medical innovation

What stories do you tell?

Lean Medicine February 25, 2019

We all have stories about what we do for a living. We tell them all the time- even if we don’t recognize that we are telling stories. They communicate how we feel about our work. Do your stories convey the impression that you are stressed out, bored, bullied, treated unfairly and in general can’t wait to retire? You realise that this is also your self talk and that ultimately you will magnify these experiences. On the other hand if you started telling stories about experiences that energized you, made you feel valued and creative then you might notice more about your job that seems to resonate with what you want and how you want to feel.

At 9 o’clock one bright morning a 32 year of man had been waiting for an hour in a busy clinic. He was called into the doctor’s office. Covered in tattoos, he was a muscular man whose tanned skin suggested a life outdoors. He wore a high vis vest and heavy steel capped boots.

I’ve had a toothache since three o’clock this morning doctor and I need to get to work

He said rubbing his jaw. His doctor was curious, it was odd that a man who seemed very robust in every other way, was getting ready to go to work would wait for an hour in a busy clinic complaining about toothache that started a few hours ago. But of course that wasn’t the whole story. The doctor watched him rubbing his jaw and the side of his neck.

Where did the pain start?

In my chest doctor, it was like someone was sitting on my chest, I felt a bit nauseous and it seems to have settled in my jaw and the side of my neck. I think it’s going into my shoulder now.

Half an hour later the man was in hospital being treated for a heart attack. His decision to get to a doctor might just have saved his life and his doctor’s curiosity paid of.

Picture by Jonathan Moureau

Lean Medicine February 25, 2019

Do you perform any rituals during your day?

Lean Medicine January 3, 2019

Do you perform any rituals during your day? Why? What is the value of the ritual?

Despite the absence of a direct causal connection between the ritual and the desired outcome, performing rituals with the intention of producing a certain result appears to be sufficient for that result to come true. Francesca Gino, Michael I. Norton

Picture by Sulen Lee

Lean Medicine January 3, 2019

What problem can’t you solve?

Lean Medicine December 13, 2018

Armed with a hammer everything looks like a nail- except it isn’t. We need to be clear what healthcare is for. Doctors cannot ‘cure’:

Debt
Workplace bullying
Violence
Illiteracy
Homelessness

In addition there are many other problems that may be beyond curative intervention and a few others that require people to make different choices more than the doctor to prescribe something.

The unbridled enthusiasm for guidelines, and the unrealistic expectations about what they will accomplish, frequently betrays inexperience and unfamiliarity with their limitations and potential hazards. Naive consumers of guidelines accept official recommendations on face value, especially when they carry the imprimatur of prominent professional groups or government bodies.

Woolfe et al BMJ

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Lean Medicine December 13, 2018

What do they know about you?

Lean Medicine December 4, 2018

Whenever someone new visits your shop, cafe or clinic for the first time they make a decision to give you a chance. It’s worth asking what persuaded them to do that. What’s their perspective on your business? Which of your previous patrons do they know? What do they expect? Can you deliver? They are telling you something merely by their presence on site.

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Lean Medicine December 4, 2018

Why the data suggests people don’t get the latest medicine

Lean Medicine April 23, 2018

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It sometimes seems ‘obvious’ why things go ‘wrong’ in practice. For example, the proportion of people with diabetes prescribed a cholesterol reducing drug is low…. because? You might have your favorite answer at the ready. Others certainly do and will climb their hobby horse with little or no encouragement. ‘Prescribers don’t accept the guidelines‘, ‘patients don’t take their medicines‘, ‘people can’t afford the drugs‘ or ‘doctors don’t monitor patients‘. The truth may encompass any or all of these.

Let’s do the maths with reference to Glasziou and Haynes.

Let’s assume 80% is true in each of the following points:

1. Doctors are aware of the guidelines.
2. Doctors accept the evidence underlying these guidelines.
3. Doctors remember to apply the guidelines when the relevant patients present.
4. It is possible to do something practical to comply with the guidelines.
5. Doctors act to prescribe the relevant treatment.
6. Doctors and patients agree on the need for that treatment.
7. Patients comply with the treatment.

If these statements are true 80% of the time then 21% of people with the relevant problem will be managed according to the guidelines (0.8x 0.8x 0.8x 0.8x 0.8x 0.8x 0.8= 0.21). Experience tells us that in many, if not most, conditions only 1 in 5 people will be managed as per research evidence.

A quick review of the literature confirms this.

1. Only 17% of patients with diabetes were screened for sexual dysfunction despite it being a common complication of this condition.

