I recently had the honour of being invited to be the guest lecturer at a university class of young students learning about chronic illness. (The word “young”, of course, is relative, since almost everybody on earth is now so much younger than I am). These students were absolutely terrific – enthusiastic, smart, full of questions and ideas about healthcare. But about halfway through our 3-hour class together, I began to observe a pattern in the way some of them approached their small group exercise assignment.
This exercise divided the class into three smaller groups, each given a patient case study and asked to identify potential barriers to good care that their assigned patient might be facing. For example, some barriers included poverty, or not speaking English, or mental illness, or no family support at home, or – more often than you might imagine – the unconscious bias of the healthcare professional against the patient’s particular demographic.
Some students stood out for me. They were the ones immediately jumping ahead to the solutions they’d already come up with to help solve the systemic healthcare obstacles faced by their case study patient.
These interruptions reminded me of something that seems to pervade our healthcare system.
It’s the almost irresistible compulsion to leap ahead to a solution in search of a problem – instead of the other way around.
Here are a few examples. . .
1. Resilience Training for Physicians: The issue of physician burnout is a problem throughout the medical profession. According to the Canadian Medical Association Journal(1), burnout can have a very serious effect on the physical and mental health of physicians. It can also lead to decreases in productivity, cutbacks in work hours, early retirement from the profession – and even higher suicide rates. Patient care can also be affected, as physician burnout has been shown to predict medical error even more strongly than fatigue does.
One recently popular solution to this growing problem has been to start teaching resilience training to physicians and medical students. If docs could only learn how to be more resilient, they wouldn’t feel so burned out – right?
Well, we don’t know if this is true or not. As suggested in the British Medical Journal (BMJ) this month, we’re asking those whose workplace is hurting them to change, rather than changing the hurtful system, as the BMJ authors explain:
“If you were to ask whether resilience training or protected break times with reliable work schedules is more likely to improve their effectiveness and satisfaction at work, support for the latter approach would surely be resounding.”
2. Self-tracking apps: When I spent several days in Silicon Valley attending the Medicine X conference at Stanford University, I met a whack of young Stanford undergrads, mostly in engineering or computer science, each one loudly eager to tell me all about their new start-up company, each start-up guaranteed to “change healthcare as we know it!”
But within a very short period of time, it became apparent that few of these hypemeisters had actually been within 10 feet of a Real Live Patient before rushing out to line up venture capital investors for their new digital health solution. And each had started out with what they wanted to create for the “worried well”, not for patients whose need to track is often viewed as yet another burden of treatment.
Their belief: there’s no problem in life (including a medical diagnosis) that can’t be fixed with technology. If your only hammer is tech, all you can see are problem nails that need your unique technology solution, even if these are marketing-based (not evidence-based) solutions. See also: ‘Healthy Privilege’ – When You Just Can’t Imagine Being Sick
As the late patient activist and author Dr. Jessie Gruman once wrote:
“I’ve been approached by a number of mobile app developers looking to speak with a real patient about their projects. While talking to potential users is generally a good idea, these developers weren’t interested in my needs, but rather were seeking endorsement of the beta version of their new apps.”
3. TeleHealth: This popular subset of tech has proven to be useful in isolated or rural areas where residents have little or no access to medical specialists. At a Vancouver medical conference, for example, I watched a mesmerizing live demo of a physician onstage “examining” a patient in a remote village hundreds of miles away, where the local nurse used a digital ear scope to film inside the patient’s ear. Thus a doctor in one location can speak to, listen to and “see” a patient in a faraway location.
But TeleHealth hit a staggering speed bump when Ernest Quintana, a patient at a Kaiser Permanente hospital in the San Francisco Bay area, was told that he did not have long to live – not by a doctor sitting at his bedside, but via a robot-powered computer screen that rolled itself into his ICU room. The images of the disembodied doctor’s face and his awkwardly delivered bad news were filmed by Mr. Quintana’s granddaughter because her grandmother (the patient’s wife of 60+ years) was not in the room to support her husband during this terrible “conversation”. Mr. Quintana died the next day.
The resulting public outrage was immediate, with most condemning the use of such technology in end-of-life care, describing this incident as “unethical” and “immoral”. The hospital spokesperson responded by saying that officials “regret falling short of the patient’s expectations” – as if the patient’s expectations of common courtesy or basic human kindness had somehow been unrealistic.
What each of these examples illustrates is a solution in need of a problem.
But it’s not that we don’t need resilience training, or self-tracking technology, or a doctor’s face on a screen riding around hospital wards on a little traveling robot.
The issue is that those who provide such solutions have successfully positioned themselves as the ones who can solve problems.
Meanwhile, most patients continue to tell anybody who will listen about real healthcare problems that are in need of practical solutions. The question remains:
Is anybody listening to patients?
When researchers at Ohio State University tried asking patients themselves how to improve a hospital stay, for example, they learned about actual problems that are commonly reported by Real Live Patients:(2)
- patients need a hospital room that provides core components of comfort to support healing (including not being ‘on display’ to people in the hallway by providing a privacy curtain at the room door)
- patients need a sense of security (like knowing who is entering the room and their role in the hospital, plus a safe for valuables in the room
- independent access to their day-to-day belongings within reach (those belongings are often stored in a tray table that gets moved out of reach)
To that list, here’s my own wish list of ongoing healthcare problems that require tailored solutions:
-better hospital food (what more can we say?)
-we need mandatory reporting of diagnostic error (we simply cannot fix what is not being acknowledged, never mind tracked, despite the Institute of Medicine’s bizarre insistence that “now is not the right time” for mandatory reporting, although they do admit that voluntary reporting is not working)
-we need a comprehensive hospital discharge plan for every patient before leaving the building (studies suggest that up to 90% of chronically ill patients are sent home without a written care plan)
-we need expanded home support services once a patient leaves the hospital (which would require hospital staff to be aware of what services the patient actually needs at home, and who in the community can provide those services)
-for eligible heart patients (i.e. virtually ALL heart patients), we need an official default referral to a cardiac rehabilitation program before hospital discharge (current physician referral rates are as low as 20% for a treatment that’s considered to be a Class 1 recommendation worldwide, or – as Oregon cardiologist Dr. James Beckerman likes to say to his non-referring colleagues: “It is bad medicine to withhold lifesaving treatment from your patients!”)
Back to my young university students: during my closing comments in front of this class, I offered this broad recommendation (i.e. not even making eye contact with those premature solution guys): we must be very careful when listening to patients.
We cannot gallop at full speed to a problem’s solution before we truly understand their problems.
To do so is to feebly accept author Steven Covey’s truism:
“Most people do not listen with the intent to understand. They listen with the intent to respond.”
1.Physician burnout a major concern” –
2. Patterson, E. S. et al. “Meeting Patient Expectations During Hospitalization: A Grounded Theoretical Analysis of Patient-Centered Room Elements.” Health Environments Research & Design Journal, 10(5), 95–110.
Q: Have you experienced a healthcare-related problem that begs for a solution?
NOTE FROM CAROLYN: I wrote much more about healthcare problems (and solutions) in my book “A Woman’s Guide to Living with Heart Disease“ (Johns Hopkins University Press, 2017). You can ask for this book at your local bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from Johns Hopkins University Press (use their code HTWN to save 30% off the list price when you order).