may start to have problems seeing clearly at close distances, especially when reading and working on the computer, the prevalence of hearing loss ranges from 20 to 40 percent. Things just don’t work like they used to!

Gen X has to stay healthy because in this economic climate early retirement is not an option. Within this context Dave and I began the work of focusing on his physical well being. The conversation was much more satisfying. This ‘teachable moment’ allowed us to engage in some simple strategies- reducing portion size, drinking less, taking up gentle exercise and keeping an eye on his blood pressure. Now Dave is earnest in his desire to invest in his health. That’s a good thing because at 50 one in 15 men will have heart disease by the time he is 60 one in four men will have developed that condition. Now is the time to invest. For his sake if not for the economy.

The average age of GPs in Australia is also about 50. We will make the journey together because that’s what general practice is all about. No gadget, gizmo or app was required to forge the connection, no research grant or policy. Just doing what we are trained to do.

Picture by Rene Gademann

Why hardly any medical invention is better than a six inch wooden stick


A timeless and effective innovation:

  • Can be deployed in any setting
  • Cheap and easily available
  • Familiar
  • Requires minimal training
  • Acceptable to all
  • Unobtrusive or at least does not impact negatively on the consultation
  • Changes how we feel

The best one yet is the humble tongue depressor. How does your gadget, gizmo or app compare?

I recall our then 14 year old returning from a visit to his GP.

Dad, he didn’t even examine me!

It seems the doctor did not look into his sore throat and somehow the patient felt ‘cheated’.

But son, it wouldn’t have made any difference if he did look in your throat, doctors can’t tell if a sore throat is cause by a virus or something else just by looking at it.

I know that dad but the ‘magic’ is in the examination.

That from a 14 year old! A few months later an older woman consulted me with the ‘worst sore throat ever!’ I took a history of what sounded like a upper respiratory tract infection and the examined her very unimpressive throat with said wooden spatula. As I turned away to put it in the bin she said:

There’s one more thing doctor. For the first time in ten years I haven’t been able to afford books for my kids going to school. So I’ve been working as a prostitute.

It is possible or even probable that she would have told me this anyway. However I posit that the an examination with a wooden spatula is a profoundly intimate act. It changes the dynamic in the consultation when your doctor is able to see your sore red throat, is able to notice what you had for your lunch, whether you clean and floss your teeth and smell your bad breath. These intimate details are not shared with everyone or even with our most trusted confidantes. Indeed breath odour has been associated with a very significant impact on self image:

…smell from mouth breath odour can connect or disconnect a person from their social environment and intimate relationships. How one experiences one’s own body is very personal and private but also very public. Breath odour is public as it occurs within a social and cultural context and personal as it affects one’s body image and self-confidence. McKeown

In that context further disclosures can follow an examination of the mouth in a way that can change the diagnosis and management.

That is a truly valuable innovation.

Picture by USMC archives

Why wearables don’t work and people don’t floss their teeth

Wearable devices are now a billion dollar business:

Fitbit Reports $712M Q415 and $1.86B FY15 Revenue; Guides to $2.4 to $2.5B Revenue in FY16. Press release.

In a wonderful article from the Washington Post the author reports:

Another friend, a woman in her 40s, explained: “I realized that there were a couple weeks where I took it off because it was making me feel bad when I was ‘failing,’ so why do that to myself?” Steven Petrow

Associated Press pointed out that:

One research firm, Endeavour Partners, estimates that about a third of these trackers get abandoned after six months. A health care investment fund, Rock Health, says Fitbit’s regulatory filings suggest that only half of Fitbit’s nearly 20 million registered users were still active as of the first quarter of 2015. Anick Jesdanun

This is consistent with what my patients are telling me. I’ve seen the same trend with relatives. But it is all very predictable because these devices fail on one fundamental count. People are not logical. Information alone does not lead people to make choices. Humans are driven by emotion and not just information. If that were not the case people would floss their teeth, not text while driving or borrow more than they can afford to pay.

