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Minor illness a cash cow?

179335018_d96941d1af_oThis week the New York Times reported that Walmart intends to set up primary care clinics in their stores. According to the closing paragraph of the article:

“To make it profitable, you need to make it have more than just a clinical encounter,” said Dr. Glenn Hammack, the founding president and chief executive of NuPhysicia, which closed the six clinics it briefly ran in Walmart stores. “You also need to sell them prescriptions, a bag of chips, maybe a magazine while they’re waiting.”

The news was met with concern on this side of the world. Australians are all too aware that what starts in the US is a sign of things to come. There was talk of:

Dumbing down of general practice

Others thought that:

This change is coming. Patients want it. Government want it. Patients vote.

While the debate continues I was reminded of Joanne (not real name, nor actual details) who presented with her three little boys a few years ago. She looked exhausted and said she needed something to help her sleep. Before long I had to rescue one of the boys who had lodged himself under my desk. Meanwhile his brother, with Down’s syndrome, was climbing onto my desk to get at my key board and the youngest had crawled into the bin. Joanne was weary. I noted that she had been seen three times already in the last month and had been started on an antidepressant. There followed a long discussion about her migraine headaches. Her love of chocolate, her recent pregnancy, her need for better contraception given that she could no longer take the oral contraceptive. Then a discussion about life as a single mum. In time she become a bit more comfortable that I hadn’t yet reached for my prescription pad or interrupted her. She said something that didn’t fit the story of a single, stressed struggling mother- she told me:

And I get breathless on the slightest exertion and have lost quite a bit of weight.

Something wasn’t right. This did not fit the story. Anyone could see how she might be worn out by her situation, but this was something else. Her resting pulse was 120. She had lost several kilograms in the past few months and was not dieting. Despite the cold she was wearing a loosely fitting dress and sweating. A couple of urgent blood tests later we established the diagnosis. She saw an endocrinologist and when we met again she was feeling a bit better- except that she continued as the mother of three demanding young boys.

Joanne, and the many other Joannes, that attend general practitioners every day have no idea what’s wrong- only that there is something wrong. They want the time and space to tell their story to someone they trust. This isn’t going to happen at a supermarket fast-diagnosis clinic where the goal is to issue a prescription and making a sale. There is no such thing as a ‘quick consultation’ in the context of ‘minor illness’. Joanne would have left the surgery with a script for a hypnotic- she needs to sleep but what she needed more than that is to be seen and heard. The crunch often comes- as it did in this case when the patient is about to leave the room- the  ‘while I’m here doctor’ moment.  Perhaps someone with asthma might know they need an inhaler- but can we assume that someone with relatively minor symptoms would recognise that their tolerance to those symptoms was reduced by some other physical or psychological problem (pneumonia, exam stress, divorce, bullying) that warrants more than a quick trip to the pharmacy? It is assumed by some policy makers that doctors respond to disordered machines (mechanics), rather than to distress. It has long been established that:

 The overall prevalence of symptoms in the community is not closely related to general practice consultation rates, and the consulting population is a selected population of those who are in need of medical care. The literature review suggests that poor health status, social disadvantage, poor social support and inadequate coping strategies are associated with higher consultation rates. Some population sub groups may experience particular barriers to seeking care Campbell and Roland.

Does Australia have anything to fear from commercial organisations seeking to cash in on minor illness? Is it likely that it will reduce the demand for traditional GP appointments? I suspect not, if only because of Joanne. What we have learned about why people make appointments to see doctors is that they are far more discerning than we give them credit for. What for-profits will achieve is to rekindle the debate about whether people would be sufficiently enamored with a watered down version of a consultation with a general practitioner to walk away from the queue. Experiments in offering people alternatives to general practice in the UK were not successful. Renewed attempts to test the ‘market’ again will only delay a commitment to the only service that keeps the cost of health care under some sort of control- general practice.

Picture by Anne.

The case for shared care

People are uncomfortable, if not alarmed, when the behaviour of someone they live with suddenly becomes ‘deviant’, ‘offensive’ or embarrassing; Grandfather becomes disinhibited, son becomes violent, wife starts shoplifting, daughter steals money from home. The unfamiliar moves us out of our comfort zone and we start to question the future, often catastrophising. Many chronic medical conditions result in behavioural changes. People hope that there is something that can be done to remedy the situation quickly so one of the first steps is to seek medical advice. It may be that the person has one of a host of acute or chronic conditions including life limiting pathology; Depression,  psychosis, dementia, substance abuse or cancer. The reaction to the behaviour may also result from misinterpretation or the complainant may be the one with the problem or feel stigmatised by the experience. Once an explanation is found it is often the case that medicine could make things worse- prescriptions, hospitalisation and tests may be harmful. There is also a risk of medicalising the problem as noted by Dworkin.

