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What do you notice?

Before making any changes that might improve outcomes where you work you have to notice things that don’t look quite right or that hint at a solution. I know someone who notices the tiniest details even when she is out shopping. She generates a huge number of ideas about how things could be improved sometimes with the smallest tweaks. Here’s an example. As a result she is the most successful person I know. You’d be lucky to have her on your side. I know I am. What did you notice about your office, clinic, shop or hospital today?

Picture by Marcin Wichary

Does parking stop doctoring

Imagine you have back pain. Your doctor suggests you need special scan. You have to travel an hour across town to get to the hospital where you have an appointment at 9 am. You take the morning off but hope you might get to work in the afternoon. It’s peak hour traffic as you arrive at the hospital. The queue to get into the car park stretches down the street. You join the line of cars and realise it’s now 8.45am. The X-ray department is a long walk from the car park. Just as you get to the entrance to the parking lot the attendant indicates that it is full and you have to try and get a spot on a side street. The chap in the car behind you is getting frustrated- are you waiting in the queue or trying to back out? It’s a one way street you can’t turn the car here. It’s now 9 am you are going to be late- not sure how late. You toy with the idea of just going home.

In November 2011, an editorial in the Canadian Medical Association Journal called hospital parking fees a barrier to health care, saying the charges amount to “parking-centred health care,” and recommended hospitals stop charging patients for parking. The editorial stirred up a debate in the media. The Ontario Nurses’ Association, for one, agreed with the recommendation and noted that many of its members could tell stories about patients who had avoided seeking care or had cut appointments because of high parking costs. Canadian Nurse

Picture by Al Ibrahim

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

What was the journey like?

Do you know what your customer, client or patient’s journey to your office, clinic or shop was like? How did they get there? How long did it take? Who travelled with them? What did it cost? If they drove where did they park? Did you take any of that into account in your dealings with them today? Does it matter?

If you’re lying on a table waiting for radiation, you can’t just jump up and plug your meter,” she wrote to the city. “As someone who has gone through and survived cancer, I can’t tell you the anxiety experienced at finding a parking ticket on my vehicle. Nancy Piling

That patient’s experience was impacted by factors that had nothing to do with the professional care she was receiving. But…..

Picture by lagaleriade arcotangente  

Could you do better?

Do you think your work could be better? How? If you think it could be improved what are you waiting for?

The intense debate about how to move forward is a sign that overtreatment matters,” Brownlee says. “We want everyone involved and sharing their expertise on potential solutions. There is room for many political ideologies and beliefs about how to pay for healthcare. The crucial step right now is to get the medical community mobilized around the idea that overtreatment harms patients

BMJ Jeanne Lenzer

Picture by Carlos Ebert

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

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

How do you explain?

In any meeting where you are the expert how do you explain technical details? As a doctor how do you explain viral illness? Warts? Heart disease? Cancer? How do you know the other person ‘gets it’? Do you say the same thing every time? Do you use pictures? Sounds? Have you practiced the script as much as you practice other aspects of your art? Why or why not?

Andrew McDonald wrote in the BMJ:

The development of such a language, securely founded in shared meanings, would be a good first step towards better communication between professionals and patients. It would not, of course, deliver the goal of full participation in decision making, but that goal will remain elusive unless we begin by understanding one another.

Picture by Marco Verch

The most valuable lesson learned on my first day as a doctor

Picture by JD Lasica

Much of what’s wrong with healthcare is in the consulting room

It’s not that complicated. Not really. So where do you look for pathology? Inspection, palpation, percussion and auscultation. How does it look, how does it feel, how does it sound and what do you hear when you know where to listen closely. I’m talking about healthcare. Take a helicopter ride through your business.

Access

What is the route to your service? Where is the delay? How long do people wait in the waiting room? How do you know? What do you know about the people who use your service even before they are seated in your waiting room?

Greeting

What happens when people call or arrive in person? What message is conveyed?

Welcome we’ll do our best to help you today OR you are lucky we are ‘fitting you in’.

Just stand there- I’m dealing with someone on the phone.

We have no time- go complain to the manager/politician/ bureaucrat-consider yourself drafted to the cause.

Hold the line. We are dealing with something far more important but your call is really important to us so just listen to how good we are as conveyed by our prerecorded message.

Associated with that is what is perceived about your attitude that is not verbalised?

Look at ALL these posters and the many ways you can be helping yourself instead of wasting our time.

People vomit and pee while they wait so the seats have to be cleaned with detergent. Plastic is the best option.

If you want a drink go buy one at a cafe.

We rely on donations for our toys and magazines- we don’t have to provide anything OK? Now if you don’t like the stuff just watch Dr. Phil.

What do you mean you have been waiting a couple of hours? This isn’t McDonalds now take a ticket, sit down, shut up and wait. And turn off your phone so you can hear the old lady at the desk who has an embarrassing problem.

Communication

How long is the meeting with the provider? How does that meeting unfold? What is conveyed during the meeting?

Welcome- I’m so sorry you are not well. Tell me what happened? OR I haven’t got long what do you want exactly, spit it out be quick about it I need to get on with the next guy. Didn’t you see the queue out there?

I’m the important one around here- you are lucky I’ve chosen to be here today. Let me tell you about my holiday, my kids, my new car. It’s fascinating really!

Room 5. Quickly. Never mind my name.

Test/ Referral and Prescription

What action is taken at the consult and are you confident that is the best possible action?

I don’t have time for talk- have this test and take another day off to see me next week.

I don’t have time for you to take off your umpteen layers- go have a scan.

The rep told me this works- I only have to write a script.

If you want to get better take my medicine/advice/ referral or get lost.

What medicine do you want? How do you spell that? Tell me slowly I’m writing it down on your script.

Outcome

What proportion of people takes your advice/medicine/test? How many people stopped smoking? How many were triggered to lose weight? How many are addicted to prescribed medicines? How many were prescribed treatment or tests that were not indicated? Where’s your data? What are your plans for dealing with this?

Team

To what extent can you say that when people transition to another healthcare professional either on site or elsewhere that the relevant information follows them? Is everyone on the same page with the same patient?

All of this matters. All of it. Some of you can fix tomorrow. No need to wait for another round of healthcare reform. No one said it was easy. And whatever their business the best don’t compromise.  A lot of what can be fixed in healthcare takes place behind the closed doors of the consulting room.

Picture by Daniele Oberti