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Why aren’t healthcare providers doing more to tackle the biggest health problem?

Obesity is the single biggest health problem facing our generation and the generations to come. It’s already killing, disabling, disfiguring and demoralising more than half of the population in most developed countries. By 2025 the majority in the developed world, and a growing proportion in the developing world will be overweight or obese. We have seen it coming, the warnings have been around for decades and yet we have done very little to combat it. Now it’s reported that doctors can’t see what they can do about it.

Until more effective interventions have been developed GPs may remain unconvinced that obesity is a problem requiring their clinical expertise and may continue to resist any government pressure to accept obesity as part of their workload.

—Laura Epstein and Jane Ogden

The reality about the problem of obesity is:

1. We are all aware that being overweight is harmful and yet we are legally bombarded with subliminal messages that promote unhelpful lifestyle choices .

2. It may be counter productive to raise the issue with someone who already feels a sense of shame and guilt.

3. Simply being offered dietary advice by a health practitioner isn’t making a difference to most people. We already know what we shouldn’t put in our mouths, that an apple is better for us than a chocolate bar.

4. People find it hard to do what needs to be done to tackle the issue—eat less and exercise more. It’s hard to sustain the effort over a period of time and to make permanent lifestyle changes.

5. Our current healthcare interventions and innovations with regard to obesity are not working.

6. In Australia the cost of dealing with the effects of obesity has reached $120 billion. We are not doing enough to tackle the root cause.

7. We must find a sustainable solution to this problem. Handing out diet sheets and making referrals to dieticians is not enough.

The challenge, for the practitioner is to present information that’s hard to hear in a way that it is likely to be taken on board and acted on. To appeal to how people feel about making changes, not just what they know. To provide information that is motivating and affirming. To reduce the time burden on health practitioners to deliver that advice efficiently. To put the tools into the hands of the person who may have to change life long habits. We just need the collective will to make it happen.

Rethinking The Benefits Of Expensive Medical Research

In the developed world the really scary diagnoses are very uncommon. More often than not a patient’s symptoms can be safely interpreted as benign. This has engendered a false sense of security because there is evidence that doctors fail to recognise presentations of some nasty diseases.

Innovators in medicine have been focused on this problem for some time. For example a research team reported in 2009 that skin cancer was much easier to diagnose with the aid of a handheld device that draws attention to cancerous changes. The problem however is that doctors need to attend a course on dermatology and take an exam before it is safe to let them lose on people with the instrument. The published report was upbeat despite the fact that one in three doctors didn’t complete the required training. The outcome of this research (and many other research programs funded using millions in taxpayer dollars), was an academic paper that will never impact on the early diagnosis of the disease.

Less than five years later some of the same team were back to test a simpler device but with a similar requirement for education of doctors before successful deployment. The negative results were hardly surprising. The team concluded that cancer was more likely to be diagnosed early if doctors followed guidelines.

History has taught us that just because an intervention may be of benefit to patients, that doesn’t mean it is likely to be embraced by overburdened care providers trying to earn a living. The most successful innovators understand the need to tailor interventions to meet the needs of both the health professional and her patient. They realise that tools that are inconvenient or cumbersome are doomed to novelty status.

Committees that determine which ideas are worthy often deny the lessons of agile, intuitive, creative and effective innovations. These are more likely to be reliable, developed relatively cheaply and don’t need an instruction manual.
How hard is it to adopt your innovative ideas in practice?

Innovating in cancer diagnosis and treatment

The experience of someone with cancer is a litmus test of a country’s healthcare system. Let me explain:

Cancer Symptoms

The symptoms of many cancers are very like those of many more benign conditions. Take colorectal (bowel) cancer. People who develop this disease present with symptoms that many of us have had at some point in our lives—diarrhoea, rectal bleeding, abdominal pain and fatigue. You would imagine that the symptoms of bowel cancer are far worse than anything following a suspect meal. In some cases, yes, they are. In many cases those who develop widespread, incurable disease have quite minor and short lived symptoms.