In the past, medical science cared for the mentally ill, while everyday unhappiness was left to the religious spiritual or other cultural guides. Now, medical science is moving beyond its traditional border to help people who are bored, sad or experiencing low self esteem- in other words people who are suffering from nothing more than life.

Nonetheless people seek help from doctors and there is great scope to assist by sharing care with others who may be able to help with a problem for which there is no pill and people have to revise their ideas, concerns and expectations. It may be that doctors are reluctant to engage people in these circumstances because they do not perceive that they have the resources or expertise to assist with what they consider outside their sphere of influence. Nonetheless people will continue to expect assistance. Epidemiology records that the rates of chronic and complex conditions are set to rise almost exponentially as the population ages and suffers the pathological consequences of poor life style choices. At the same time the cost of healthcare is increasing to the extent that services may be rationed. Already in Australia, even with a relatively healthy economy, the government is proposing cuts to healthcare expenditure. Meanwhile the number of people living with a family member who has a condition where behavioural changes are possible, if not likely, will increase. For instance the prevalence of dementia in Australia will increase from 332,00 to just under a million by 2050. The proportion of people with behavioural changes in the context of  this diagnosis is the majority of patients with an average duration of about 8 months during the illness. Such behaviours may have a profound impact on the emotional well being of the caregiver. It is  acknowledged that some caregivers do not easily adapt to the stresses of caregiving and are at risk in terms of their ability to continue in their role. A failure to maintain this unpaid caring role would have a significant impact on the cost of caring for the patient who may have to be institutionalised sooner rather than later. The conclusion of a study from Sweden was that:

Informal care, measured as hours spent caring, was about 8.5 times greater than formal services (299 and 35 h per month, respectively). Approximately 50% of the total informal care consisted of time spent on surveillance (day and night).

Therefore innovations that allow the medical practitioner to quickly incorporate assistance from organisations that specialise in supporting caregivers will enhance the prospects of sustaining an effective health service for all. The services of organsiations such as Alzheimers’ Australia may be underutilised because of a failure to respond to calls of help from stressed carers. Similar observations can be made about other chronic illnesses including substance abuse, cancer and palliative care where changes in behaviour may be common and medication has a limited role.

 

Innovating for exemplar conditions

Colorectal Cancer (CRC) impacts on every part of the healthcare system. If a solution can be found to the challenges associated with CRC then they can probably be found for dealing with many other chronic and complex conditions.

  • CRC is one of the commonest malignancies in the developed world and often presents too late for curative treatment.
  • It may be related to a poor diet and is associated with obesity. The incidence is rising.
  • The vast majority of CRCs present with embarrassing symptoms.
  • Such symptoms are common and are also features of benign disease. People find it difficult to decide when they should see a doctor.
  • They often choose to consult other than a medical practitioner and there is evidence for procrastination and for inconsistent advice from the other healthcare providers.
  • [We need tools to assist those healthcare providers to signpost people to a doctor. Such tools need to fit seamlessly into their way of working]
  • The investigation of lower bowel symptoms are invasive and involve unpleasant intimate examinations.
  • Men are more likely to delay consulting a doctor than women.
  • [We need to understand why that is and what we might be able to do about it.]
  • Eventually anyone who develops CRC has to visit a doctor occasionally as an emergency. Symptoms may not correlate to the severity of the disease.
  • Those at highest risk of cancer are older people with lots of other problems.
  • They are all referred to a surgeon. Sometimes the diagnosis is delayed longer than it need be.
  • The treatment of CRC may include surgery, chemotherapy and or radiotherapy. Most people survive.
  • In a typical group of people treated for CRC a large proportion will develop long term side effects.
  • After treatment most patients will attend a specialist clinic briefly once a year, they will have unmet needs.
  • All patients will visit their GP/Family physician/Primary Care Practitioner more often than that mainly about their other problems.
  • We know the sorts of problems they present to their GP.
  • We also know that there are many problems or concerns that the patient does not voice to their GP and that treatment for CRC diminishes quality of life.
  • Primary Care Practitioners have the skills and resources to help people in these circumstances although they might need some additional guidance.
  • [We need a tool to help patients focus on these side effects and help them present this information to their GP.]
  • We need a tool that does not require fundamental reform of the healthcare system.