2. A primary care study has shown that despite an active education program over two years the proportion of treated patients whose blood pressure was controlled to < 160/90 mm Hg remained at only 33%.

3. When examining the referral origin of all Colorectal cancer patients diagnosed in one study only 24% had been referred on a pathway that was consistent with national guidelines.

A video summary appears here:

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Lean Medicine April 23, 2018

Designers will rescue the health sector

Lean Medicine November 19, 2017

Much of what we do in healthcare is communicate ideas. That is far more common than ‘doing’. Executive control over decisions are the purview of the patient. It is a basic tenant of medicine that the patient has autonomy.

Often armed with little more than a stethoscope doctors must communicate to the patient that:

The cause and treatment of that rash are unknown.
Antibiotics won’t help.
The ugly warts on those feet will resolve spontaneously.
That person does not have asthma.
A colonoscopy is necessary
That is a ‘panic attack’.

When communication about the evidence base is effective the patient, the practitioner and ultimately the economy benefit. How we communicate such ideas is where innovation has the brightest future. It gives us hope that we can improve outcomes in health without recourse to major policy change or curbing freedom of choice.

We communicate in words, pictures, video, audio and using models. Yet so much of how that is done in the doctor’s office hasn’t changed over the decades. ‘It’s just a virus’ doesn’t cut it any more.

We experience the power of effective communication everyday and in every other area of our lives. Look at your credit card statement this month- does it all make sense? What pressed your ‘purchase‘ button?

What if this extraordinary power deployed so effectively in commerce was unleashed in the clinic?

Picture by Dan Moyle

Lean Medicine November 19, 2017

It is time for primary care to enter the triggering business

Lean Medicine June 18, 2017

It has been suggested, some would say demonstrated that doctors know very little about their patients. If you are a doctor could you identify your patient’s partner from a line-up of strangers (other than people you see as a couple)? Or could you tell without seeing the name on the document if this bank statement belonged to that patient? Or whether that utility bill was from where that person lives? Is this internet search history theirs? Do you know how much they spend on lottery tickets? Alcohol? Vegetables?

A few years ago our team then based in the UK was evaluating an intervention to increase access to general practitioners. If the intervention worked we would have to demonstrate improvement over the course of a whole year. Here’s the thing, we noted that year after year there was a pattern to the demand for same day (emergency) appointments- with definite peaks and troughs. So if the intervention worked it would have to be sustained during both the peaks and the troughs. It did. The data on out-of-hours services exhibited very similar patterns- with definite peaks and troughs and at unexpected times of the year. We could not explain the patterns but noted that when the meteorological office recorded 22 hours or more of sunshine in the week the demand for appointments dropped. Not the prevalence of viral or other community pathogens but sunshine of all things! Okay may it was some factor that we hadn’t modelled in the analysis but there was a definite pattern that we could not immediately explain on the basis of what seemed plausible at the time. We called it the Spring Cleaning Effect– we hypothesised that people in the UK were less likely to attend doctors in general practice when there was a run of sunny days on which to do outdoorsy things. We didn’t anticipate this- nor did clinic managers because the patterns of demand were not used to inform the scheduling of doctors’ on-call rosters. It was clear that they were blind to a phenomenon nobody understood fully.

More recently I reviewed some data on certification for low back pain and noted the pattern that as unemployment rates in a locality increased the rates of certification dropped and then plateaued.

Our team is now investigating similar data from a large employers’ records. We hypothesise that rates of submission of sickness certification will show a sharp drop when vacancy rates fall and other markers of economic health decline. People may be far less likely to take time off sick if they are fearful of upsetting their supervisor. With respect to primary care, it is unlikely that doctors will know everything that impacts on their patient’s choices. Time spent with the patient in discovering these things is unlikely to increase as it comes at a financial cost. Therefore doctors will never fully anticipate all the drivers to patient behaviour. Why does that obese person fail to take action on weight management? Why does this other person take ‘medication holidays’ when they need to take the treatment consistently to benefit? Why does the next person refuse to have an X-ray? Why is there a rush of people with relatively minor conditions demanding appointments this week and not last?

Some drivers lead people to behave in unexpected ways as I have commented here previously. Not only that but as Mullainathan and Shafir have postulated people are often unable or perhaps unwilling to follow doctor’s advice. In the end, the best we can hope is to trigger the relevant behaviour in people who are already motivated and seek teachable moments to inspire people to act for their benefit. Primary care may be more about recognising or fishing for opportunities and much less ‘educating’ for change. Such triggers need to fit within the final moments of a 15-minute consult. The work to develop and evaluate such triggers is only beginning. Counselling patients to stop smoking will yield 1:20 quits in a year, showing them a trigger (in less than 5 minutes) that appeals to their vanity results in 1:7 quits. A substantial number (1:5) of obese people will lose weight in 6 months if they are shown what difference that would make to their appearance without having to be extensively counselled on diet and exercise.

