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I saw a 57-year-old Caucasian female with a past medical history of diabetes, hypertension, hyper cholesterol and coronary artery disease. Apart from taking a history, doing a physical examination planning assessment and plan, I always ask this question, “What else do you want to know about diabetes?” Diabetes is a complex disease and if I ask, “Do you have questions?” Most of the time my patients’ answer is nothing. If I ask do you know about diabetes, their answer is always affirmative as they know everything about diabetes. I think either patient knows everything or know nothing. Asking a closed-ended question usually ends the communication with the patient and health caregiver goes to the next patient room. After the encounter with the patient, usually a medical assistant, or a nurse prints out diabetic education material which some patients leave in their cars, others throw in the trash or put in a shredder. Giving a pamphlet and checking the box to appease insurance companies is considered patient education. Can we change habits by just handing a pamphlet?

How did the idea to Flip the Healthcare occurred?

I coach USMLE Step 2 Clinical Skills and have portrayed as a standardized patient for medical students. Young medical minds have taught me how to become a coach and a standardized patient and this practice have helped me in my real-life patient scenarios. I have wondered about health literacy and how should medical students ask questions from me when I am in the workshop with them. I have experimented with many questions asking techniques and discovered a non-threatening way to ask questions is by telling the stories of other patients. However, time being a big constraint, storytelling is next to impossible. I have adopted Lisa Bernstein’s question asking technique— “Many people dealing with diabetes want to know more about complications associated with the disease. Patients are not aware of what to ask, why to ask and how to ask as the medical knowledge is complex. Even as physicians, we forget medical knowledge and must take CME’s, do MOC exams, and recertify for board exams. On occasions, the Utilization Review team has to remind us about ICD 10 coding and mandates. If we as health care providers forget, can we expect lay people to remember the complex medical jargon in just 15 minutes to 30 minutes of the office visits? Coaching medical students and becoming a standardized patient has taught me how to teach real-life patients. As a standardized patient, I increase the difficulty level of the clinical scenario according to the acumen of the medical students and this is where I use the Vital Checklist to portray clinical cases. Sometimes I act as a stubborn patient and on other occasions, I am an angry patient. On occasions, I tell my students to explain about the HbA1C in a layman language and on another instant, I will see if they are asking me about the blood sugar logbook. To teach medical students, I had to devise a checklist of the diabetic complications so as they could explain and communicate easily in the exam. In USMLE Step 2 CS exam, medical students don’t have models or posters and they must memorize symptoms, signs, assessment, and plan. If medical students, our future doctors, memorize the complications of diabetes in the formative years of becoming doctors, they will have an easier time in coaching real-life patients in the future. (iCrush) Diabetes Vital Checklist was developed for medical students but I used for my diabetic patients and everybody loved it. This was the AHA moment for me as I thought of developing a dedicated portal for diabetes where patients can download the (iCrush) Diabetes Vital Checklist in their own native language and be ready to ask questions from their doctors. Giving a patient (iCrush) Diabetes tool may help to flip the healthcare, an idea adopted from the Khan’s Academy Flip the Classroom. Proactive patient education is a key to improve the patient experience. Therefore, I have developed L.E.A.N. Patient Experience and this L.E.A.N not only represents Lean Health Care but also represents Listen >> Educate >> Activate >> eNgage. My work heavily depends on checklists and these checklists are not there to tell what to do but they are gentle reminders of what we should not forget.

Changing Habits: L.E.A.N Patient Experience

Dr. Atul Gawande has shown how safe surgery checklist dropped the mortality and morbidity and this was the idea which has encouraged me to implement my idea of (iCrush) Diabetes. To make the checklist memorable, I needed to chunk the checklist and include the actionable words, and this is how I came up with my checklists. I am indebted to Charles Duhigg (The Power of Habit), Nir Eyal (Hooked), B.J. Fogg (TinyHabits.com), David D. Burns (Feeling Good and Cognitive Behavior Therapy) whose work I have combined to make one Benzene Loop which I also call L.E.A.N. Patient Experience.

Benzene Loop or LEAN Patient Experience.

Disclaimer: I have derived this LEAN Patient Experience model from the work of great philosophers and psychologists—Charles Duhigg, Nir Eyal, B.J.Fogg and David D. Burns. I don’t claim this to be my work. I have read their books and combined to make one model and use this model to make happy patients.

L.E.A.N. Patient Experience

External Trigger:
• Doctor‘s visit
• High Blood Sugar
• Family member encouraging taking care of diabetes
• advertisement about the diabetes
• Email notifications

Internal Trigger: Stroke, Eye damage, Kidney damage, Heart Attack, Amputation. Just giving a pamphlet about the side effects and complications cannot create a strong internal emotion. Giving a structured checklist (iCrush) Diabetes, may provide more recall of the complications

Behavior, Action or Routine:
• BJ Fogg’s behavior model focusses on the ability first and then on the motivation. Change tiny habits like learning a symptom and complications checklist rather than exploring the internet for the symptoms of diabetes.
• (iCrush) Diabetes Vital Checklist patient education tool is the starting point.
• Top of mind awareness about diabetes with various touch points—web apps, apps, t-shirts, flash cards, books.
• Instead of symptom checker, we provide chunked symptom checklist for an easier memory and recall.
• An easy to share checklist with family and friends