Innovations that rely on people acting on information to improve healthcare outcomes have no longterm future. If we want people to change their choices we need to accept that information alone does not lead to behaviour change. Functional Magnetic Resonance Imaging studies of the human brain have identified that our brains are resistant to change even when the change might be in our best interests. Habits drive our behaviours and are as an old pair of slippers, comfortable, familiar and easy. Change requires us to activate other parts of our brain, expend energy, learn and adopt new habits. Change requires effort which most people find uncomfortable. As a result, change is avoided and the easiest thing is to refuse to heed the message and bin the device.

There are three stages to adopting new behaviours:

  1. Unfreezing current patterns/unlearning old behaviours.
  2. Changing/applying new behaviours.
  3. Embedding new behaviours.

Of these wearables provide information that might get us underway with the first step by getting us to question the status quo. However that is far from what is required to get us to adopt a diet and exercise regimen. This so-called ‘disconfirming data’ is not enough – we can easily dismiss it, ignore it, or deny its validity. Which most people seem to be doing because it isn’t enough to generate new habits. Two other factors that are also essential to get us to the next stage:

  1. We need to accept that something is wrong and
  2. We need to believe that we can do what is necessary.

The ‘something wrong’ is the problem. Many people who are overweight or obese don’t see themselves are having a problem because in most cases the condition is asymptomatic. They may be surrounded by people who are of a similar body habitus and are therefore resistant to any notion that this body shape is in any sense abnormal. Finally for many people the idea that they might be able to change their shape is hard to swallow as in many cases they do not see results after weeks of effort.

For innovators a fundamental message is that there is no quick fix to healthcare problems because fundamentally humans are feeling not thinking creatures and therefore not responsive to messages that only tackle part of the drivers for change.

Picture by Philippe Put

The essence of Patient Experience Design


The Journal of Health Design has been launched to serve innovators who are inspired by unsatisfactory patient experiences. Stories that suggest that by working with people and focusing on their needs as well as their wants we can develop much more effective healthcare solutions. Stories such as those described below.

I saw him many times over the years. He was Indian and he had diabetes. His blood results were seldom within target and he was obese. He had heard why this condition might impact on his future. We spent many weeks and months getting to know one another. I consulted other members of his family. I saw him through several life events including his spiritual rebirth. Finally his blood sugars come within target and his weight drop to within the ‘normal’ range. All this was achieved through his own efforts.

Diabetes impacts on people in very different ways. The prognosis depends on how the person with the condition responds to their body’s inability to handle sugar.

If medicine can be framed as an art it involves the practitioner being able to elicit information. Then working with that individual within a common frame of reference so that less sugar is consumed.

Therefore context is everything. The following may all apply in assessing outcomes in relation to practitioner-patient dyads:

  1. The age and gender of those involved
  2. The social, political and economic conditions
  3. The history of both in the lead up to current events
  4. The culture of both
  5. The professional interests of the practitioner
  6. The ideas, concerns and expectations of both

Nowhere in medicine is this more important than in general practice. Here the patient is most likely presenting at a very early stage of a potentially life limiting condition. The stakes are high insofar as early intervention leads to better outcomes.

At the same time in most cases, in general practice; what the practitioner offers has only a peripheral impact on the outcome. Most minor self-limiting illness is just that. In time the condition will resolve spontaneously. However there is a significant risk that inappropriate treatment, or for that matter any prescribed treatment could do more harm than good. The outcomes are similarly dependent on the ability to practice the art of medicine.

The first and most important question is why has this person sought the help of this practitioner at this time? If you don’t know then you are unlikely to be able to say if what subsequently transpires is for the best or if it failed, why it failed. The context is often locally and personally defined. Any successful attempt to improve outcomes in healthcare requires attention to context. This is the essence of Patient Experience Design. It is also why general practice is at the heart of the best healthcare systems in the world and why progress in healthcare will be determined by shifting the focus from policies and systems to individuals and relationships. Data is important but no innovation can be deployed without the lens of context.

