Health care practitioners have traditionally relied on clinical heuristics to select, encode and process information from the patient. When a patient is presenting with multiple and complex issues, these heuristics reduce the patient’s difficult question of “what’s wrong with me” to easier ones, such as “is this person presenting with depression”? The use of heuristics is then reinforced by operationalizing evidenced-based care into protocols, procedures and checklists designed to increase efficiency and reduce variation in process.
The trouble with this approach is that medical professionals are so busy looking for what they’re trained to find that they can often completely ignore information staring them in the face. When Harvard Medical School famously conducted research in this area, 83% of radiologists studied did not see a gorilla superimposed on an X-ray, even when it was 48 times the size of the nodule they were looking for. Optical tracking devices showed the radiologists had all looked directly at the gorilla.
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While the heuristics-based approach is logical at one level – given the operational and cost pressures faced by health services – the impact on patients is that too many receive multiple diagnoses and treatments, without recovering. When Monash Health (an integrated health care provider based in Melbourne, Australia) gathered data, both quantitative and qualitative, in the form of patient journey maps and admissions and diagnostic information, we found that re-presentation among mental health patients was rising, even though the percentage of new patients presenting had fallen over the previous 10 years.
What’s more, over 50% of the most frequent presenters have had over four different psychiatric diagnoses and have received the recommended treatment for the conditions concerned. Further analysis revealed that the reason for this failure was the fact that underlying trauma issues in the patients concerned had not been treated. Because we had not been primed to attend to the significance of trauma in our patient’s lives, it was hiding in plain sight from us, like Harvard’s gorilla.
How could we avoid missing the gorilla in future?
Learning to see what lies beneath
The answer, our research told us, was to build strong trust-based patient relationships with our patients, in which clinicians could work more responsively with patients to uncover and eventually treat their traumas. This would require building a feedback loop in the treatment process to ensure the system could adapt and change.
To pilot this new approach, Monash Health established the new Agile Psychological Medicine Clinics (aPM Clinics). At each interaction, the clinician requests feedback from patients on treatment outcomes and their experiences of interaction with Monash professionals. This builds in an opportunity for patients to air their concerns and provide data in their own way, which takes clinicians out of their heuristic box. And although the process creates extra work on the spot, it also enables the therapist to respond and adapt promptly to what the patient is telling them and ensures that a patient is treated in the context of their culture and preferences.
The results from the experiment are encouraging. Patients visiting the clinics have on average reported high overall satisfaction levels (96%) with their work, dialogue, and relationship with their therapist. The patients receiving trauma treatment have experienced a 52% improvement in their trauma symptoms and a 39% improvement in depressive symptoms (from severe to mild). And, significantly, the proportion of patients in the group re-presenting themselves during treatment has decreased by 30%. All are clinically significant results.
Let’s turn to look at an example of what the new process is delivering
A Case in Point
In January 2016, Ash (not her real name) turned up in Emergency for pain and severe difficulty walking. She was admitted into the neurological ward for assessment; but no biological origin was identified. This was not her first visit to Emergency. Over a period of eight years, Ash had already received several psychiatric diagnoses from different specialists – PTSD, depression, and other disorders – and had remained on anti-psychotics all that time.
After the neurological admission in 2016, Ash was referred to the Agile Psychological Medicine Clinic. The clinic established that Ash’s first diagnosis for schizophrenia, which was treated with anti-psychotics, had been given after the traumatic birth of a son who turned out to have severe developmental issues. Through the years following she was not only her son’s primary caregiver, she was also in an abusive relationship.
Although Ash had been asking for treatment for her trauma since that traumatic birth and had repeatedly complained that the medication turned her from a smart woman to someone who could not make a sandwich without following written instructions, she had been caught up in a pattern of clinical activity that largely ignored the information she volunteered, and the question of her trauma was almost completely ignored
After just 14 sessions of treatment at the Clinic targeted on the trauma of her son’s birth, Ash no longer met the criteria for schizophrenia, PTSD, depression, or any of the other diagnoses she had received. She is off all antipsychotic medication, feels she has her life back and has been studying at university for the last two years.
Building empathetic, patient relationships is not only proving effective in treating seemingly intractable mental health sufferers such as Ash. We are finding that many chronic patients presenting with physical symptoms also benefit from the approach.
Keeping an Eye on Our Most Vulnerable Patients at Home
This is the motto of Monash Watch, a service that focuses on the small number of people who are identified as being at high risk of three or more admissions in the subsequent 12 months using an algorithm based on administrative and routinely collected clinical coding data. Since these “top 2%” of acute hospital presenters in any year are responsible for 25% of direct health care costs, the program aimed to reduce patients’ reliance on acute hospital services by helping them improve wellness.
Based on the Patient Journey Record System (PaJR), an analytics software developed by Carmel Martin, an expert in chronic illness and patient-centered care and an adjunct professor at Monash Health, the service offers patients lay telecare guides, who call participants one or more times per week. The same guide calls the same person each time, the goal being to build a relationship of trust with the patient.
After running through a simple script of health questions the guides discuss the patient’s responses with them and engage them generally in a relatively unstructured dialogue that is driven by the patient and which is recorded and analysed by PaJR. The software generates alerts if responses suggest health decline, and if a change in condition is confirmed, the patient is handed off to a clinician for follow-up.
The telecare guides can also detect changes in health status by listening carefully to the words in the responses, the change in intonation, and pauses, because they have come to know their patients as people, not just as anonymous check-a-box responses to questions. As they have grown into their jobs, they have become skilled at observing and communicating the signals and messages that patients give them. We call our tele-care guides “professional good neighbours” and that is exactly what they have turned out to be.
Over time Monash guides and coaches have observed a number of common features among their patients: many had lost a sense of purpose, had become depressed and/or anxious, and were experiencing pain. Some had resorted to self-medication with pills, opioids, and alcohol. By delving more deeply into the stories trusting patients told their tele-care guides, the Monash Watch team found that once again a history of prior trauma often lay at the roots of the conditions presented.
Most Monash Watch patients recognize that treatment – even for trauma – will be unable to significantly undo the physical impact of their past on their health but they also report that having someone lay who is in regular contact and is willing to listen to anything on their mind reduces anxiety and restores hope – and that itself has a positive impact over time, and helps reduce the frequency of unsettling visits to Emergency.
The general lesson that we have learned from these experiences is that building an empathetic, trust-based relationship with patients is not a nice-to-have but a must-have. It creates the possibility of identifying underlying hidden conditions whose treatment prevents the occurrence of overt symptomatic conditions that cause distress to patients and place huge strains on the capacity of healthcare services. Empathy saves not only lives but also money and time. It’s time to build a place for it in the clinical process.