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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

Are you curious?

In your dealings with people who seek your help- Do you ask a lot of questions? Do you make many assumptions? How is that working out for you? How do you know you already have all the information when you start to offer the advice? What do you know about the context in which they are seeking your counsel?

Picture by Scott Billings

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 credible as a lifestyle coach?

The commonest conditions doctors encounter are illnesses directly related to poor life style choices. Diseases that arise because we eat too much and don’t take enough exercise.

People who seek healthcare advice will be told more often than not that they must make different choices. How credible is your advice as a doctor? How persuasive are you as the messenger? How could you do this better?

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Are you sure you will focus on the right problem?

In any business where you are paid to solve problems you need to be clear that you are indeed solving the right problem. Doctors can frame the problem in many ways- if their patient has been brought in after a car accident then ‘the problem’ is  clearly the broken leg or the bleeding wound. What’s much less obvious is the problem that needs to be solved in all other circumstances.

In the moment you are sitting in front of the doctor the problem isn’t the runny nose, the headache, the sore throat or the anxiety. Being told it’s just a virus won’t help. You need that  doctor to give you their undivided attention and to see the context in which you are experiencing that discomfort. To acknowledge your distress. There is ‘no cure’ for a viral upper respiratory tract infection and you knew that before you walked into that office. Right?

Pcture by Luis Sarabia

Essentialism wins

Dear Friends,

I have decided to take a break from my blog for a little while and focus on writing my book.

Sometimes it is a case of realising that you must invest in the big things in your life.

Thank you to my partner and mentor Bernadette. In case you are wondering-yes, she is even better than you know.

Thank you to Greg McKeown for persuading me to focus.

See you again very soon.

Moyez.

Picture by Bethan

If your fix only works if people choose option A abandon it

There is an obsession with getting clinicians to ‘follow guidelines’. There are those in the world who appear to believe with an evangelical zeal that ‘if only’ people over there would do as we tell them everything would be fine. They rely on the questionable assumption that human behaviour is always rational.

If only doctors would refer those people or prescribe that drug in this instance. If only doctors ordered this or that test in these circumstances. If only this or that which relies upon someone making choices that solve somebody else’s problem.  And so as conference season approaches academics will share stories about experiments that all too predictably didn’t end well. Or pretend that they have finally solved a problem that no one in history could sort out. Except that neither have they.

Because access to specialists is limited by cost there is a belief that family doctors can ration care by referring urgently only those cases that ‘merit’ referral based on criteria determined by ‘experts’. Cancer is a case in point. Except that ‘cancer’ is not a single condition, its biology varies as do the complex responses of its victims. General Practitioners (GPs) know this. A patient can present with hardly any symptoms and die of metastatic cancer within 3 months or present with a plethora of complaints and be diagnosed with a very early and treatable malignancy.

The ‘solution’ to selecting people considered to be at high risk for referral to a specialist appeared to be an interactive referral tool that automatically deploys algorithms based on guidelines. This ‘solution’ relies on GPs recognising anyone who presents with ‘red flag’ symptoms, deploying the software and patients being prioritised once an urgent referral is received at the hospital. The solution is based on the assumption that if one person in the chain does X then the people in the other part of the system would do Y and the outcome would be Z. Maybe you can already see it wasn’t going to end well.

  1. GPs did not always recognise the symptom complexes that were touted as the hallmarks of risk.BMJ open
  2. GPs were reticent to deploy the software other than in the conditions of a simulation. BMC Family Practice
  3. Specialists did not prioritise those cases that guidelines identified as urgent. BJGP

There is also limited evidence that people referred with reference to such criteria are always going to have better outcomes.

Here’s the thing:

  1. Diseases like cancer have a different impact on everyone
  2. People with cancer don’t present the same way
  3. Doctors may not agree with the experts
  4. Doctors may choose not to deploy an innovation for reasons various
  5. The ‘system’ consists of many moving parts. Supposing there were seven such parts. If the ‘right thing’ was to occur 80% of the time at each step then only 21% of people would benefit from the ‘plan’. Glasziou and Haynes

In the innovation business solutions cannot rely on the ‘if only’ option. Effective innovations trigger people to do what they already want to do. The best innovators work on solutions that are easily and enthusiastically adopted by their target audience.

