Well, Doc, I Must Confess...

Anytime I go to a doctor's office, a hospital or a pharmacy, I like to think of this as "fieldwork" for my area of expertise. Because I write about health care in the real world, it's important that I know what happens "on the ground" in the physicians' waiting rooms, the hospital floors and the pharmacy counter. 

Often, my contacts at the health system or the pharmaceutical company assume that processes go the way they are supposed to. However, this is one of the things I find so fascinating about medicine -- the human element always emerges. Sometimes systems can handle that, and sometimes they can't. 

I recently had surgery, and of course, I'm a better-informed-than-average patient. I scrutinized the recommendations, the doctor reviews and cross-checked whether I really needed the surgery. Having satisfied my questions, I scheduled it. Then I had to cross the incredible bridge of surgery prep. I read the "Patients' Guide to Surgery" produced by (someone like me) in the hospital marketing department. I read the handouts from my physician (even the parts crossed out by the nurse that didn't apply to me!)

And still, in this fieldwork, I found some mysteries. Why couldn't I wear nail polish? Did that include toe nail polish? I knew I couldn't eat anything after midnight, but not even tea? no water? This was arduous for a person who constantly hydrates like me. What I wanted more than instructions was the rationale. (See Gretchen Rubin's Four Tendencies -- I'm a Questioner.) I'm happy to comply when I know why! 

So I did my own searches on the internet. I asked my nurse friends and relatives. I looked at recovery yoga breathing videos. And I went in prepared. In fact, the last thing I remember before going under was talking to my nurses about all the services that my health communications company provides. #alwayshustling

But, not everyone asks the questions, even if they want to. And more importantly, how many people don't follow the instructions because they didn't read them, they didn't understand them or they fibbed about when they did them?

The answer to the nail polish question is: it can interfere with the pulse oximeter, so you need ONE nail free of polish, and it doesn't apply to the toes. 

The answer to the water question is more complicated. It's to avoid aspiration of food particles or liquid into the lungs while under anesthesia. But there's some controversy over whether two hours prior is enough time. More on that as the research evolves. 

This week, I interviewed a surgeon about the very same type of surgery that I had last week. I thought maybe I could just not mention it, but turns out -- I had to, because I have what's known in the industry as "lived experience." This is one of the most interesting challenges for medicine today, I think -- the integration of clinical knowledge and procedures with how things actually work in the real world. It's a constant striving to make things optimal (the cleanest incision, the tightest margins, the fastest recovery) while acknowledging that everyone has their own particular situation (their health history, their phobias, their home environment.) 

I'm happy to continue my fieldwork, but let's hope it's all outside the operating room for awhile!

Doc, Come Quick!

Besides reading about modern health care innovation, I love to read historical and fantasy fiction and watch historical dramas. One things I've noticed is this: health care skills have always been valued. I expect this will continue. 

Take the case of Claire Fraser, heroine of the Outlander series. She's a time travelling nurse who goes from World War II to 1743, and although she lands in hot water almost immediately, she is able to win the trust of her captors with her medical skills. Not only is she an amateur botanist, she knows about...germs! Which puts her ahead of her sudden contemporaries. She's got excellent diagnostic skills, having read and seen all manner of illness in her time. Ms. Fraser is experienced with sutures, tinctures and identifying whether a rash is a serious or fleeting illness. Her skills amaze others and she saves lives and wins the trust of many who help her find her way. (Of course, much of the delight of her skills for readers is that in 1743 everyone thinks she's a witch...but it's just modern medicine transported 200 years in the past!)  

Same with Doc Cochran, the only medical professional in Deadwood -- based on a true town in South Dakota. He's a grump Gus, and he should be because his patients are nearly all in bad shape. They've been injured in a mine, shot in a gunfight or are infected with a veneral disease. The show is all about this violent town's struggle for gold and independence, but Doc is able to disagree or raise a holler without any consequences...because everyone knows they soon may need his services. No matter how vicious relations get, the Doc is able to treat people, insist on better public conditions and even defy some of the more powerful people to do what he needs to do, because he has the medical skils that anyone may need imminently.  

I note these two characters, but there are many more, on apocalypse shows like The Walking Dead or CW's Hart of Dixie or BBC's Call the Midwife that make the same point. People will always be in need of health care, at some point. That makes these skills invaluable -- and I would like to note, we need to prioritize public first aid response training, professional health care education AND preventing burnout for our health care professionals, too. It's part of the human condition, and today we know that more than ever -- so we should be ensuring that we recognize this value. 

Baseline: Why You Should Go to the Doctor Even When You Aren't Sick

There's a very famous family story where I made my husband go to the urgent care with me because I thought I had strep throat and if I did, he must too. It all started when one of my co-worker's sons had strep and she was telling me about it. I woke up the next day with a scratchy throat and knew it was time to go. In my family, both of my parents worked at hospitals and we were fairly quick to be seen if it appeared to "be something." My husband's family, on the other hand, not so much. These cultural influences play out as adults, as we try to make our own choices. I convinced him that we needed to go to the urgent care. We each got that awful gag-inducing swap and...he didn't have strep. Neither did I. He thought that was a wasted trip, and was very embarrassed that he'd gone to the doctor when he wasn't sick. 

