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Address the patient’s greatest fears ASAP

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I think my son has meningitis.

I glanced at the boy who was now walking across the room to look more closely at a poster on antenatal care.

I don’t think so was my first thought, followed by thank you for telling me exactly what you are worried about. It’s not always that easy. Often the ‘hidden agenda’ remains just that- hidden. The longer it remains unchallenged the greater its hold. Then it’s much less easily to address head on. Sometimes you get a sense of it from the smell of fear as it comes into the room. Occasionally it’s hidden in a request for curious tests:

Could you check my vitamin levels?

My favorite is those who come for ‘check ups’ and are seemingly asymptomatic. I recommend the paper by Sabina Hunziker and colleagues. They studied 66 cases of people who explicitly requested a ‘check up’. All consults were video recorded and analysed for information about spontaneously mentioned symptoms and reasons for the clinic consultation (“open agendas”) and for clues to hidden patient agendas using the Roter interaction analysis system (RIAS).In RIAS, a cue denotes an element in patient-provider communications that is not explicitly expressed verbally. It includes vague indications of emotions such as anxiety or embarrassment that patients might find difficult to express openly and that prevent the patient from being completely forthcoming about his or her reasons for requesting a consultation. All 66 patients initially declared to be asymptomatic but this was ultimately the case in only 7 out of 66 patients.

Back to the boy with ‘meningitis’. He had a fever and aches and pains. However according to Dr. Google, who mum consulted just before rushing to the surgery, if the child had ‘cold hands’ one of the possibilities is that the child has meningitis.

I examined the child thoroughly and found that he had a mild pyrexia and signs of an upper respiratory tract infection. He was awake, alert and clearly interested in his surroundings. He was persuaded to smile and had no signs of septicemia. As this is a common fear in anxious parents I am prepared with standard advice that might be helpful and outline the way meningitis presents. Something I have encountered in practice.

There are many other fears that are presented in an urgent consult. In 99.99% of cases, they are unfounded. However the opportunity to allay the patient’s fears is also an opportunity to forge a bond that may be of enormous assistance when those fears prove to be well-founded. It may be worth considering how you will respond to patient fears of the many monsters that appear in the dead of night; cancer, heart attack, Kawasaki’s disease and meningitis in particular. Bearing in mind these monsters do occasionally present in the most atypical fashion.

Picture by Pimthida

 

We have to be part of the solution because we are part of the problem

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She blinked at me expectantly. Her companion sat in the corner of the room, arms folded staring at the floor. She glanced at him side ways and then said in a loud whisper

We are here about that business last week. You know.

I didn’t know. So I frantically searched through the notes. The man in question had been seen here several times recently for various dressings. Nothing to say how he had been injured or the nature of the wound. At that point she lost it.

I don’t like talking about it in front of him! Because of his you know……well I told the doctor everything a couple of weeks ago. We need a report for the police and a referral for counselling.

I was mystified. The cryptic notes mentioned an injury to the arm and the application of various dressings but nothing about a bashing. She would have to see ‘the other doctor’ for the report. He was on holiday and not expected back for 10 days. Neither of us was satisfied. The next patient didn’t help matters. She had been pushed to the ground at the railway station and injured her wrist. She had been to the Emergency Department a couple of days ago and had been sent to the practice for an X-ray report. I assumed that someone had seen the X-rays and that she hadn’t been discharged with a bony injury. But there was no note from the Emergency doctor, hand written or otherwise and I now had to spend the next 20 minutes listening to musak while the ward clerk searched for a copy of the report and faxed it to me. In any other industry this waste of time would be tweeted as an example of bad service.

Meanwhile we are spending millions of dollars in search of electronic records that will somehow transform continuity of care. The assumption is that given such a record a doctor will document the circumstances in which she has come to reviewing a patient repeatedly or that the emergency department will reliably record why a patient was fit to be discharged. All of this is possible now if only doctors will plan for when the patient turns up when they are on a day off or choose to go to another provider. Hours can be saved each day, millions of dollars can be redeployed to make a system that already serves us well even better.

Assuming the technical challenge of a personal electronic record can be overcome the question is whether such a record will deliver its promise given that not all who work in healthcare are committed to treating the patient as they would wish to be treated themselves. There is no doubt that the free flow of information will help improve healthcare provision however the most valuable data that helps us serve people (history and examination) have to be documented by a human rather than a machine. Innovation should start with a change in the mindset of those who work in an industry. Are you confident that no one you served today would have to have their problems reassessed if you didn’t show up for work tomorrow? If so then we will be on the way to better outcomes overnight.

