A Lesson from Steve Jobs: Start with the Customer Experience

Paciente: No sé qué es, es una de las razones por qué estoy aquí por un examen – no sé pero, de vez en cuando, en seguida, la visión se vuelve borrosa, empañada. Y en ese momento, cuando lo pasa, tengo que parpadear rápidamente o frotarme el párpado, y a veces todavía, es difícil ver claramente. ¿Qué es??

(después del examen)

Doctor: Primero, quiero decirle buenas noticias – no tiene retinopatía diabética, y es por el hecho que se controla el nivel de azúcar en la sangre.  Pero, los nervios ópticos aparecen sospechosos de glaucoma. Con la historia de esta enfermedad en su familia, pienso que sea importante hacer un campo visual para determinar si tiene glaucoma o no.  

Paciente: Gracias a Dios que la retina sea normal. Y estoy de acuerdo, quiero hacer el examen por glaucoma. Mi padre perdió la visión debido de esta enfermedad.

Doctor: También, usted tiene una condición muy común, algo se llama ‘sequedad de los ojos’.

Paciente: ¿Qué significa eso? Puedo llorar, ¿cómo tengo sequedad?

Doctor: La manera en que el ojo se lubrica es complicada. Hay glándulas que producen aceite para mantener la capa de lágrimas,  hay glándulas que producen lágrimas naturales para lubricar la córnea y hay glándulas que producen lágrimas reflejas – cuando, por ejemplo, tenemos un cuerpo extraño dentro del ojo, o un rasguño de la córnea, el ojo produce un lagrimeo reflejo.

Paciente: Okay..entonces, ¿qué es el problema que yo tengo?

Doctor: Usted tiene una condición de los párpados se llama ‘blefaritis’-  las glándulas que producen aceite para la capa de lágrimas no funcionan bien, son inflamadas—las lágrimas se evaporan y el ojo se vuelve seco. (satisfecho que le ha explicado este estado enfermo del ojo completamente). Usted necesita utilizar gotas artificiales diariamente.

(le da al paciente una botella)

Paciente: (mira la botella) ¿Qué es esto?

Doctor: Es una de las muchas marcas de gotas artificiales que puede comprar sin receta en la farmacia. Debe echarle una gota 2-3 veces al día. ¿Tiene preguntas? ¿No?, okay, entonces, las muestras son para usted – son gratis, y ahora escribo la receta por lentes, y bueno, si los síntomas disminuyen, y no tiene otros problemas, regrese aquí por un reconocimiento de los ojos en un año.

Paciente: Está bien, pero tengo otra pregunta.

Doctor: (le mira al paciente)

Paciente: ¿Por qué tengo visión borrosa a veces?

*

I  find the late entrepreneur, inventor, innovator, dreamer and Apple co-founder Steve Jobs to be truly awe-inspiring. Besides re-infusing life into a company at the brink of failure and single-handedly imagining, believing in and creating devices that have become a standard part of our everyday lives,  he was human. He was fallible. He made mistakes, he admitted them, learned from them and moved on.  He has made many statements reflecting on his experiences in such a way that any of us can relate to his musings:

“Innovation distinguishes between a leader and a follower.”

“Sometimes when you innovate, you make mistakes. It’s best to admit them quickly, and get on with improving your other innovations.”

“Your time is limited, don’t waste it living someone else’s life...most important, have the courage to follow your heart and intuition,  they somehow already know what you truly want to become. Everything else is secondary.”

These are a few of Jobs’words which highlight his point of view and his thinking. But one particular thing he said, during the 1997 World Wide Developers Conference when posed with a question from the audience, really touched me on a personal and professional level. When talking about new technology, creating it and building it, he said:

“You‘ve got to start with the customer experience and work back toward the technology - not the other way around.”

At hearing this, a light bulb went off! This has been a recurring theme of my daily life in the medical office. I’ll reword it like this:

“You’ve got to start with the patient experience and work back toward the disease – not the other way around.”

When you’ve made a diagnosis for a patient, the next part involves explaining that diagnosis and what to do about it. I’ve mentioned in previous blog entries, namely A Rose by any other name…well, except for ischemia...  and Lenguaje “Llano” – Common Words & Plain Language

that it is important to consider your listening audience when choosing how to explain a particular ocular problem. Looking at the patient in our dialogue at the beginning of this blog entry who is suspect for open angle glaucoma, and also happens to have blepharitis with secondary dry eye disease, we need to refrain from launching into the entire pathogenesis and refrain from using extensive medical terminology to review the condition. Though the explanation is stellar and detailed, it obviously doesn’t register with the patient. It didn’t allow her to make a connection between her symptoms and dry eye because she’s still asking why she has blurry vision at the end of that grandiose explanation.

This type of, lecturing, if you will,  will not connect you to your patient. You can’t start with the disease and relay it back to your patient. It has to be the other way around. So, instead of starting with the disease: blepharitis! dry eye! glaucoma!, we need to take a cue from Steve Jobs and start with our audience, The patient:

(después del examen)

Doctor: Buenas noticias, no tiene signos de diabetes en la retina.

Paciente: ¡Qué bueno!

Doctor: Pero, Usted tiene nervios sospechosos de glaucoma, debemos hacer el examen por glaucoma, el campo visual, cuando regresa aquí en 2 semanas.

Paciente: Está bien. ¿Y mi visión borrosa?

Doctor: Usted tiene ojos secos y inflamación del párpado, blefaritis. Las dos condiciones hacen que el ojo es rojo, con síntomas de picazón y visión borrosa.