But wait. Let me make the case for going to the doctor when you aren't sick. As a person who works in health care now, raised by people who had easy access to professional health care -- I'm shocked by the number of people who just don't want to or can't access health care. This means that they wait and see as their main method of dealing with health issues, and when they see that it's not getting better, they head to the drug store. Not to pick up a prescription called in to their doctor, but to browse the over-the-counter aisles to see if anything matches their symptoms. (Here's a great article from Altarum about lower income people's health habits.)

With increased health care access through insurance, these habits are still hard to break. Many people want to "save" going to the doctor for when they really need it. But here are three reasons to go now:

1. Build a relationship with your doctor and talk about your current health. How do you feel? What could you be doing better? What advice does the doctor have for you? Are you due for any screenings?

 2. Think about your health. If you are avoiding the doctor because you think she's just going to tell you to lose weight -- think about that. What are your obstacles in losing weight? How do you think it's affecting your health? What are your goals, for your health and your life?

3. Get your vitals taken. These data points help provide a baseline for the future, when your doctor might notice a spike in your lab results, your blood pressure or your weight. These things can help catch serious problems sooner (when they might be solved more easily) but they can't catch anything if you don't go in! 

In short, don't be embarrassed to go in for a check up, or just to check in about your health questions. Your health is an important part of your life, and these maintenance appointments can help in the long run. As for my husband, he is still more doctor resistant than I am, but he's getting better. My work is not clinical, it's patient experience and patient-centered qualitative work -- so I consider every encounter a learning experience. Try to schedule an appointment when you don't need it so you can improve your experience when you do. I try to schedule an annual check-up near my birthday as a kind of self-care, and my very smart PCP always makes me tell him what's on my mind so we can work together on it. Try it!

(Originally published on LinkedIn June 13, 2016)

Hospital Marketing is Not the Same as Other Marketing

After a lunch-and-learn about branding, and a "red paper" from SPM Marketing, I'm seeing an intersection of the ideas. Hospital marketing can learn so much from marketing in general, in how they reach their audience, and the ways they do it effectively. BUT, and this is big: people don't want to go to the hospital. (I want to buy some Sugar lip gloss and a Dyson vacuum cleaner, to name two ads that reached me today.) But still, you are marketing to them in many of the same ways: online, on billboards, mobile ads and magazine spreads with friendly yet competent-looking doctors, and they still don't want your product! 

That's why I think that branding is the most valuable tactic. Because when they do needto go to the hospital, it will be the sum total of all their impressions about your facility, doctors, emergency room and staff that tips it one way or the other (your competitor's nearby hospital.) In his fantastic book, "Joe Public Doesn't Care About Your Hospital,"author Chris Bevolo gets it. Being a marketer in this space is hard. Everyone thinks they know what patients need.

I am a big believer in asking patients what they need. And in general, that works for doctor's office and specialty care, and maybe even lifelong health care like skilled nursing and rehabilitation. In those cases, you may want to use some marketing tactics used in other industries. But for emergency room care, it's an emotional decision. That means branding needs to appeal to our deep need for life-saving; our hope that we'll get the smartest doctors and the most compassion nurses. In surgical care, they may have more time to make the decision, but it may also be an emotional choice based on what you've built your brand on. 

Health care is essential. That doesn't mean it doesn't need to be marketed, but it must be marketed differently than our earbuds, lip gloss, paper towels and vacuum cleaners.

(Originally published on Linked In March 16, 2016)

Everyone Thinks Research Takes Too Long...

Patients in need of urgent care (like in cancer care) want the new drugs to come out now. Doctors want to know whether the new protocol their being pressed to use actually works better than the old one. Parents want to know about long-term effects before they vaccinate their children with something new to market. These are part of the frustrations of the field of medicine -- which is always changing. 

It's also a field with a lot of missteps -- the experiments of the past sometimes had horrible effects that ruined or took people's lives. The tragedies of William Halstead who, in the nineteenth century, disfigured women with radical mastectomies, or the forced Tuskeegee University syphilis experiments. These history lessons offer a caution for us. 

The tension between these two imperatives appears to be a paradox: to bring lifesaving medical technology quickly to people who need it urgently, and to carefully evaluate these advances before offering them to large numbers of people. 

This is why clinical trials are so important for medicine to move forward, safely and quickly. A recent SubjectWell poll found that 96 percent of people never participated in a clinical trial, and 50 percent had never even heard of one. The enhanced consent, participation rules and safeguards on clinical trials make it a better regulated field than ever before. Consider participating in research - so that we can do our best to have safer and faster results.  

I Thought They Could Fix Anything....I Was Wrong.

A few weeks ago, I saw a great patient video discussing a woman in the MidWest talking about her snowmobile accident and she gave great feedback for the staff. But she also said "I knew I was hurt but I thought, 'it's 2015, I thought they could fix anything.'" She lost two of her fingers permanently. During the interview, she mostly kept her right hand over the left hand with the missing fingers. She talked about the confusion when her doctor told her that the fingers were beyond saving. But her comment on the perception of most people that hospitals in America can fix anything has stuck with me. We do have amazing trauma teams. We have technology that diagnosis quickly, stabilizes and can mimic functions that the body can't manage on its own. We have blood transfusions and intense surgical techniques. 