Picture by Aimee Rivers

Lean Medicine June 18, 2017

Can the patient relay what was done for them?

Lean Medicine April 30, 2017

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

Lean Medicine April 30, 2017

Doctors need better tools to help people recognise danger

Lean Medicine April 23, 2017

Doctors see it all the time. The fifty-year-old with a BMI of 28, the teenager who is developing a taste for cigarettes, the twenty-year-old who now binge drinks every weekend, the soon-to-be-mum who is ‘eating for two’. Small choices that may become habits and habits that lead to consequences. Where I work the average consultation is fifteen minutes. In that time we address whatever symptoms or problems have been tabled. The list may be long. Occasionally it’s possible to raise a topic that I’m worried about. The problem is the patient may not be worried about that issue.

Afterall doctor I don’t drink any more than my mates do or I don’t really eat that much.

What’s needed are tools that help frame the issue from the perspective of the patient, not the practitioner. Tools that help us address public health priorities that speak TO that person, not AT everyone. Before making any changes the person needs to agree that their choices might blight their hopes for the future. These are not inconsiderable challenges given the gloomy predictions for the future.

At the other end of the malnutrition scale, obesity is one of today’s most blatantly visible – yet most neglected – public health problems. Paradoxically coexisting with undernutrition, an escalating global epidemic of overweight and obesity – “globesity” – is taking over many parts of the world. If immediate action is not taken, millions will suffer from an array of serious health disorders. The World Health Organisation

Diabetes is likely to cement its place as the fastest growing epidemic in history. The Medical Journal of Australia

In addition, youthful drinking is associated with an increased likelihood of developing alcohol abuse or dependence later in life. Early intervention is essential to prevent the development of serious alcohol problems among youth between the ages of 12 and 20. NIH

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Lean Medicine April 23, 2017

Perspective is crucial when considering changes in healthcare policy

Lean Medicine November 6, 2016

It was summer of 2010 in Australia. I had been working hard in the garden one Sunday afternoon. Feeling the need for a little mindless entertainment I suggested to our then 14 year old that we might rent a sci-fi movie. It was around 7pm and getting dark. My son jumped into the car beside me and we took off toward the video shop. That’s when I noticed that the car headlights were far too dim. I turned on full beam- but it didn’t help. I ranted for a good five minutes about how difficult it was going to be to get a mechanic to look at the car so close to Christmas. I was also a bit put out that our teenager was showing no concern for my predicament. At this point he quietly reached across and took my sunglasses off my face.

There. Problem solved dad.

I learned something that day not least what it would cost me if that story was not be retold to his brothers.

I love the work of Deana McDonagh and Joyce Thomas, especially their thinking on empathic design. Deana and Joyce begin their sessions on empathic design by inviting participants to try on their designer glasses- the ones that demonstrate what it must feel like to have tunnel vision. They’ve written about it in the Australasian Medical Journal. I keep those glasses in my office to remind myself and visitors of the valuable insights they offer but also as a treasured momento of a fun workshop generously organised by a brilliant team.

Their work came to mind later when we were investigating the attitude to self-management of a condition that is progressive and for which there is no cure. Patients and doctors in an Asian setting were interviewed. We recorded poignant stories about the impact of this condition on people’s lives- resulting in social isolation, self loathing and a need to feel supported by a health practitioner:

Both patients and doctors were against the adoption of self-management strategies. This is contrary to recommendations for the management of COPD by many studies and guidelines. However, another study has similarly shown that self-management skills were not rated as important by patients. Furthermore, the psychosocial impact of their disease such as fear limited their ability to manage their own symptoms. A lack of knowledge may also contribute to their dependence on doctors and health care providers.

We concluded:

In reality, patients have to conduct self-management daily and it is not feasible for physicians to provide all of the management needs that patients have during their day-to-day lives. Therefore, self-management remains an aspect of overall COPD care. However, it should not be the only focus and future interventions should also examine ways to improve access to health care.

On reflection we noted something similar with patients in Australia. Those who had an established medical condition were much more likely to ‘trust’ their doctor than those who were not currently unwell or those from higher socioeconomic groups. Innovating requires the ability to see people as heterogenous having very different perceptions on the need to be in charge of their own health, perceptions that are liable to change with circumstances. I also wonder if policy makers consider what it must be like to implement their big ideas from this perspective:

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