By Gerrit Van Wyk.
The health care product.
In the movie What Women Want, Nick Marshall is an advertising executive and chauvinist. One day he gets drunk and falls into the bath holding an electric dryer, and when he wakes up is able to hear what women think. He is shocked to find out women hate him, not love him as he believed, and eventually realize when listening to them, how wrong he was in the past, and how wrong men are in general about what women want.
Like Nick Marshall, I realized many years ago those of us working in the medical profession don’t have a clue what patients really want. To find out I performed a study that was too small to reach statistical significance, but the results were off the charts skewed which makes the conclusions relevant. I know of no such study performed before or since.
Most patients and physicians agree patients see their doctor because they discovered something changed, they can’t solve the problem themselves, and they would like to know what the problem is because they worry it may be serious. If the problem is not serious or harmful, most patients are happy just to be reassured and prefer not to take a prescription or have surgery, but if it is serious, most want something done about it. They take prescriptions or agree to surgeries because doctors recommended it. As far as the wrapping of the product goes, patients want staff to treat them well, want consultations to be on time, offices to be neat and clean, and have sufficient parking close by.
The problem is, most doctors think patients want prescriptions, tests and procedures and will be unhappy if they don’t get them, which is exactly the opposite of what they want, and prescriptions and procedures can have unwanted side effects, may cause harm, and has a cost attached to it. There is a discrepancy here which means health workers need an electric jolt to wake them up to see what patients really want.
Why do we have this situation? My study confirmed Kenneth Arrow’s contention the health care product is knowledge; if I know what my problem is, I don’t have to see a doctor, I only need to do so when I don’t know. But that creates a problem; if I don’t know I also cannot tell whether the knowledge I am given is true or valuable, therefore I must trust the provider which explains why patients take doctors’ advice.
It means we can’t judge doctors on their ability and therefore judge them on the wrapping instead, including such things such as bedside manner, staff interactions, their offices, parking, etc., which have nothing to do with competence. The nicest provider is not necessary the best doctor. Websites with physician ratings express the wrapping, not competence.
It leads to another problem; there is a widespread unconscious assumption all health care providers roughly have the same skills and talents, reinforced by a licensing system that says if you passed your knowledge exams, you are competent. In a clockwork world, universities and colleges supposedly produce little boxes all the same, but in a complex world skills and knowledge is distributed, and on a bell curve about two thirds of providers will have average skills and knowledge, about 15% will be above average and the same number below average.
Right now, we don’t have a clue which providers are where and have no way of telling. Knowing that is important; we can learn from the above average what makes them better, and prevent harm by coaching those who are below average. Not even physicians can tell if a colleague is competent until they have a big enough sample of patients on which to make a call, hence referrals are often not made on competence but just like patients, based on whether the colleague is a friend, affable, known from medical school, is a member of the golf club, etc.
Another reason why we want to know this, is registering Colleges do nothing about incompetence until there is an incident leading to a patient complaint, and by then the harm is done. I would suggest an approach pre-emptively identifying possible problem providers before the harm is done is better.
The same problem exists collectively. We have enough evidence showing vastly different outcomes between different hospitals, or even health care regions. We have less evidence about why that is. A clockwork approach is used instead, suggesting the problem can be made to go away by making everyone use the same approach. In a complex world, different hospitals and regions are never exactly the same and have different combinations and quality of resources, therefore expecting them to use exactly the same approach to get the same outcome makes no sense; best case scenario is clustering somewhere around the mean. Which still leaves us ignorant about those below average, and unable to learn from those who are above.
Our current health care system is designed around tests, procedures, and prescriptions i.e., acute care and physicians’ misconception about what patients want, and pays no attention to how knowledge is produced to give patients what they want. Redesigning it around knowledge as the health care product has profound implications. Given the knowledge overload in health care, no single provider can hope to be competent or know more than a fraction of it. We don’t need to know everything ourselves; we need to know who has the knowledge and skills we lack, and how we can access that efficiently. Different providers have mini-libraries and go to different conferences and learning experiences and I can get instant access to it simply by asking.
Now we run into a big social problem. Society confers the title “expert” on providers, signified by a degree certificate and medical license, and an expectation of all-knowing competence. In a knowledge-based system I must be able to confess I don’t know the answer, but if I do so I am no longer an expert in my colleagues’ and society’s eyes, and lose the social status and perks coming with it.
So, to give patients what they want, health knowledge, we must start a conversation about slaying a number of dragons before we can redesign health care systems and processes.
In the old days, if you wanted something, you had to find someone to make it for you; demand exceeded supply. The Industrial Revolution made it easy and cheap to mass produce the same item, hence supply then exceeded demand, and to get rid of excess inventory, businesses started advertising to sell and get you to use more of the product. To shift from industrial to social marketing, you need to move from creating demand to finding out what customers want and produce it to their specification. In health care, consultants tell politicians and bureaucrats what to do, leaders tell managers who tell workers. That follows old-style top down industrial marketing in which patients must use the product we tell them as if they don’t know what they want. Like Nick Marshall, health care needs an electric jolt to wake us up to the fact we don’t provide what patients need and want, we treat them like infants and give them what we think they want instead, That must change.