It’s also hoped the new system will reduce the high rate of medical errors (18%) that occur from inadequate patient information, reduce unnecessary hospital admissions, and save doctors from collecting a full medical history each time they see a new patient. The conversation

Picture by Ben Hussman

 

What do you want from your doctor?

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Finding a good doctor is like finding a good lover: there are lots of anecdotes but no data Richard Smith

Our family has moved to an new city and we are looking for a family doctor. What would you look for if you knew a little about evidence based medicine? Would you want your doctor to have read the latest medical journals and could quote research evidence for every decision they make? New premises? New furniture? Free wifi? Short waiting times? A coffee machine? Text messaging? Internet booking? A PhD?

How do you choose a new dentist? A new hairdresser? Do you just walk in to the nearest premises and hope for the best? Do you ask your neighbours for a recommendation? Do you google the names you see in the phone book? The chances are you spend more time choosing a restaurant then you do choosing your doctor. And yet there is far more at stake other than a good meal or a hair cut.

For us in selecting a doctor nothing matters as much as the doctor’s interest in our family. Our new doctor may not have read this week’s medical journal but he or she will be curious about our family because they will want to understand the context of any symptoms . That isn’t simply limited to our medical history, allergies or genetic predisposition. It also means the fact that we have moved interstate, we have new jobs, renting for the first time in years and experiencing a number of other life events. They will take into account any support we might be receiving from friends or family and our satisfaction or otherwise with our decision to relocate.

If you feel the same way then you might agree that doctors, especially family physicians aka general practitioners, provide a relationship and not just a service. This is what we seek when we consult a doctor:

Their willingness to make eye contact, to listen actively, to pick up verbal and non-verbal cues, to be respectful  and unwavering in the opinion that our perspective on our bodies and its functioning is what matters the most. To our new doctor we will be free to make choices. They will see their role as adviser and advocate rather than enforcer of what’s best for us as determined by somebody else. The best doctors understand that they may not have all the information on which we make decisions but faithfully realise that we also want what they want i.e. what’s in our best interests.

I love this quote from Anatole Broyard:

What do I want in a doctor? I would say that I want one who is a close reader of illness and a good critic of medicine…I see no reason or need for my doctor to love me, nor would I expect him to suffer with me. I wouldn’t demand a lot of my doctor’s time, I just wish he would brood on my situation for perhaps five minutes, that he would give me his whole mind just once, be bonded with me for a brief space, survey my soul as well as my flesh, to get at my illness, for each man is ill in his own way.

We will choose our next doctor based on how we feel not what we think. Is that a good thing? It’s not logical, but it’s the only basis on which humans make the most important decisions in life.

Picture by frances1972

The case for innovation up close and personal

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In the same week that my colleague drew my attention to the new book ‘ The patient will see you now‘, I became part of John’s story. I quote from the book:

Doctors are still labeling patients as difficult. Patients are typically unable to see, let alone keep or contribute to their office visit notes about their condition and their body that they paid for, Frequently they have to consult multiple doctors for the same condition. It may take weeks to get an appointment. The time with the doctor is quite limited, typically less than ten minutes, and much of that is without eye contact because the doctor is pecking away at a keyboard.

John (75) was born and lives in Dublin. He has the generosity of spirit that made Ireland what it is. A working man all of his life he lives to walk to the shops on Saturday morning. Two years ago he had a bilateral knee replacement. In the past six months he has become severely disabled with back and hip pain. He now walks with crutches and spends most of the day in a chair. His aging wife has to help him put on his socks, a friend ferries them to the shops in his taxi once a week. He is in constant and relentless pain. He attends a pain clinic and visits his general practitioner on foot, a hour long walk on his crutches every week. His aging prostate requires him to be within a short dash of a toilet. He finds life a struggle each and every day. He needs a hip replacement.

He was offered a review appointment at a Dublin teaching hospital. The appointment last Thursday was for 2.30pm. Not wanting to keep the doctor waiting he turned up on time and patiently waited in a chair until 6pm when he was finally called in. The senior house officer who saw him was ‘multitasking’, fielding calls from the wards. The patient’s records were strewn on the floor at his feet.

After a cursory examination he advised John that he would have to be ‘worse’ before they could do anything. John politely thanked him for his concern but asked to see the consultant. The consultant offered to refer him to a pain clinic but added that it would take months to get an appointment. John pointed out that, as their records would show, he was already attending a pain clinic and the specialist there told him nothing more could be done and that he needed a new hip. The consultant was unfazed by this news and said he would ‘write to the pain clinic’. They watched him struggle out of the chair and leave the room.