Despite the wide availability of screening tests, the majority of bowel cancer diagnoses in the developed world happens after presenting to a doctor with symptoms. Those who are ‘lucky’ present with lots of symptoms, but have a curable cancer. Many patients present with late and incurable disease, sometimes with relatively minor symptoms. Studies of people who turn up with symptoms, suggests that there are patterns that describe cases more likely to have the condition. However these patterns are not reliable and in many cases the chance of being diagnosed with cancer, despite the ‘data’ is, thankfully, relatively small. That means that of all those who present with symptoms for the first time, it is the communication skills of the doctor they consult that determines if that person is identified as someone who would benefit from a colonoscopy. But also , crucially, whether the person who is at no risk at all is subjected to a colonoscopy.

The reality seems to be that more people have a colonoscopy, than benefit from the experience. The greatest gripe in many health care systems is that people are left to languish on waiting lists. The finger is pointed either at primary care for selecting too many patients for referral, or at hospitals for not providing enough clinics. In my view the truth is that neither is to blame. Humans vary in their ability to seek help, they vary in their ability to apportion limited resources and in the end the system depends on people. Our human frailty is the weak link.

Cancer Treatment

Once ‘in the system’ the patient is subjected to all that can be offered by the King’s horses and men. Large sections of their anatomy may be removed. Chemicals and radiation may be administered, and weeks if not months of their lives may be spent in an alien, clinical environment. Here they have to adjust to life without the familiar and predictable. Many make a full recovery, which is testimony to the resilience of human beings. Some don’t make it and the rest never fully recover, if not from the cancer, then from the effects of the efforts to save their lives. While being treated they are segregated from their families, their support structures, including their family doctor, who will be consulted in the future, about the diarrhoea, the fatigue, the urinary and sexual dysfunction and the fear of recurrence that may be a feature of life after bowel cancer.

Cancer Support

What happens after this ordeal is that people either recover fully and rarely need to think about it again, or continue to suffer debilitating side effects related to the assault on their physical, psychological and social self. In these circumstances the health care system is either supportive and offers all manner of ‘interventions’, or barely supports people who have been ‘cured’ of cancer and now need to get their lives back on track. When the health sectors are divided along funding lines, as is the case in Australia, the scope for it to be someone else’s job are greatly increased. In these circumstances we can detect so-called ‘unmet need’.

Innovation In Cancer Care

Academic careers are being made of documenting all of this. It sounds like chronicling what common sense already tells us. It’s about lack of knowledge, unhelpful attitudes and questionable beliefs. But as a proponent of ‘lean medicine’, I wonder if those who refer people for life saving treatment and then pick up the pieces have something to offer? Can we generate solutions, rather than apply for yet more tax payer’s money to explore what our patients and colleagues are already telling us? The challenge is that we already have a growing demand in primary care, based on the rising incidence of chronic and complex conditions, consequent to an aging population and poor life style choices. How can the care of these patients be improved without relying on people recognising it as simply ‘the right thing to do’? How can we generate a solution that makes life better for everyone. Failure to do so has brought us to the current impasse, and the aforementioned ‘unmet need’. A lean medical solution will allow people to access, and assimilate more information about their symptoms, their treatment and life after treatment. Perhaps it will empower practitioners to be more proactive, without having to increase an already overburdened health work force?

What are your ideas to improve things for the one in four people who will develop cancer in the course of their lives?

You don’t need permission to begin innovating

imageLast weekend I spent four hours in the air sitting bolt upright crammed next to a fidget on a budget airline. The plane was full of sunburnt youngsters flying back from Bali. Years from now they’ll turn up at the doctors convinced that a mole has changed. Sadly malignant melanoma is the commonest malignancy in this part of the world.

Maybe much sooner they’ll be worried that the insect bite on their shoulders is infected. Spots, sores, moles if I had a cent every time someone wanted reassurance about one of those I’d be doing well. I’m sure many of my colleagues would agree that it would be great to have a reliable way to keep an eye on skin lesions that change when the doctor isn’t there to inspect them. It’s also hard to look between your shoulder blades. On the other hand the doctor in me wouldn’t want you to use your phone to make a diagnosis, it has been shown that technology can’t do better than a doctor with a good eye. Nonetheless we need something to track changes in our skin, to alert us if things aren’t looking the same. It would also we helpful to have a record of lesion changes to show when we turn up at the clinic.

