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whatifhc

what if corporate personality tools were used in medicine?

Treat me how I want to be treated at that moment without knowing me or how I feel. Seems like a reasonable request, right? Maybe not so much. And still, it’s what our modern —indeed overdue —conversation about patient-centered care demands. Patients and providers are clamoring for better partnerships; they desire to communicate effectively, to understand one another. But we don’t really have great tools and processes in place to support fast, low-effort assessments of learning styles and communication preferences.

Are you visual or aural? Do you need control or want to be directed? Does the nature of a situation affect how you might answer that question? Do you want reenforcement, an opportunity to teach back, an opportunity to question? Do you need time to reflect, or do you make quick decisions? And how many of even clearly know these things about ourselves in our daily lives, let alone when we are dealing with our health and wellbeing.

Imagine this scene: you arrive at your annual physical. Except for the occasional cold, you really only see your physician once a year. How well do you really know each other? You are highly visual and prefer diagrams to lengthy documents. You also like to have all the facts and tend to worry when you feel under informed. You are ok to let someone else plan things, so long as you know the plan. Your physician, in her spare time, is an amature writer. She would much prefer writing to talking, and is often reserved during your interactions. She is of a generation where her training reinforced a paternalistic, I know best style of practice.

You have 25–30 minutes together for your visit. Most of that time is spent doing a physical exam and updating your history. But your physician finds something unexpected, a lump. “Get an MRI and I’ll call you soon when we know more…”

Do things break down?

Do you leave feeling informed or terrified or somewhere in between? Could you describe to your spouse what happened, where the lump is and what it might be?

The challenge with treat me how I want to be treated at that moment without knowing me or how I feel is the unfair burden it places on both parties. How, in a time-restricted environment are two parties supposed to quickly get to know one another’s styles and preferences in a way some spouses even spend years working towards? And, for patients and physicians who have a long-standing relationship, wouldn’t an aid at least help remind you of the other person’s prefernces, so you don’t have to rely on memory or assumptions?

When I worked for a large multi-state health system, we used a commercial tool called Personalsys. Everyone in a management role took an online personality preference test. The computer spit out a brief narrative and color-coded chart. As will not be a surprise to those who have worked with me, I tend to be highly energized by ideas and creative brainstorming and am less driven by deadlines than others (something I’ve had to build systems to help support). Many of my healthcare finance coworkers, at the risk of generalizing, were, conversely, highly structured. They like plans and deadlines and clear objectives. If we had a meeting, someone would see my chart and the spikes in my green creative areas, where they might have spikes in their red structure areas. “Ohhh you’re one of those aren’t you? All creative and loosey-goosey…” And we’d laugh and poke fun at each other’s personality traits and preferences. “yeah, well I bet you’re all tightly wound and obsessed with numbers…”

Personalysis

In reality, the framed charts behind everyone’s desks became a bit of an inside gag. The insecure among the lot would cast their doubts on the efficacy of the hippie tools and new age management practices. But even the doubters knew there was some benefit to understanding how their colleagues work and think. You could walk into someone’s office, and know within seconds how they like to interact and work with other people, and in turn what you might expect from them.

There are other examples of these types of tools which are being deployed increasingly in large corporate settings. The DISC assessment, for instance, looks at how a person feels about control using the vernacular of dominance, inducement, submission and compliance. And what discussion of personality inventories would be complete without a mention of my personal favorite, the Myers-Briggs Type Indicator (I’m an ENFP for the inquiring minds out there)?

DISC

Visual and narrative aids like Personalysis or the DISC assessment, are not commonly a part of patient-provider interactions. But why shouldn’t they be used? Imagine if every patient had a card with a visual indicator on one side, in a short narrative about their preferences and styles on the other. What if every doctor had a similar tool framed on the wall of their exam room and office? Patient styles and preferences would be stored in medical records and patients could learn about their physicians’ styles online before visits.

Now imagine this scene: you arrive at the emergency room with chest pains and shortness of breath. You are scared, but not in dire straits. You are taken back, immediately, into an exam bay. A physician comes in, sees your chart and knows right away that you like to be in control of situations. You are aural and work better with big pictures than minutia. How might their communication style change to meet your needs, where you are, at that exact moment? Perhaps, in stead of patting you on the shoulder and saying “you are going to be fine dear…” they might instead offer “Ok, we’re going to move quickly, my concern is a blockage, so we’re going to get you to the cath lab, you’ll remain conscious, this is a great team who has done more of these than anyone else in town, after the cath, we’ll know more. Is that plan ok with you?”

To be fair, I suspect the later example is more typical of modern physician communication styles than my patronizing former example. But there is still room for a tool to help aid the process.

We need something quick, easy to understand and effective. It should be a two-way tool, allowing both patients and providers to quickly understand each other and meet in the middle. If this idea of participatory shared decision making is to work, it’s going to need some aids. The good news is some examples already exist. The folks at Diagram Office, a New York-based design firm have created some fantastic conversation aids around shared decision making.