[A team of PhD students is working to fill in the blanks- their expertise will give us the capacity to focus on other such conditions]
In developing this program for innovation they worked with people who have been closely affected by this condition. They worked quickly, economically, creatively and in partnership with the healthcare practitioners involved in responding to the needs of patients and their families. Their work is beginning to be published.

Innovating for multimorbidity

Most people who consult doctors in primary care have more than one problem. The proportion of people with so called multimorbidity is set to rise exponentially as the proportion of older people in many countries rises. The problem is that the length of consultations is limited and therefore the patient and practitioner are already at a disadvantage before they begin. Do you focus on the rash which the patient is anxious about today and which may be the beginnings of eczema, or the hypertension which isn’t at target despite therapy, how about the cigarette smoking and the aching hip and to what extent does the chemotherapy treatment in the past have a bearing on the fatigue that the patient has complained about in the previous consultation. In theory consultations can be extended for patient with greater need, assuming that the need is expressed. According to one team:

Approximately 9% of the patients had 1 or more unvoiced desire(s). Desires for referrals (16.5% of desiring patients) and physical therapy (8.2%) were least likely to be communicated. Patients with unexpressed desires tended to be young, undereducated, and unmarried and were less likely to trust their physician.

Bell et al JAMA 2001

The bottom line is that there is significant unmet need. In theory, in many countries the general practitioner has a longitudinal relationship with the patient and will eventually get around to some of these other issues.  Even in those countries that espouse the concept of  primary care as the first point of contact for people with the healthcare system, the reality is that people tend to consult more than one GP, either by choice or because they have no option and therefore continuity of care is theoretically possible but never actually achieved. The consequences include poor outcomes. It’s even worse in the specialist sector where regular turn over of junior staff means that people seldom see the same doctor from visit to visit.

Here is an opportunity for lean innovators to proactively screen people with a specific problem- for example all patients who have been treated for cancer attending a practice or by offering people an opportunity to have their needs met in another way– either by empowering self care or by enlisting the support of a nurse or allied health care provider. People in distress who are in contact with healthcare organisations cannot be left to fend for themselves or allowed to live under the impression that a diminished quality of life is the best that is now on offer.

Integrating primary care providers

People can, and do, consult other than doctors when they are unwell or perceive that there is something the matter with them. The list is large but includes:

  • Pharmacists
  • Nurses
  • Podiotrists
  • Dentists
  • Physiotherapists
  • Opticians

These care providers offer  a specific skill set but this does not include the ability to deal with undifferentiated conditions or to make a definitive diagnosis of a condition outside their scope of practice. However research suggests that such primary care professionals are often among the first to treat someone with depression, cancer, atheromatous vascular disease, hypertension and or dementia. Early diagnosis and treatment of any of these conditions would result in a much better outcome for patients. That does not mean that these health care professionals could or should be a substitute for medical practitioners. For one thing their business model does not allow them to spend time on dealing with the complexities that are inherent in establishing a diagnosis of such conditions, or to deal with the many others that need to be ruled out in the differential diagnosis. Nor are they equipped to coordinate the care of people with such conditions.

Cheap intuitive and creative solutions include ways to signpost people who present with such problems to the care professional best placed to coordinate their care. Research suggests that when someone is offered a note to present to a medical practitioner suggesting investigations for significant pathology, people will follow up with an appointment and benefit. The components of such an innovation include a way to screen people for risk of significant pathology- the person with persistent diarrhoea seeking advice from a pharmacist, the person with unrelenting back pain who might be clinically depressed, the person with undiagnosed diabetes presenting with visual problems. All these people need to consult a medical practitioner. However they are not always recognised and here lies the scope for relatively cheap innovation to integrate care providers without interfering in the way care providers function within their own domain of expertise.

