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

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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

Are medical students already healers?

I recall the awkward silence when I couldn’t decipher the carotid angiogram thrust at me on Monday morning. As a newly qualified doctor who’d spent the weekend on-call, I would not have been able to describe my route home much less recognise the stenosis in the relevant cerebral artery. Never mind ‘doctor’ spat my boss. Tell us is the patient I’m about to operate on a nice man? He said winking at the gathered retinue.

Actually professor he is. Trouble is he asked me the same question about you and as you can see I’m not a very good liar.

That cheeky reply probably spelled the end of my surgical career. This style of ‘education’ was known as pimping and that day I had just refused to accept it. Among the legions of would-be doctors, there are a few who will go on to be brilliant in the course of their careers. There are those who will one day discover the cure for Alzheimer’s or cancer. There are those who will perform surgery to save life against impossible odds. There are those whose pills or devices will earn fortunes. But brilliant are also those who will reassure and revive. They will be the unsung heroes whose name won’t appear on any honour’s list. They will offer that undefinable quality that helps us to prime our regenerative capacity and immune systems, more often than not in spite of the limitations of technical fix-its. Those who will be the healers of tomorrow already have the qualities within them even before their first anatomy or physiology lecture. They are intelligent and resourceful but also have an innate sense of what to do when faced with a human being in distress. Our job is to hone those qualities and help them to recognise the precious gift that lies dormant until it is needed on the wards, in the clinics and at the bedside. It is truly a privilege to be part of their journey to nurture their talent despite the many disappointments and frustrations that are part of the landscape of any medical career.

We conclude that compassion is everyone’s business and that learners require early and sustained patient and client contact with time for reflection to enable the delivery of compassionate care. Davin and Thistlethwaite

What the world needs is healers, not technicians because doctors care for people and not machines. So in answer to my boss’s question the man he was about to operate on was an incredibly nice person. He would hail us over in the middle of our shift and insist that we took the fruit that his family had brought knowing that we were unlikely to have made it to the canteen before closing time. My boss really was an excellent technician. What helped the patient through this episode wasn’t just this technical skill, it was the compassion and concern that was lavished on him by the dedicated team of nurses and doctors who would ensure that he was pain free, that his questions were answered, his wounds were dressed and that his family were informed of his progress through intensive care and on the wards as was his wish. I’m sure he remembers his surgeon fondly as the brusque, brilliant and efficient man who helped keep him from a stroke but I’m sure he also remembers the junior doctors who would come to him in the middle of the night when his temperature spiked and the staff nurse was worried that his wound was infected. Without this care what was a difficult time for the family would have been a nightmare and the outcome may not have been as good. There were many times during that illness that we came close to losing that patient except that he had the resilience to hold firm to life and we were in his corner.

Picture by Spirit-Fire

There is no curriculum for kindness

For months, my wife had been worried about the mole. I couldn’t see anything wrong with it but then it was on my back and I was peering at it through a mirror. In the end, she put the job of getting it examined by a doctor into my diary and it became ‘urgent and important’.

I decided I’d ask my colleague in the office next door if he could recommend a dermatologist.

Do you want me to take a look?

I hated to impose, it seemed hardly worth wasting a surgeon’s time looking at something I was convinced was benign.

Without a second thought, he bounced out of his chair and headed to his car appearing a moment later with a head-mounted magnifier.

It looks benign. However I have three rules with these things. We remove it if your wife is worried about it, if you are worried about it or if I’m worried about it. It’s a five-minute job. We can’t be sure until it’s sent to the lab. But you know that.

He smiled kindly. It was a small courtesy to a colleague,  but a telling example of how a man you had been a surgeon all his life could still be spontaneously kind. His rule made excellent sense. This behaviour is not in any medical textbook. It’s not recognised as an ‘innovation’ that can improve outcomes. It’s just plain old-fashioned, good-natured thoughtfulness. It doesn’t require a grant or a special piece of equipment or anyone’s approval. It makes all the difference to all of us every day. It’s the sort of thing that speaks of vocation. I’m grateful that my colleague works with me, he is a wonderful communicator and that matters when you are training future doctors.

Picture by British Red Cross

In healthcare better right than fast

365651675_f53581b7f6_zIt may be tempting to dream about being presented with a list of options, preferably as colour pictures. Standing in a very short queue or better still ordering by text and minutes later collecting the order (or have it delivered) complete with a discount coupon for the next visit. You’ve heard the words:

Have a nice day

This MO has been highly successful for selling things that we have now come to realise are harmful. The young lady at the fast food counter doesn’t have to care:

  • If you’ve been there before.
  • What you expect from the product (other than not to be poisoned any time in the next 24 hours).
  • If you can afford it (as long as you pay up today).
  • If you know and understand what you are about to eat.
  • Even if you enjoy the product as long as it complies with the description on the menu.

She is paid a wage and all she wants is to get through her shift and go home.

Joe (not his real name, nor any of the details below), whom I had never seen before, turned up one day and before he sat down starting fumbling through his wallet.

Won’t keep you long doctor. My own doctor is off sick, so I thought I’d pop in here.