Taking photos on a smart phone might help but tracking symptoms and measuring changes in the appearance of something that might need to be removed is a good idea. iMockApp is a free app that enables anyone to create wireframes. I used it on my iPad mini (on that flight from Bali) to develop the idea for an app that could monitor skin lesions. Of course it would need a lot more work before it was made available to the public, but it was a start and spending time on the idea stopped me reaching across to strangle my fellow passenger who had just managed to punch me, accidentally I think, in the side.

The point is that as an innovator you are rarely without the tools to create—diaries, iPads, laptops, note books, napkins, pens, pencils, whatever. You don’t need a whiteboard, a ‘team’, a budget, grant or a mandate from the ‘boss’ to create something new. The world appears divided into two simple typologies- creators and consumers. Will you wait for someone to give you the permission to innovate, or have you taken out pen and paper and begun sketching your design already?

Symptom or disease? The four circle rule.

Four Circles for innovators in Lean Medicine

Four Circles for innovators in Lean Medicine

Most people with symptoms don’t seek medical advice. Those who choose to make an appointment with a doctor are more likely to have a disease and those who are referred to a hospital specialist are even more likely to have pathology. Lean medicine takes account of Bayes’ theorem that demonstrates this simple truth mathematically.

I like to think of it as ‘the four circles rule’.
This schematic tells us that many people with pathology do not seek medical advice and some don’t even have symptoms. It also tells us that doctors have to find those with pathology from among the many who do seek their advice. Often patients present with a host of problems, so that the four circles become 8, 12, 16 or even 20 different circles, one set for each condition.

My team have applied this principle to study people with bowel symptoms. It is a fact that most people with bowel symptoms do not have pathology, or at least not cancer. Epidemiologists have identified groups of symptoms which when they occur together are most likely to signify pathology. This isn’t always reliable and there are lots of false positives, leading to anxiety among the worried well. On the other hand it is also true that people with pathology may or may not seek medical advice. The latter is especially true of men who find discussing their bowels embarrassing. Sometimes so much so that they don’t mention the diarrhoea or rectal bleeding to anyone, least of all their doctor. The consequences are that in some cases they delay seeking help for potentially life limiting disease until it is too late for curative treatment.

We also know that colorectal cancer is diagnosed in most cases only after the patient has developed symptoms and sought medical advice. Only a minority of cases are diagnosed from among those with no symptoms who have been screened for the disease. Whatever the case the sooner a diagnosis is made the better the chances of successful treatment. Because the symptoms can be so embarrassing and to some extent because some men procrastinate with seeking advice colorectal cancer has a worse prognosis in men.

It’s in situations like these that innovations which are low cost, personalised and offer creative solutions to healthcare problems come into their own. The focus could be to provide opportunities for as many people as possible to get convenient, reliable, personalised information in privacy without necessarily going to a doctor. What’s more such an innovation needs to make life easier for the practitioner and the patient.

Health Innovation Beyond Statistics And Meeting Patients Where They Are

Every day doctors advise patients to lose weight, stop smoking, take more exercise, drink less alcohol and take time off. And yet obesity, depression and alcohol abuse are set to feature among the top health care problems for some time to come.

Associated with these problems is the rising incidence of cancer, heart disease and diabetes. There are also a number of parallel trends that aren’t obviously linked to these issues. More people are online and using smartphones. More people are having cosmetic surgery. More people are spending money on gym membership and health clubs. Common sense suggests that there must be some way to help solve the health problems by tapping into the trends.

It is contested how well doctors know their patients. But they cannot ignore these other behaviours. Doctors complain about patients who answer their phones during consultations, or those who come with questions via ‘Dr Google’. So where does this leave health innovators? The old way was to preach the message of abstinence, exercise and fruit and veg. It isn’t working. Taxing cigarettes might be a good public health policy, but it doesn’t change how young women feel about the happy side effect of appetite suppression.

Communicating statistics hasn’t enabled us to solve these problems. Far more effective is the notion that smoking and obesity might impact adversely on your appearance. Smartphones enable us to get up close and personal. Not just in order to communicate and connect with patients and their quantified self, but to add meaning, personal relevance and context. As a ‘lean medicine’ innovator you can do all this with a minimum of technical skill, but not without imagination, observation and interpretation.