The JHD invites papers that explore the insights of healthcare practitioners gleaned through their interactions with people. Such insights can be harnessed to deliver more effective ways to achieve outcomes that enhance diagnostic acumen, improve prognosis and satisfaction with what we can provide to alleviate symptoms and reduce distress. Join our facebook page, follow our twitter feeds.

Picture by Christian Senger

Effective communication speaks to something people already believe

131417495_81e95b261d_z A doctor who urges a patient to quit smoking ‘to reduce the risk of lung cancer’ may well hear the retort

My grandma smoked until she was 96 and she barely even caught a cold until the day she died in her sleep.

Obstetricians advise women to stop smoking ‘to avoid harming their baby’ may face the rebuttal

My sister is a chain smoker and she gave birth to 3.8kg baby!

General practitioners advise a parent about the dangers of passive smoking may be dismissed with

I never smoke in doors.

Increasing motivation in the hope of changing behaviour is a very hard to achieve. Everyday dozens of men and women will get behind the wheel of a car intoxicated despite dire warnings. Hundreds of informed pregnant women will continue to smoke cigarettes and intelligent teenagers will expose themselves to the sun until their skin peels.

The most effective call to action relates to something people already want. They offer something affordable and speak to something the person already believes. A seductive:

Why have cotton when you can have silk?

In reality not every life time cigarette smoker will develop lung cancer, in fact most won’t.  Not every woman who smokes will have a ‘small for dates’ baby. Not every sun burnt teenager faces the prospect of a malignant melanoma. Unfortunately when people want something, a sun tan, to ride home in their own car after party or to continue a bad habit they chose to believe the facts that support their view. The job of the innovator is to make the messages about less risky life style choices personalised, offer something that seems easily attained and resonate with what that person believes. Each person with whom we wish to communicate speaks a different language and has different ideas, concerns and expectations. We also do well to remember that the choice is theirs to make. We sincerely hope that they are not among the unfortunate few who might suffer the bad outcome that we seek for them to avoid. Just because some smokers don’t develop lung cancer it doesn’t mean that none do.

Picture by Kelly Sue DeConnick

Not disordered machinery


When we think of hospitals we think of a sterile environment. It is assumed that it is a place where your health and well being will improve. That each of your senses can be assaulted in all manner of ways and that because of this, rather than in spite of it, you will get better.

My 30-something year old brother-in-law died in hospital six years ago to the day. He died alone, confused and incontinent. Separated from his beloved daughters and in isolation. The lymphoma that riddled his body was undetected as immunosuppressive drugs stood sentinel over his new kidneys. Everything that could be done was done. He was a young man and the oncologist was determined that he would receive aggressive chemotherapy until she decided that he was beyond her help. We could only watch as he lost his dignity for the slim chance that he might walk out of the place alive. In reterospect it was hard for everyone. He was not ready to die and nor were the medical team prepared to call time. He might have beaten the pathology but it is the journey and not the destination that was the worst aspect of the experience.

Medicine has advanced so much in the last few decades. We now have many life saving drugs or procedures that can be deployed in what were previously hopeless cases. But what hasn’t changed much is the experience of being hospitalised. In the world of blogs and social media we can read the accounts of patients without having to experience them for ourselves:

A man in his fifties who was admitted to hospital with autoimmune haemolytic anaemia, a complication of chronic lymphocytic leukaemia (CLL), first went into a general cancer ward as the haematology unit was full. The ward was depressingly full of very ill old men some of whom died while he was there…..Living in isolation for long periods could be difficult for people who were not used to being alone. Some had felt lonely, frustrated, hemmed in or bored…..Some people found their room pleasant, peaceful and well equipped with television, phone, hi-fi and ensuite bathroom. Neil said his was better than some hotel rooms. Jim said the showers were awesome. Others found their room depressing and had problems with temperature regulation or hygiene. Some people personalised their room with possessions from home. Gilly arranged hers with kitchen, study and reading areas. Brian was disappointed to have no internet connection so he got a modem that would connect his computer via his mobile phone. Some hospitals restricted what people could bring in from home.