Picture by Jurgen Appelo

Deploy rituals and be present in practice

Your next patient or client will want you to:

  • Smile (23.2%);
  • Be friendly, personable, polite, respectful (19.2%);
  • Be attentive and calm, make the patient feel like a priority (16.4%);
  • and make eye contact (13.0%).

(An Evidence-Based Perspective on Greetings in Medical Encounters- Arch Intern Med)

Showing up this way for every patient has to be a habit. Essentially you need to be “present or “mindful”. The issue of mindful practice has also been the focus of academic interest:

In 2008, the authors conducted in-depth, semistructured interviews with primary care physicians .. mindfulness skills improved the participants’ ability to be attentive and listen deeply to patients’ concerns, respond to patients more effectively, and develop adaptive reserve. Academic Medicine.

To make a habit of showing up in this way it may be worth considering deploying a ritual.

Hurdler Michelle Jenneke has her famous warm-up dance, long-jumper Fabrice Lapierre competes with a gold chain in his mouth, Usain Bolt points to the sky before breaking yet another world record, while Michael Phelps blasts Eminem to fire him up before hitting the pool. My body+soul

Consider the distinction between a habit and a ritual:

Habit

An acquired behavior pattern regularly followed until it has become almost involuntary: the habit of looking both ways before crossing the street.

Ritual

An act or series of acts regularly repeated in a set precise manner.

Rituals support habit and focus. Rituals support you to repeat habits and create new behaviour patterns over time. Daily rituals can support you to make new habits stick. You can move from doing something that might take a lot of effort, to it becoming almost automatic or done unconsciously. Mary- Ann Webb

Establishing a ritual can be the prelude to a habit.

The term ritual refers to a type of expressive, symbolic activity constructed of multiple behaviors that occur in a fixed, episodic sequence, and that tend to be repeated over time. Ritual behavior is dramatically scripted and acted out and is performed with formality, seriousness, and inner intensity. Rook, Dennis W. (1985), “The Ritual Dimension of Consumer Behavior,” Journal of Consumer Research, 12 (December), 251-264.

The pathway goes from behaviour, to ritual and then to habit. Charles Duhigg  spoke of the ‘habit loop’.This loop has three components:

  • The Cue: This is the trigger that tells your brain to go into automatic mode and which habit to use.
  • The Routine: This is the behaviour itself. This can be an emotional, mental or physical behaviour.
  • The Reward: This is the reason you’re motivated to do the behaviour and a way your brain can encode the behaviour in your neurology, if it’s a repeated behaviour.

All habitual cues fit into one of five categories: location, time, emotional state, other people, and immediately preceding action. An immediately preceding action is the most stable cue because it’s triggered by an existing habit. So to build a new habit match it with an old habitual cue.

B.J. Fogg, asks:

“What does this behaviour most naturally follow?”

To implement this technique, decide on an existing habit and complete the following sentence:

“After I [EXISTING HABIT] I will immediately [NEW HABIT]”.

Therefore to make a habit of being present for the next patient the “cue” is when you terminate the previous consultation.

The “routine” or ritual: At the end of one consult you might close the notes, tidy your desk and wash your hands. Metaphorically you also wash the previous consult out of your mind. This has physical and psychological components.

Then when you are happy that the previous consult no longer lingers in your thoughts proceed to the next consult, stand in a specific spot, call the patient, introduce yourself and smile. Shake the patient’s hand. Walk with them to the consulting room. Don’t start the consult until you make eye contact. How the patient responds to such a greeting is the “reward“.

Picture by Rob Bertholf

Can the patient relay what was done for them?

A perennial source of dissatisfaction in healthcare (as documented here and here) is the poor flow of information from one sector to another. ‘Joe’ (speaking here– video from BMJ open) couldn’t tell me, his doctor, anything helpful about what had been done while he had been in hospital. That means we have to schedule several appointments to try to unpack it all. He was an in-patient for two weeks and someone had decided one Thursday morning that it was time for him to go home. It wasn’t really clear to Joe or to me why that particular morning or what was to happen when he got home other than that he should contact his ‘local GP’. A letter would follow some time in the future. There may have been good or bad reasons for sending him home. We could only guess what was in the mind of the person who made the decision:

We needed the bed. Joe was fine. His observations were normal, he was ambulant his wife was happy to take him home.

