Latest blog postsLearn More

How do you enjoy musac?

It’s Friday evening. Your customer, client or patient needs something. You’ve been trying to arrange it or get the necessary authorisation over the phone and now you’ve been put on hold listening to musac. You had advised this person in all good faith that what they need to make a decision will be here today. The minutes tick by and then the phone goes dead. The queue of people waiting is growing longer. A tired child is screaming somewhere nearby and you are already running late.

Over 54% of physicians report a loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment. The number is up 10% from just three years ago. Who is to blame? If you ask many physicians, the fault lies among leaders involved in healthcare finance, policy and clinical administration. Sachin Jain

You can choose your reaction to the trial by phone on Friday evening. This scenario is not uncommon and as a doctor it won’t be the first or last time you will experience it. Yet each time it happens it may evoke the same negative emotions until you choose otherwise.

Picture by Clurross

You can’t fix what you don’t know

Georgia has been waiting to see you for over an hour. She has been ignoring the pain in her side for days. Initially she hoped it would just go away. There is too much else to deal with. Josh her partner lost his job last week. Her mother had a stroke 3 weeks ago. Her dad is barely coping with caring for his disabled wife. The children are going to a new school this year and Emily (9) is having trouble settling into the new class. Meanwhile Georgia was hoping for a promotion at the office. With Josh out of work they need the money and it looks like she might now need to spend her weekends helping dad to manage at home. The pain in her side has got steadily worse and now it’s disturbing her at night. She mentioned it to her friend who forced her to make this appointment. Georgia doesn’t know her doctor well. She just wants this nightmare to end. She imagines this might be a urine infection but surely that wouldn’t last this long? She doesn’t want to think about the other possibilities. She especially doesn’t want to think about the lump she found in her right breast last month. She hasn’t told Josh she was coming to the clinic today and gave a vague impression that she needed to come to this end of town to collect something for work. She doesn’t want Josh to worry even though she thinks he might have noticed her holding her side while making the children’s lunch last night. Please let it be a urine infection so that a course of antibiotics will fix it. Georgia isn’t ready to handle any more bad news. A quick visit and a prescription is all she expects.

In 2 national, nonprobability online surveys of 4510 US adults, most participants reported withholding at least 1 of 7 types of medically relevant information, especially when they disagreed with the clinician’s recommendations or misunderstood the clinician’s instructions. The most commonly reported reasons for not disclosing information included not wanting to be judged or hear how harmful their behavior is. Levy et al

The outcome doctor is up to you but it all hinges on you being able to get the picture. Georgia isn’t sure she is going to tell you any of this even though she desperately needs someone to make it alright. Will you notice? Are you set up to receive the signals?

Picture by Drew Leavy

Do you take the shortest route to add value?

Every thriving business adds value. If it didn’t it would not exist. Healthcare shares many points of difference with any other service but none is more remarkable than the  ability to forge connections via the physical examination. It meets our fundamental need when we are ill.

Treatment that uses direct touch can have a depth and potency that can have a great therapeutic impact, which provides some explanation for why so many people are seeking out their own “professional touchers” or are filling the waiting rooms of physicians, waiting for the doctor to find the cause of the pain and make them better. In the process, they are touched. When the patient is assured that the work of the professional toucher is free from infringement, that sexual contact is clearly out of bounds, and that the patient can say “no” to any intervention the body-work practitioner proposes, then the patient can have the experience of trust and physical touch in the context of a controlled respectful relationship. Sharon K Farber

If you are a healthcare professional in what proportion of cases don’t  you perform a physical exam? Why?

Picture by Army Medicine

Do you advise or dictate?

What do you advise most people who seek your help? What will solve most of their problems? It was interesting to read an article this week suggesting that junk food may be associated with depression. In her commentary Megan Lee notes:

Depression has long been treated with medication and talking therapies – and they’re not going anywhere just yet. But we’re beginning to understand that increasing how much exercise we get and switching to a healthy diet can also play an important role in treating – and even preventing – depression.

For many of the most coveted outcomes in healthcare three things are paramount:

  1. Eat less
  2. Exercise more
  3. Don’t smoke

Simple focus. Not easily translated in practice because selling a healthy lifestyle is tricky:

Interviews with 130 mothers of lower social class provided the basis for studying their views on the desirability of general practitioner intervention in their lifestyle habits; the study used both quantitative (questionnaire) and qualitative (interview) techniques. The majority of women were in favour of counselling on specific topics by the general practitioner but the qualitative data also revealed that most respondents expected the issues to be relevant to their presenting problem. Moreover they were keen to assert their right to accept or reject the advice given. Stott and Pill

Picture by Fit Approach

How do you prepare for disagreement?

Sometimes you might be asked for something that seems entirely pointless. In healthcare almost every speciality has examples of such challenging situations. In intensive care and oncology such issues are most poignant as patients may end up suffering before death:

In a retrospective review, we identified 100 patients of 331 bioethical consultations who had futile or medically inappropriate therapy. The average age of patients was 73.5 ± 32 years (mean ± 2 SD) with 57% being male. Fifty-seven percent of the patients were admitted to the hospital with a degenerative disorder, 21% with an inflammatory disorder, and 16% with a neoplastic disorder. The family was responsible for futile treatment in 62% of cases, the physician in 37% of cases, and a conservator in one case. Unreasonable expectation for improvement was the most common underlying factor. Family dissent was involved in 7 of 62 cases motivated by family, but never when physicians were primarily responsible. Liability issues motivated physicians in 12 of 37 cases where they were responsible but in only 1 of 62 cases when the family was (χ2 5 degrees of freedom = 26.7, p < 0.001).

Seth et al

This scenario may be avoided if it is anticipated as a ‘set play‘. List all the ways you may be adding to the person’s problems and consider how you might avoid contributing to a bad situation.

Picture by Isabelle

Are you ready yet?

What do you do before you interact with your next customer, client or patient?

Gaze and body orientation communicate levels of engagement with and disengagement from courses of action. As doctors and patients accomplish regular tasks preparatory to dealing with patients’ chief complaints, doctors use gaze and body orientation to communicate that they are preparing but are not yet ready to deal with those complaints. In response, patients wait for their doctors to solicit their chief complaint. These findings have implications for research on nonverbal communication, interactional asymmetry, and power.

JD Robinson

Picture by Mad African

I am Joe and I get what I want

As I surveyed the new intake of medical students one student found his way to the front of the room.

Are you the associate dean?

When I confirmed he went on:

My name is Joe ( Not his real name- to spare his blushes). You need to know that I get what I want.

Now two years later here was Dr. Joe graduating, resplendent in his academic gown. He has his wish which I hope is for a lifetime of selfless service to people in distress. So when he is called to the patient in bed 9, on the wards tonight and he is told:

I’m Mr. Smith, and you need to know I get what I want. Tell your boss to come to my room at 11am, I’ll be ready for him then and by the way I’m not happy taking those pill, please take them away.

Joe will know he has got his wish.

Picture by KC

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?

Picture by Cocoabiscuit ,

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

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