Managing demand for primary care

Why do people consult doctors? At first glance because they feel unwell. However research suggests that the reasons are far more complex than that. Innovators also know that the answer to this question is vital for those seeking an agile, intuitive, creative and cheap solution to the demand for their services. Theories predict the consultation habits of many patients. I especially like this summary:

The overall prevalence of symptoms in the community is not closely related to general practice consultation rates, and the consulting population is a selected population of those who are in need of medical care. The literature reviewed suggests that poor health status, social disadvantage poor social support and inadequate coping strategies are associated with higher consultation rates. Some populations subgroups may experience particular barriers to seeking care. Campbell and Roland

Innovators might also ask why are those patients sitting in my waiting room? I remember a hoary old tale of a doctor who was feeling especially grumpy one day and stormed through the waiting room announcing that anyone who thought they had a ‘real’ problem should stay everyone else should go home- half the waiting room emptied.

It seems quite a few people who go to doctors will have symptoms- however a proportion will be back there by invitation. How big a proportion and why have they been invited back? There are many reasons to schedule a repeat appointment. It conveys the notion that the patient will be harmed if they don’t see a doctor on a given day for one or more of these reasons:

1. Their response to treatment is unpredictable and the dose or drug may need to be revised

2. They have a condition that can’t be diagnosed or may progress or need additional measures by a specified date

However other reasons for requesting a review include:

1. The doctor isn’t confident that the diagnosis is correct and wants a chance to review the advice issued.

2. The patient is required by someone (e.g. an employer) to produce evidence of a visit to a doctor

3. A full waiting room ensures the doctor looks busy for whatever other reason.

4. The doctor needs to reinforce the impression that the condition has been taken seriously.

The time cost for doing everything that could possibly be recommended for patients with chronic conditions  has been shown to be untenable. Either the guidelines are wrong or a different solution needs to be found for at least some of these people. What is the evidence for asking a patient to return within a week or two with a specific new condition and within a month with a longstanding condition?

There is a need to be proactive in some cases. However is it possible that we encourage people to attend for review appointments when there is a low probability that they will benefit? Are there other reasons to fill the waiting room?

Putting the patient first is not just good medicine, it’s good business

Primary healthcare is mostly organised as if all patients had the same needs. Patients who have a chronic illness who are repeat visitors and those with significant risk factors for future disease, are expected to fit into a system that is designed to meet the needs of someone with urgent and temporary illness. The current system is designed as if it doesn’t really matter which doctor consults them or what is known about their needs.

These are the facts:

1. Each week, there are 1,700 new cases of dementia in Australia; approx. one person every 6 minutes.

2. Cardiovascular disease affects one in six Australians

3. In 2011/12,4.6 million Australians(32%)aged 18years and over had high blood pressure (systolic or diastolic blood pressure is ≥140/90 mmHg or taking medication). Of these, more than two thirds (68%) had uncontrolled or unmanaged high blood pressure (not taking medication), representing 3.1 million adult Australians.

4. 1 in 2 Australian men and 1 in 3 Australian women will be diagnosed with cancer by the age of 85.

In some cases patients are expected to make appointments at a time and place that suits the practitioner. They might be seen for as little as 10 minutes and can feel that their questions and concerns have been addressed. The consequence is that both the doctor and the patient become frustrated.

The clinician complains about workload while the patient seeks alternative ways to meet their needs. There is published evidence that patients with chronic illnesses have significant unmet needs that impact on their quality of life.

The lean innovator knows that the future success of healthcare depends on serving the needs of those who are likely to need to consult a doctor many times in coming years. These patients need to live life despite pathology and to care for others even when they are not feeling their best. The person with enduring health problems also needs to believe that their doctor knows them, understands their perspective and has their best interests at heart.

In the business world such a loyal customer is prized. The business strives to make them feel valued. Great businesses constantly reinvent themselves and look for new ways to ensure that the customer is happy with the service on offer. It takes relatively little to satisfy the patient in a primary healthcare setting. We know, but sometimes forget, that what the patient craves most of all is their doctor’s undivided attention. Like a customer in any other business our patients want to feel that they matter.

We don’t need a department or a huge budget to innovate, because as both business owners and doctors we have the authority and insight to redesign how the patient feels from the moment they walk through the door and at every stage before and after their appointment.

If research has taught us anything it is that the fundamental need in healthcare is for their doctor to have good communication skills. Without that foundation nothing that technology can do for the patient will ever be good enough. Every touchpoint of the system needs to reflect the experience in the consulting room and should say to the patient—we know and care about you.

What is the most important thing you do for the people you serve? Do they get a sense of that from the moment they look for your help?

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?