He produced a business card from an alternative health practitioner. I noticed that he struggled to take the card out of his wallet.

I just need a letter of referral to this place

Apparently ‘this place’ won’t see patients without a ‘referral’ from a doctor. It could all have been over in less than five minutes. The letter might have said:

Thank you for seeing this man who has asked to be referred to your clinic.

It’s highly unlikely that anyone would have cared what it said as long as it was on a doctor’s letterhead. I could have collected my fee and moved to the next patient. But that’s not how I think it works. I coaxed Joe to sit down. He blinked in surprise. Was I really going to waste time when he just wanted a referral? Turns out he was a widower. He lived with his daughter. He moved to Australia 40 years ago. He was a motor mechanic until he retired and now in his late seventies he spent much of the day pottering in the garden.

That’s the problem doctor. I can’t do any weeding. My shoulders are killing me.

He described severe shoulder stiffness in the morning so much so that he occasionally asked his grandson to help him dress. The stiffness improved in the course of the day but his upper arms were still tender. He had lost weight recently but his own doctor didn’t seem too concerned. No headaches and his jaws didn’t hurt when he was eating. I couldn’t find anything wrong on examining him other than tender upper arm muscles. I had a hunch I knew what was wrong with Joe. I sent him for a blood test and arranged to see him the next day. If I was right I could fix this relatively quickly. Joe was nonplussed.

Thank you doctor. I really don’t know what’s wrong with me but my own doctor says it’s a trapped nerve and should get better. I’m in agony and the painkillers aren’t helping. But these guys at this clinic said they needed a letter before I could see them. So that’s what I was after. I will definitely come and see you again.

Joe was a frail old man, impeccably dressed with a politeness that is typical of his generation. He would have accepted anything and been grateful for it. Joe deserves the best and that doesn’t mean getting him in and out the door quickly with an insincere ‘have a nice day’. Why are colleagues encouraged to behave in this way? MacMedicine is not what the taxpayer ordered. Joe didn’t know what he needed other than pain relief. That’s not the same as being hungry and wanting a burger.

Picture by Brian Wallace

How you might stumble during a marathon medical career

299398986_994a9e9feb_zMedicine is an art. Sure there is science involved but in essence it is an art because science alone does not guarantee good outcomes in healthcare. If you fail to communicate with the patient, no amount of science is going to make a difference if the patient does not choose to act on your advice. That means the neither doctor nor patient can be removed from the outcomes equation. The needs and wants of the physician have as much of a bearing on the outcome as anything else in the mix. How we feel as health practitioners, how we are perceived, our biases and shortcomings are worthy of close attention and may be a great place to focus efforts to innovate in healthcare. Here are ten videos, reports or papers that identify the pitfalls.

Workloads can make it difficult for some doctors to perform optimally.

We may not be communicating effectively.

4 out of 5 doctors don’t get enough exercise.

Nearly 60 per cent of doctors may be overweight or obese.

Some doctors might lose empathy in the course of their training.

Burnout is a real risk in medicine.

While obesity may be increasing some doctors can harbour prejudice.

Dangerous drugs may be over prescribed .

The evidence doctors adopt in a specific case may be flawed.

Some doctors don’t explain risk well

Picture by Giulio Volo

Innovation doesn’t always have to mean new

In a world of new gadgets and gizmos we have lost sight of the fact that medicine is a social construct and that there have been some extraordinarily successful doctors who never ordered an X-ray or prescribed penicillin. That does not mean to say that X-rays or antibiotics don’t make us better healers but if we lose sight of the reasons why people have always needed doctors then we face a very uncertain future. In the world of business it is recognised that people buy ( i.e. make decisions or commitments) based on how they feel about something, not just, and sometimes in spite of , the information available. Heart always trumps mind. How else do you explain so many of our questionable decisions in life? By corollary we need to invest in the experience we offer as health care providers, perhaps more than the devices we chose to purchase that keep us at arms length from the patient.

What that means for innovators is that we occasionally have to rediscover the ‘innovations’ that are already in our offices. Possibly the most celebrated research I led was a study that demonstrated that people trust you more when you are seen wearing a stethoscope. It followed on from research that confirmed other things we have ‘always known’- what you wear matters, how you greet your patients/ clients matters and if you seem distracted in the consultation then it detracts from the patient’s experience.

At medical school one of our tutors offered this advice:

Always stand to greet the patient, never sit down before the patient and always find a reason to touch the patient even if it is only to take their pulse.

Simple advice that speaks to the art of healing- because in the end that is what gives medicine its mandate to be involved with people in distress. We were reminded that for some of our patients, perhaps those who need us the most, the unemployed, the marginalised, the unfortunate  the doctor may be the only person in any authority who will greet them with respect that day. Therefore innovation begins and ends with a review of the basics- What is it like for your patients or clients? How are they welcomed to the service? Is your telephone message welcoming? Are your reception staff professional? Do you offer privacy at all times? Do you seem interested or concerned? Would you trust someone who presented themselves the way you do?  Would you feel better after a visit to your clinic? Do your staff need a new machine more than a better way to make people feel they care?

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.

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.