No big investment required, other than the determination to make a difference for people working to solve the problem from their perspective.

See demand in context and respond creatively

9645066390_babd98c3f1_zHello Jill, Oh, I’m sorry I have no appointments to offer you today. the doctors are all fully booked. If your son has a fever try him with some paracetamol and call back on Friday when I might be able to squeeze him in with Dr. Jones. Ok, bye.

Many years ago I overheard this conversation in my reception. Our receptionist giving medical advice without any qualifications. The surgery was over booked. She was harassed, doctors were grumpy and the patients were being turned away without being assessed by anyone.

We noticed that there was a seasonal pattern to this demand for appointments. Most doctors were aware of this trend because there were specific weeks of the year when they avoided taking holidays. Our reception staff kept meticulous colour coded records of such ‘same day’ appointments. When we entered this data on a statistical database there could be no doubt of a seasonal pattern with definite peaks and troughs. What’s more, we could predict the demand for ‘same day urgent appointments’ with reasonable confidence. At this point, it may be important to stress that doctors in the UK are paid a ‘capitation fee’ for serving patients. That means they are paid an annual fee no matter how many times they see the patient.

Understanding that people have a fundamental desire to talk to the decision maker, we settled on the notion of putting the doctor in charge of making the appointment. Patients who requested a ‘same day’ appointment were offered a telephone consultation with a general practitioner initially. Not with a nurse, as happened in some practices, but with their doctor. We believed patients wanted to speak with a medical practitioner, not because the advice they received was necessarily better than that given by another member of the team, but because people in distress want a doctor. Whatever the reason it worked. Important policy makers noticed. Doctors could deal with most requests within a couple of minutes, offer a ‘same day’ slot or something else without the need for a face-to-face appointment. We calculated a 40% reduction in demand for such appointments. Patients loved it, reception staff loved it too (no more arguments about lack of appointments with irate patients) and doctors found themselves in control of their workload. What’s more, we could prove that this simple intervention worked from the impact on longitudinal seasonal trend.

By allowing patients to speak to their doctor when they felt they couldn’t wait our practice chose to treat this small minority of patients differently to those who were happy to make a routine appointment. We acknowledged that these patients had a need that warranted a creative solution. Perhaps you have a group of patients who would benefit from being treated differently too? What is the context in which they seek help? The tired mother with a fevered child does not have the same needs as the young professional who requires a convenient appointment to obtain a prescription for the contraceptive pill. Both might seek an urgent appointment.

Picture by Marjan Lazerveski

The context is often private and confidential

7257592240_6759efd5a5_zThe consultation between a doctor and patient is private. Innovators hoping to improve outcomes in that context can’t observe the exchange directly because some presentations are very uncommon and because neither the doctor nor the patient welcomes the intrusion. There are many outcomes of the encounter between patient and doctor that we still don’t fully understand. Why are some patients’ cancer symptoms not recognised as early warnings? Why do carers of patients with a life-limiting illness fail to have their own medical problems addressed? Why do people living with some chronic conditions continue to have problems with intimacy?

People deploy verbal and non-verbal cues to communicate. They choose when and how to disclose their ideas, concerns and expectations. However in an average consultation in my country, the patient has fifteen minutes to ‘spit it out’. Similarly, clinicians vary in their ability to pick up cues or to probe with the right question, assuming they get the right answer. Hence errors of omission and or commission.

Lean medicine is about being intuitive, creative and agile. Lean innovators, clinicians, are already on site. Therefore, they can reproduce the context in a way that can be observed and where they can be tested with other clinicians. Video technology and a fusion of skills across disciplines allow the depiction of those encounters in such a way as to present the critical decision point for close examination. Do you prescribe, refer or investigate in these circumstances? What do you say to the patient?

How do you explore hard to reach elements in your practice or business? How can you hope to innovate for encounters that are strictly private and confidential but where mistakes or misunderstanding can be very bad for business. Who has the insight to show you? How can you generate valid hypotheses? How do you test ideas without a real risk of casualties?

Picture by Urbanbohemian