PookieMD's Blog: Where Physicians Learn About the Business of Medicine

Switch–how to change things when change is hard, by Chip Heath and Dan Heath. I loved this book.  It talks about making changes, especially at a business level, when change is hard to do.  I happen to be at a hospital where change is rampant– almost a perfect storm of change!  But why did I love this book so much? Because it describes real life and gives concrete examples of change.

The essence: each of us has two sides to ourselves when it comes to making change: the rider of the elephant and the elephant.  The rider is the goal directed, results oriented persona, and the elephant is the emotional, peanut loving, lumbering beast that takes us down the path.  The rider can only direct, cajole and threaten the elephant for so long before the elephant takes off on his own.  The elephant  goes down the path of least resistance.

Who cares? Well, you should! We have to channel our inner elephant, which goes further than the munching peanuts.  The key is to recognize we need riders to direct the elephants down the path, but  the elephants have to be motivated to go down the path.  So what to do:

“Direct the Rider” –look at what is working, and why, and then clone these “bright spots”.  Create simple directions for concrete behaviors. Make the destination visible.

“Motivate the Elephant”–appeal to to elephant’s so called emotional side.  Visual representations are key (not power points!) with graphic demonstrations of the positivity of change versus the negativity of doing things the same old way.  (The book notes how one company collected piles of gloves to demonstrate how much the company was spending on gloves. Once the employees saw the visual representation of how many different kinds of gloves the business was buying, the employees agreed to buy a standard glove.)

“Shape the Path”–try to change the situation rather than the person.  Frequently, people behave a certain way because of circumstances, not because of a charcter flaw.  When trying to create change, make it easy for people to comply.

I am part of a study that looked at how often PCPs got discharge summaries from hospitalists.  Only 50% of all discharged patients had a discharge summary sent to their PCP.  So why weren’t dictated discharges getting to the PCP?  The docs weren’t specifying who the PCP was, although it was in the chart, and the dictated discharge summary ended up in cyber lost and found.  But why? Good question! Using the techniques in the book, I will dig in and find out if there isn’t a clear path, and why the elephants (the doctors!) aren’t following the path directed by the riders.

I’m back from a well needed vacation. I skied my little heart out, had dinner out with family and friends, ate lots of pot luck dinners, went to a musical, and am finally refreshed.  Boy, did I need the break! It was getting so bad that I had to psych myself up to go to work every morning before vacation.  That’s pathetic.

I did have time to indulge my thirsty brain in some books.  Here is what I read:

Switch–How to change things when change is hard, by Chip Heath and Dan Heath.  More on this tomorrow.  It’s a must read, and I gave it to someone I work with as a peace offering after I made an idiot of myself.  He loved it, and we smoothed things over.  This was inspired by reading the book, and caused me to think about how I had been approaching the huge change my hospital will be undergoing.  Buy the book, read the book, highlight the book, share the book!  I will post on it for tomorrow’s book club.  It’s applicable to just about everyone, no matter their field/specialty.

Drive–the Surprising Truth About What Motivates  Us, by Daniel H. Pink.  Basically, rewards don’t motivate, so don’t bother.  I’m only half way through, so can’t comment any more.

And lastly, Making it all Work, by David Allen.  This is more from the GTD (getting things done) guru.  It certainly inspired me to get back to my list making.

It’s nice to be back! Would love it

I just finished The Checklist Manifesto, by Atul Gawande, and it is a must read.  Checklists are making their way in to medicine, particularly in the area of surgery.  Dr. Gawande is a surgeon, and most of the anecdotes in the book are surgical.  As an internist, I have struggled to find a way that checklists can make an impact and improve my practice as a hospitalist.  Most of the current checklists are oriented toward procedures, and as an internist, most of my time is spent thinking about patients, rather than doing a procedure.

However, the chapter titled, “The End of the Master Builder,” was worth the cost of the book.  In this chapter, Gawande examines how a sky scraper is built.  He notes that there are multiple check lists developed by each of the trades involved, and milestones that must be met before the next step can be taken.  He explains  that originally there was a master builder that would design an entire structure and supervise the building of that structure to completion.  However, today’s building are too complicated for one person to know everything about how to build a sky scraper.  Hence, the demise of the master builder.  Gawande states that physicians view themselves as a master builder (the “Master Physician”), but argues that technology and the human body are just too complex for this to be an effective way to heal people.

Instead, he notes that the building industry also has a communications check list.  This is a list of which contractor should talk to which and at what time to guarantee safety of the building at each step.  This was striking.  I have been analyzing what makes difficult medical cases go well and go wrong, and I found that a key item was communication (or lack of) with subspecialists helping manage the patient.

So this week, as part of check list I use when I am rounding, I put “cons” for consultant by each patient name.  This was a way to remind me to 1) call a consult if needed 2) speak to the consults on the case.  I think we are relying too much on written notes, and not enough on verbal interactions to discuss care and management of patients.  My deliberate efforts made me feel that I was delivering better, more cohesive care.  None of the subspecialists appeared annoyed or upset that I was taking more time to talk with them.

It was an unscientific test, but I think we (Gawande and I!) are on to something.  In this complex world of medical care, we need to hone our communication skills and standardize them.  Now, I just need to design a study supporting communication check lists, and get buy in from the physicians where I work…

You may be wondering what a fiction book is doing in the book review section of a blog dedicated to medical practice management.  You have good reason to wonder but bear with me.  There is a method to my madness.

During my vacation (that was not long enough!) I read My Sister’s Keeper, by Jodi Picoult.  As you may know, it has been made in to a movie, which I have not seen.  The book is a somewhat manipulative tear jerker, and is a “tense, high concept piece of women’s fiction…” So what does that have to do with anything?  Well, a lot.  Particularly interesting is the way physicians are portrayed in this book about a young woman dying of leukemia, and her parent’s attempts to save her.  Below is an excerpt from the mother’s viewpoint:

“The nurses, I have already learned, are the ones who give us the answers we’re desperate for.  Unlike the doctors, who fidget like they need to be somewhere else, the nurses patiently answer as if we are the first set of parents to ever have this kind of meeting with them, instead of the thounsandth.”

Ouch. The sad part of it is we physicians DO fidget because we DO have somewhere else to be.  Last week, I actually made the time to attend a meeting with the palliative care team, who was meeting with a patient and family to discuss various options as the patient neared end of life.  Guess how many times I was paged out of the meeting?

Three times in twenty minutes.

Boy didn’t I fit the stereotype?!

I was asked what I meant when I stated in an earlier blog that we should “slow health care down.”   This is what I mean.  I should have had the time to complete a meeting in which we disucssed options for end of life care.  But, instead I answered three pages of marginal significance.

No wonder Picoult describes physicians as always in a hurry.  It’s because we are, but that doesn’t make it right.