Paciente: ¿Qué es lo que tengo que hacer?

Doctor: Utilice este limpiador (le da al paciente un atomizador) para limpiar los párpados dos veces al día. Póngase este lubricante dentro de los ojos 2-3 veces al día.

Paciente: Está bien.

Doctor: Lleve este papel a la secretaria en la frente. Ella hace una cita para usted en 2 semanas, para el campo visual y evaluar los síntomas.

Paciente: Gracias. Hasta la próxima vez.

Adirondack Balloon Festival, Queensbury, NY

2016. What is the future of the patient exam?

They call the Hanukkah-Christmas-New Year’s time of the year the most stressful. People are trying to get everything done at once and run themselves ragged. There is work, there are travel plans, there are family get-togethers, there is buying the latest gadgetry. There is cooking and eating, and the obligatory extra-gym visits. And then there is the stress of all things combined. A new year is coming, of hopes, yes, but of challenges. And one would think that with all this planning, and traveling and cooking and eating going on, that there would be little time to set appointments for check-ups at the doctor. But from a medical standpoint, this actually ends up being the busiest time of the year in the office. Particularly for the eye doctor. Whose glasses broke before the holiday season? Who ran out of contacts and can’t possibly have their picture taken without them? Who has had an optic neuropathy for ten years and decides that Christmas Eve is the day to start  the workup? Who got poked in the eye by their Menorah? Or their Christmas tree lights? Who simply cannot have a stye when boyfriend comes to visit? (I’m not making this stuff up. Truth is indeed stranger than fiction).

But, as I reflect on the last year these first few days of 2016 – (which, incidentally, marks almost 10 years post-residency of providing care to the community. Where did the time go?)- I ask myself: If I were to pick one thing that makes me feel like I’ve accomplished something worthwhile every day, what is it? What gives me a sense of satisfaction when I go home at night? For me the answer is simple : I get more out of teaching patients how to seek out information about their health for themselves than I do actually diagnosing and treating them. You cannot even imagine how many of my Spanish-speaking patients are surprised to find out that there are certain medical websites online where they can read up on their eye health in Spanish. And, surprising as it may seem (especially in this day and age when vast knowledge is available at our fingertips) they wouldn’t know this information unless I shared it with them. 

One patient in particular comes to mind in this regard. She’s been coming to the practice for many years, although I myself have only begun to examine her recently. She has Fuchs endothelial dystrophy and has been given the typical OTC regimen of hypertonic saline drops and ointments to help control the disease.  One would think that after so many years of being told to use this eye drop or that ointment, that somewhere along the line she would have developed a profound knowledge and understanding of her eye problem. But the truth is, one day she expressed confusion after I explained why she needs these drops and how they work. She appeared utterly bewildered. I repeated the name of the disease. I explained what it is. I explained why it happens, and what can be done about it, both medically and surgically. And after explaining this in Spanish, I told her that sometimes a person needs more than spoken words to understand a concept. I directed her to www.ojossanos.org , and clicked the links to Distrofia de Fuchs and printed out the pages and gave them to her. With papers in hand, her appearance was not unlike that of Helen Keller’s  in the Miracle Worker- understanding and relief at the realization that the letters being spelled out in her hands truly meant something. Here, my patient finally understood her disease and better yet, knew how to find out more information regarding it.

I think this is an important point. I have learned in the course of my profession that being a good doctor, rather, being a good anything, is not about having all the answers. It’s about knowing where to find the answers, and about teaching others to find the answers for themselves. I got such satisfaction out of this one patient encounter, that it makes me sad to think, especially as one year rolls into the next, that where medicine is headed, less and less time is being made available for teaching and for caring of patients.

Out-of-control patient schedules are not uncommon for the holidays, but unfortunately the future of medicine is that these schedules will become the norm. When this is the case, everyone loses, but especially the patients. This isn’t the field I signed up for years ago. It’s not the field that my beloved family doctor from childhood practiced in. One where he created his own patient schedule, took time to examine and re-examine. Time to talk to the patient and hand-write his findings. He could take 45min to an hour with each patient if it so required, and the other patients were not unhappy with the wait because their appointments were scheduled accordingly, giving ample time to everyone.

But today, doctors aren’t doctors anymore. We’re providers. We’re employed by insurance companies. We survive in groups where business hierarchy dictates that the office manager with a business degree has more value than we do. He dictates my schedule—someone who’s never examined a patient in his life. He decides when I should be double-booked and how many patients I should be seeing in a day. And his administrative assistant henchmen see to it that I’m booked every 5 or 10 minutes. Insurance companies decide what medicines to cover for patients and what tests can be ordered to rule out disease. It makes me very angry and I want to stand up and say, no more! But all the other doctors comply. They fall into line like cattle corralled for the slaughter. If doctors as a whole continue to ask “ how high? “ when told to jump, what are a few dissidents like me to do to improve the system?

I am not sure what the answer is, or if there even is one. I can’t leave you, my reader, with a clever anecdote and a problem-solved moment of satisfaction. All I can say for myself is this, that for 2016, I am going to work hard to wring 5 minutes dry. I will continue to examine and diagnose and treat, but especially and most importantly, I will work to create an education plan for the patient’s well-being. I will continue to make time to teach, because knowledge and how to find it is what keeps a patient healthy in the long-run.  Woe is the society that takes away a doctor’s ability to do just that:

doc^.tor, from Latin docere, to teach.

References

http://www.merriam-webster.com/dictionary/doctor

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