But we still can't do it all. When I gave a presentation recently on infectious diseases, I reiterated this to the audience -- avoiding getting sick is still really important. We can kill bacterial infections with antibiotics, but it's getting harder. We can't kill viruses with antibiotics though, and there are few anti-virals available. We have to be smart and avoid injury and disease -- and be grateful for the advances in medicine should we ever need them.  

"I think the doctor said..."

I just read an article in the Journal of Patient Experience with this statistic in it: 

"Miscommunication between physicians and patients is the most common cause of medical errors and is responsible for more than 60 percent of sentinel events that lead to increased mortality or injury among hospital patients." 

Think about that. More than half of errors are caused by two people trying to communicate but failing to do so. And, I'm sure you've been there. I know I have. The doctor says to do something, in a regular tone of voice, and I'm not sure if it's a suggestion or an imperative statement. Or the doctor says "make sure to..." and I'm so overwhelmed by trying to remember it that I get confused. If you aren't in the habit of repeating it or writing it down, you may very well forget it. 

The journal article was about AIDET training (created by the Studer Group) for physicians. It seems simple but patients know that many of these steps are missed. 

A: Acknowledge (address each person in the room)

I: Introduce yourself  (and your role and your specialty)

D: Duration (how long will you be in the room, is there a procedure happening?)

E: Explanation (what's the treatment? what's the diagnosis?)

T: Thank You (appreciation for their time, questions, etc.)

In a hospital environment, these common courtesies can easily be overlooked, because everyone is in a rush. But it matters. It matters to patients, and it may prevent medical errors and miscommunication. That seems like a great reason to take the time to do it. 

Hospitals -- More than a Building, Part of the Community

I finally sat down to read the Community Connections publication put out by the American Hospital Association, a book full of ideas and innovations for health care leaders related to community programs around the country. The range of programs was interesting, from offering volunteer doulas to pet care during hospice to arranging for meals to be delivered home for food insecure seniors. I think that hospitals sometimes get a bad rap for their size and the amount of money they circulate in the community -- but they are often at the heart of communities in the United States in big cities and small towns.

I think that in our great cultural shift in health care we will see more partnerships and more preventive care -- both essentially important to our community health. From cultural health navigators who assist female refugees from the Middle East / Southeast Asia / Subsaharan Africa in Phoenix to training African American barbers how to measure blood pressure and serve as heart health advocates in DC -- identifying cultural barriers to health is important.

It's heartening to see things that didn't used to fall under "health" be recognized as part of our whole selves. For example, dinner programs for breast cancer support that include communications skills, nutrition, stress management, intimacy and finances, which both builds a sense of connection with the group but also recognizes that resources are needed for these challenges. A retreat for stroke survivors and their families meets similar needs in support, education and socialization.

Prevention is also more of a focus, looking to prevent falls and injuries by strengthening flexibility with exercise (Idaho), student health coaches for those with chronic conditions (Pennsylvania) and instruction for physically disabled individuals to play sports like fishing, swimming, wheelchair basketball and hand-cycling (Iowa.) A hospital in Oklahoma offers a drive-through flu shot clinic to encourage high risk patients. It's important to address the current issues while preventing future ones and there are many adaptations we can make to help keep communities healthy. I applaud hospitals for their innovation and compassion. 

Rounding Up

Rounding has become a buzzword in hospitals in efforts to focus on patient experience, but most non-health care people know what it means. (rounding numbers? killing weeds? corralling sheep?)

Rounding is "making rounds" to patient rooms to ensure that their needs are being met proactively. Resistance to rounding is that it's one more thing to do. People who work in hospitals are BUSY. But, the research on rounding is that it saves time because patient anxiety and dissatisfaction decrease.  Here's a study from Stanford on nurse rounding.

It's struck me, in my reading, that a patient in a hospital bed can't really think about anything else. They are afraid and full of anxiety because (especially these days) if you are in the hospital, it must be serious. When no one comes to see them, they think they've been forgotten about or that their must be terrible news that no one wants to tell them. 

So, having someone check in, to see if you need help going to the bathroom, to get something from your bag or to help you adjust your bed, can help you be more comfortable and reduce some of that anxiety. See the Four Ps: Potty, Pain, Position and Possessions.  

Personally, after the birth of one of my children, nurses took the baby (and my husband) to the nursery for tests and I was left alone for quite awhile. It felt like about two hours, but I couldn't tell you how long it actually was. I was desperately cold and really wanted some socks or slippers to warm up my feet. But I didn't want to bother a nurse to come help me put my slippers on. So I waited, miserably, until my husband returned. My frustration and anxiety levels were very high -- and this could have been avoided with better understanding of when someone would be by to check on me. 

Rounding experts (like the ones on the Association of Patient Experience webinar right now) say that it's critical to frame this practice as "not just another thing to do." It's important to make it about quality and safety.  Rounding is a practice that is practical and proactive -- Let's add those Ps as well.