Not one to make a fuss, ever, John took a taxi home. By the time he got home he needed to ‘go straight to bed.

John’s story is typical of the many Irish people who daily endure a third world healthcare system. Ireland’s tax payers, men and women like John forked out for the training of tens of  thousands of doctors who form the backbone of healthcare organisations the world over. But John gave me more. He is grandfather in our family. It pains us deeply to hear that healthcare in that country is now for those with private insurance or those who are prepared to voice their displeasure. Surely it can’t be beyond the pale to organise an outpatient clinic where people are treated with dignity even if, it seems, nothing can be done for them? How do specialists determine who merits the rationed healthcare resources now on offer? John was advised to be very polite to secretaries who have power and influence over their boss’s schedules . The need for reform is compelling. It may not be obvious in ‘official’ data because the whole unpalatable truth is only apparent to those who have not. It doesn’t require research to know that something is very wrong, it simply requires an interest in the experience of those who need healthcare the most.

Picture by Julie Keryesz

No budget required to make a difference

3386629036_0b929ebb7f_zI said good bye to my patients and colleagues this week. Next week I move to a new job in a new city. It is always surprising what people say to you when they think they might not see you again for a long while.

They don’t recall the grand gestures or the major projects. Instead they talk about the little things that made an impression. Things that made them smile sometimes at your expense. Things that made you human in their eyes.

But perhaps that’s a lesson I should have learned on the 26th Jan 1986. It was a bitterly cold Australia day in Dublin. I was invited to celebrate with my Australian flat mates. As I stood there mouthing the words to Waltzing Matilda on a stage in St. Stephens Green I caught the eye of this gorgeous creature who seemed to be thinking the same thing. These people are mad! And if this is what Australians are like- then that’s where we want to be.

As we left the Green and headed home I unwittingly did something that became the defining moment in our relationship- I offered the girl my gloves. The rest as they say is history and frankly I had no chance once she made up her mind I was the man for her. And now almost 30 years later we are proud to call Australia home.

As you consider how to make a difference – perhaps it’s the little things that you can do that will have the greatest impact. The things that people will recall when their association with you, your team, your organisation or your business ends. Practice random acts of kindness, you don’t need permission, a budget or a committee to do that.

Picture by Ed Yourdon

Staff needs should drive improvements

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I sometimes go to the bank on a Saturday. It’s the only day when I can afford to take the time to pack a picnic and wait in the long queue with everyone else who can’t make it there during the week. This week I sold some unwanted furniture and decided I didn’t want to leave the money in cash. So I made my way to the shopping centre and then to the back of the queue and waited with parents who were trying, feebly I thought, to keep their bored kids taking all the leaflets out of their holders. The attraction I’m sure wasn’t the apparently lowest ever interest rates.

Then, and I could have sworn she simply apparated Harry Potter style, a teller sidled up and asked what business I had at the bank. I explained my need to deposit money so she led me quietly outside to the ATM. As if talking to someone very old and deaf she explained that I did not need to queue to deposit money. It can all be done via an ATM. She talked me through the process, waited till I collected my receipt and then smiling kindly waived me off to my next destination. This got me wondering how many patients feel the same way about taking the time to visit a clinic. Waiting in line even when their need is not urgent and when it may be possible for them to get what they need without the inconvenience of attending in person.

The secret to dealing with the problem is to reframe it as staff’s problem. I hope the bank teller is rewarded for assisting me, for taking the time to make some Saturday excursions to the bank unnecessary, perhaps even getting a high-five from her manager. She certainly needs to make a habit of what she just did. I bet even bank tellers prefer to have their exploits celebrated by bloggers than deal with grumpy people who have waited an hour on a hot Saturday morning.

The issue of improving customer service can be reframed as something to be tackled in response to staff needs. Only then will it be a sufficient priority for front line staff to act in response to a trigger- such as ‘there are now more than five people queuing at the counter’. It’s time for someone to see if we can send some people on their way sooner rather than later.

That was quite different from my experience with Rain man’s favorite airline. My flight to Sydney was diverted to Melbourne three months ago. The ground staff gave me a note to send to their customer service people to refund me for the flight to Sydney early the next morning. Three months later and despite following instructions the money wasn’t credited to my account. Eventually I found the number for customer service and after waiting what seemed a very long time spoke to a human being. She assured me I was given the wrong information.