Diagrams OpenIDEO submission

I’m still looking for a solution which fits upstream of decision making. I’m suggesting something which exists as the very first step between a patient and provider, before a word is ever spoken.

Anyone have a prototype?

What if … there was a scale for patient-identified outcomes?

pain scale

After every knee surgery I’ve had, there’s this strange period where you float in and out of awareness. Those moments where my eyes are open rearrange themselves in time, like one of those puzzles where you have to slide a tile out of the way to make room for another one. But one of the constants is the first question: “How’s your pain level? On a scale of one to ten, how do you feel?”

The patient pain scale is has been called the fifth vital sign. Today, we often see the scale as a range of faces — from grimace to smily —on the walls of inpatient rooms. Asking about pain, on a scale of one to ten, is a pretty good assessment of how someone is feeling in that moment.

Unlike pain, we don’t have a great way to indicate our true goals, the outcomes we want. In fact, the term outcome has different meanings depending on our frame. To a provider, a successful, safe, infection-free surgery could reasonably constitute a great outcome. Oncologists may see the completion of radiation therapy, particularly when a patient is in remission, as a successful outcome.

But what about skiing?

For me, being cleared to ski has always been the canonical milestone after knee surgery. Six months, that’s the minimum amount of time which must pass, regardless of surgical site healing or amount of physical therapy, before someone can ski after an ACL repair. Making those first turns, hopefully on hollywood snow on a blue bird day, is what I call a successful outcome.

When my dad and I stood at the top of Vail Mountain, in February 2012, we hugged and cried. That was the end of being a cancer patient for him. That milestone, skiing again, was his goal during treatment.

Goals vs Outcomes

Are goals and outcomes different? I suppose, on some technical level, yes they are. If you believe in dictionaries and particulars and whatnot. Still, fundamentally there’s an important connection.

Rehab therapies have been practicing goal attainment for a long time. When you start PT, a therapist is likely to ask: “so, what activities do you want to be able to do again?”

That’s an important question for two reasons. First, it’s part of motivational interviewing. The patient is establishing their own goal, rather than being told what to do by the provider. It’s like deciding I’m going to eat better vs being told by your doctor you need to diet and lose 20 lbs. We’re more likely to work towards choices we make ourselves.

Secondly, it builds an important bond between the provider and the patient. If I tell you I want to ski again, you know skiing is important to me. You know a little about me now too. I probably like adventure sports and travel. (Actually, I just like the aprés ski part). Now we’re working towards something together.

why scales matter

The nice thing about a scale is it allows for a range. Our idea of ideal goals for outcomes change depending on our circumstances. If you arrive at the hospital via ambulance, during an emergency, your goal may simply be to receive the best clinical care possible - to have your life saved.

After a week-long inpatient stay, your goals may be to return home. It may be to attend your child’s wedding, or to hold your grandchildren. It may be to have your own children.

The circumstances around a visit might also effect our answer - type of visit, type of doctor, check up vs chronic vs acute.

Having a scale allows us to reframe our goals based on our health circumstances.

The patient goal scale

What if there was a patient goal scale? On a scale of save my life to climb Mount Everest, what are your goals? What moment or activity are you most looking forward to after treatment or discharge? And what would happen if that scale were as visible as the pain scale to both you and your doctor? Would it help build a deeper connection between you both? How might your treatment plan be affected, based on your goal, your definition of a successful outcome?

I polled twitter and Facebook about the idea of goals and what matters:

I’m no graphic designer, but it might look something like this…

goal scale

What if…

  • it was in every waiting room, and you could ponder your goals and identify them before each visit?
  • it was on the bedside of every inpatient room, and you could write out your goal, so everyone entering your room knew what you were working towards?
  • there was an app with examples from others and simple questions to help you identify goals?
  • and you could share your outcome goals with your doctors, friends and family?

How else might this work?

Orthopedic Surgeon and healthcare social media expert, Howard Luks, MD, wrote a blog post pondering a similar theme. Its well worth a read to understand the physician’s perspective.

What would you list as your outcome goal?

_______

Edited to include this absolutely brilliant idea:

What if… patients had ID badges too?

Doctors, nurses and administrators all get badges. You can tell a lot from someone’s badge. I prefer to be called Bob instead of Robert… Smile or no smile, our photos say a lot too.

And what about all those degrees and certifications? They are indicators of accomplishments and knowledge and often serve to endear trust. A brain surgeon with alphabet soup after their name is probably a pretty smart cookie.

What if patients had ID badges of their own? What might we convey in a small 4x3 square of plastic? And, for starters, how do we ensure they increase trust, empathy and dignity?

Erin Keeley Moore chimed in:

Another ePatient friend, who’s account is private and thus will remain anonymous here, suggests:

it would be nice to earn an honorary doctorate for my “field work” as a patient since age 13

What would your patient badge look like?

Would it have a playful photo, or a serious one?

Would you list your given name, or a nickname?

What areas are you an expert in?

What's missing or would make this better?

badge

explained