As new hospitals are built de novo or to replace aging and outdated institutions we have an opportunity to build new ones that facilitate the innate healing powers of the human body. Healing is ‘the result of intention, personal wholeness, relationships, healthy lifestyle, collaborative medical care, healing organizations, and healing spaces’ (The Samueli Institute). The optimal healing environment addresses issues such as: ‘Connection to nature, options and choices, positive diversions, access to social support, reduced environmental stressor, private and  adaptable rooms, less noise, better wayfinding, lounges and waiting rooms with a purpose’ (Terri Zborowsky and Jo Kreitzer). None of this requires a Nobel laureat to spend a lifetime ‘proving the case’. What it does call for is the determination to ensure that hospitals are a place where it is joy to be born, a refuge when you are ill and somewhere to die in dignity when there is no other option. Humans are not disordered machinery to be parked on a ramp in public place while technicians attend to their under belly. If they are treated as such when they are ill their chances of recovery are diminished. Rest in peace Johnny.

Picture by CJ Sorg

Innovate for quality first

Use of the term ‘quality‘ needs definition before it can be interpreted in any critique of the health service. I propose a definition of a quality as one which can be measured by the extent to which the person with the problem feels that s/he has been seen and heard by a healthcare professional with the requisite expertise. It has resonance with business where if the customer feels that she is not valued she takes her custom elsewhere. However as is sometimes illustrated by some aspiring healthcare providers they understand business but have no clue about medicine. There is a burgeoning of primary care providers, offering something akin to fast food outlets but these are likely to disappoint their clients.

Quality has four benchmarks:


There is no ‘quality’ if the patient has no prospect of consulting the person best placed to assist and especially when need is greatest. There are many examples of disastrous outcomes for people who have not been able to access the required expertise in time. In healthcare that may be a surgeon but it could also be a dentist, a physiotherapist, a pharmacist or an allied health practitioner. On that basis it is telling that in Australia access to general practice may be challenging in some communities but so is access to allied health practitioners. For this reason alone these communities have a diminished quality primary care service regardless of any other benchmark.

However ‘access’ alone is a poor proxy measure of quality although it often seems as if the public believes it is the only one that matters. It certainly makes very bold headlines when it fails. On the other hand there is little point in a very accessible service which is not effective. Once the access issue has been addressed the focus shifts to effectiveness. The Royal Australian College of General Practitioners offers a useful list of indicators that might guide a medical practice. Each discipline or organisation is likely to have its own list of ‘quality’ indicators for effective care.

The integration of care providers is a sensitive marker of quality in health care. There are many healthcare issues where a team approach is of critical importance to timely diagnosis or rehabilitation especially when transitioning from another setting. Practitioners in different disciplines rarely work as an effective team not because they don’t wish to, but because team work is inhibited by funding and or organisational  structures. This may be the one area where collaboration could improve quality for modest investment.

Finally, and crucially, continuity of care is a vital component of quality. Simon illustrates the point well. He has been admitted to three different hospitals in the same town over the past three years. He usually finds his way there in an ambulance or via the emergency department. He has two different problems which have been diagnosed as ‘alcoholism and  neurosis’ or ‘epilepsy’ and ‘stroke’ or ‘migraine’. Simon has certainly enjoyed access and on every occasion he has consulted someone who is suitable trained but there has been no integration of providers and the only hope for a good outcome is continuity of care. By any standard, eight CT scans later, he is at risk of iatrogenesis.  After three years he has been told he is fit to drive and not drive in the same month by practitioners with the same specialist qualifications. He has been commenced on antiplatelet medication by one  and advised to discontinue all medications by another. The only hope is that he has the same general practitioner and that continuity of care might be the light in an otherwise dark and it seems radiated tunnel.

‘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.