You must claim the money from your insurer.

Nope. No can do. Your staff told me to send you the invoice and I will call you every hour until you credit my account. What your staff are telling your customers in these circumstances is not my issue.

That’s all it took. I got the money refunded before the second call. No good will generated despite, eventually, doing the right thing. It was much easier to hide behind the anonymity at a call centre. Little motivation, despite the ability, so not triggered to act to when the customer calls. How often does this happen in medicine? How often are front line staff put in the position of fending off demands from the customers even when the customer is acting in accordance with information received? This does untold damage to the brand. Our time is at least as important as those who provide services. We scarcely put up with shoddy service in other aspects of life. Why should medicine be a special case?

Picture by A. Currell

The power of the pregnant pause

313238312_3c0b16565f_zJohn made an appointment recently. Never seen him before. He shook my hand enthusiastically as he strode into the room. A forced smile. Lots of eye contact. A need to look brave. I remember noticing his hand was a bit wet and his deodorant was working hard. He had flu like symptoms, runny nose, dry cough, sore throat. He had taken a few days off and needed a certificate for this employer. That didn’t explain his anxiety.  He seemed to have come to the right conclusion about his symptoms. I examined his throat, listened to his chest, took his temperature and agreed it was probably ‘a virus’ and that he should be fit for work before the end of the week. Then he hesitated. A pregnant pause. Seemed a bit unsure and blurted out those immortal words

There is just one other thing.

I was expecting it. I’ve seen this before. Adult males who exhibit signs of anxiety in a seemingly ‘routine’ consultation. If I’d looked closely I’d have noticed the dilated pupils and slightly rapid pulse. Sometimes ‘John’ comes with a request for a ‘full body check up’. Nonchalantly declaring that he’s getting older. Occasionally he brings his wife or partner, or perhaps they bring him. But when he comes alone the potential agenda is quite short- an embarrassing problem- impotence or sexual indiscretion and a need to be screened for ‘those other infections’, prostatism or something like what brought John in.

I have a very itchy sore bottom.

A life long problem it seems. Been using creams for years. Not helping. Bleeding a bit too. He knew what was coming. Hence the anxiety. The erythema and excoriations around his perineum verified the history. He left with a prescription for a steroid cream and a request to make a review appointment. It wasn’t as difficult as he had imagined. I clearly had heard all this before and he was pleased to be congratulated for being brave enough to ‘do the right thing’. The smile was now genuine. The prescription tucked away into his top pocket. It doesn’t take a lot to work out that there is more to the patient’s need for medical attention then meets the eye. The ‘Flu thing’ is what he tells people why he needs to see a doctor. In reality it’s a lot more serious- not the eczema that remains undiagnosed but the fear that the ‘itch’ is never going to go away and can’t be brought up in polite conversation despite ruining his life. It’s worth offering every man the pregnant pause. They might spit it out, if you’ve done your job right till that point.

Traditional masculine traits intersect with other physiological, sociological and cultural aspects of men’s lives when deciding to seek help. Andrology Australia

Often the patient wears the hidden agenda on their sleeve. No data or app necessary, just be interested enough to notice.

Picture by Drew Leavy

The importance of touch in the medical consultation. There is no app for that

When people are scared or in trouble what they want most is to be touched. Information alone is never enough to satisfy the deepest human needs that bubble up when our bodies appear to malfunction. This was recognised generations ago and the role of doctor was socially ordained. Doctors are licensed to examine the body intimately. Any doctor who abuses this trust is severely punished. The examination provides the healer with the information required to make a diagnosis, but more importantly it comforts the sufferer through human contact.

When I was a ‘wet behind the ears’ GP trainee, my clinical mentor offered me two pieces of advice in relation to the medical consultation. He told me to always stand up to greet the patient as they walk into the room and to look for an opportunity to lay hands on the patient, even if only to take their pulse.

Innovators may be tempted to think that everything that takes place in the consultation can be distilled down to the exchange of information and advice. However the consultation is designed to promote healing by allowing people to express concern and empathy through verbal and nonverbal behaviour. The former requires excellent communication skills, the latter is conducted as a series of rituals: ‘inspection, palpation, percussion and auscultation‘. And even as the body is examined the patient needs to feel that the examiner is concerned and respectful. If this is done well, healing can begin, sometimes against the odds.

This has important implications for innovation in health care. It’s not possible to interrupt or diminish the direct association between the doctor and the patient with gadgets or gizmos. If we do we may lose more than we gain.