But of course Joe comes home with lots of questions, which I now struggle to answer without making phone calls to track down the busy medical team. The problem is articulated by several ‘stakeholders’ members of the ‘multidisciplinary team’ on the ward none of whom feel they own the problem of telling this man what he needs to know. There is only one constant in this story- Joe. If Joe can collect the information we need during the course of his hospital stay we might begin to improve the outcome:

In addition to increasing the burden on GPs, it engenders a need for a subsequent GP appointment; it limits GP capacity to respond to patient concerns and queries, at least on one occasion; it may result in a re-referral to the specialist; and it increases GP dissatisfaction with the care provided to the patient by the hospital. BMJ

The problem is Joe often does not know what he needs to know by the end of his hospital stay. It isn’t impossible to work out how to trigger questions for Joe to ask throughout his hospitalisation. What is far more difficult is to motivate every hospital ward and every discipline in a team to address this challenge consistently. It is ‘easier’ to nudge one individual than enlist the cooperation of the dozens of health professionals who will come into contact with Joe. Making people active in healthcare processes has achieved results before:

Influence at Work, a training and consultancy company that Cialdini founded, worked with the United Kingdom’s National Health Service (NHS) in a set of studies aimed at reducing the number of patients who fail to show up for medical appointments. They did this by simply making patients more involved in the appointment-making process, such as asking the patient to write down the details of the appointment themselves rather than simply receiving an appointment card. Sleek

Picture by Michael Coghlan

Profiting from vanity- they may be targeting someone you love.

Where I live you’d be forgiven for thinking that you will be reported for child abuse if your teenager has less than perfectly straight teeth. Kids are growing up believing they need to be physically perfect.  So when the first crop of zits appears there is a hasty and often expensive trip to the chemist. Treating acne is a $3 billion industry in the United States alone.

..but i just feel so ugly when i see pretty girls with perfect skin around me.. it just makes me feel terribly disgusting, honestly. like i’m less of a person. it’s not fair. at my age there’s so much pressure to look beautiful constantly. even though i know most people don’t care how good you look a lot of them are secretly judging inside… everyone does it, even me..Nyla

Those in the age group 15-24 account for 7.6%  of consultations in general practice. Significant or life limiting pathology is unlikely in this age group but for many these meetings with their doctor will set the tone for a life long relationship with their main healthcare provider. For young people acne and eczema are the reason for almost one in three consultations with a GP. Sadly it has been reported that some teenagers get a very poor deal when they pluck up the courage to see a doctor:

It’s not that he doesn’t listen … sometimes he doesn’t fully comprehend that he’s talking in a way you can’t understand … it would help if they talked to teenagers. ( As reported by Jacobson et al in the BJGP)

This could be a missed opportunity to forge a relationship with the patient. If you are a doctor it may be worthwhile rehearsing a lucid explanation of common problems presented to you, including and especially acne. There is a bewildering array of opinions on this problem. Indeed the conclusion of research on this topic was that the majority of young people are getting information from non physician sources and there may be a need to evaluate the resources they are using to make sure they are receiving appropriate, helpful information. That includes parents who would rather their teenager would learn to live with her spots and expect you to endorse that view.

For those who want a ‘cure’ the opportunity for to profit from their distress makes them vulnerable to the most unscrupulous practices. $3 billion USD represents a substantial market for lotions, potions and diets that don’t work.

Substantial numbers of those surveyed had ideas about cause, treatment, and prognosis that might adversely affect therapy. Rasmussen and Smith

The truth is acne is a manageable condition, it’s just a matter of finding a treatment that works for an individual. For most people, it may take few attempts at find something that works. For some, over-the-counter topical creams are fine, for others, oral antibiotics or hormonal treatments work better, and yet others only respond to drugs prescribed by a dermatologist, with multiple courses required in relatively rare circumstances. The goal of having clear (or at least totally acceptable) skin is not unreasonable. This is a teachable moment in the interaction with young people.

Picture by Caitlin Regan