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

It’s hiring season at my compnay, ExtraMD, a “local locums.”  My group of doctors has too much work to cover, so it’s time to add to the stable.  I finally realize that I need to have more doctors that I think I need.

But how to find good, caring doctors that want to enjoy medicine, life, and a balance in between? How to find physicians that put integity as a core value?  How to find physicians that do what they say they are going to do?

Here’s what I have tried so far, and accompanying results:

Craigslist.org: best response from this.  Two physicians interested, will be interviewing one on Friday.

Linkedin: no response

Sermo: no response

Bounty offered for referral: two responses, no interviews.

Mass emails to my friends and acquaintences: no responses.

On the docket for more recruiting: a post card mailing, advertisement on the Colorado Medical Society site, placing ad on medical job websites.  My best results have come from referrals from my friends, but that well seems to be dry.  Any thoughts on how you have successfully recruited the right doctor for your practice?

Most physicians, sometime in their career, end up becoming involved in some way with administration, whether running a practice or taking on some sort of leadership role at their hospital.  Such is the case with me, as I am heavily involved in a large change coming with the EHR that my hospital uses.

The one thing I find foreign is the amount and length of meetings that I go to.  One trait (a good one!) of physicians is the belief that we must get things done.  We are trained early on that if we don’t make something happen, it doesn’t happen.  In addition, we are held medically and legally responsible for things that don’t get done.  That’s enough to motivate just about anyone, and gets magnified in the usual type A, driven, get-things-done physician.  However, meetings are a dangerous place for such driven physicians.

Some meetings can suck you dry like a thirsty vampire at a blood bank.

Meetings can be divided in to 2 types: the “informational” meeting, whose abject purpose is “share” information so we are all “on the same page.”  These are the meetings that run the longest and seem to be the least productive. At these meetings you are  likely to encounter a species of meeting goer–Humanis chatterbox.  This meeting goer loves to hear himself speak.  And sadly, physicians seem to be a large percentage of this sub-species.  Favorite saying, “In my experience….”

Other meetings are the “solutions” meetings.  At these meetings, solutions are to be developed for problems.  This meeting is the purvey of another species–Humanis negativus.  This species has a rubber stamp that gets hauled out and used at every opportunity– the “NO” stamp.  Favorite saying of this subpecies? “Just say NO!”  Profession most likely to be represented by this species? The lawyer.

Of course, no meeting would be complete with out the technical folks.  This species–Humanis technacus, speaks a language most of us don’t understand.  They speak a language called “information technology” and use words like “interface”, “mapping” and “HL7″.  They love their product, the EHR, and frequently forget that it is a tool for care, rather than the end product.  Favorite saying? “But look, we just built this and it’s so cool!”

My advice, when attending these meetings is several fold:

1. Be grateful that you are a doctor, so when you go back to your practice you can glory in feeling of getting something done!
2. Bring a giant latte so keep you in the game.
3. Realize that good results and ideas do come out of these meetings, but just not at the speed you or I are used to.

Talk later! I’m off to get a cappuccino before my next meeting!!!

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My Tweenager Daughter has anaphylaxis to tree nuts, walnuts in particular.  Earlier this year she accidentally ate a cookie containing ground walnuts, and you guessed it, was as near to anaphylaxis as I want to see.  After skewering her with an EPI pen, tossing in the car after she vomited, I raced to my local Emergency Department, picking up a police escort in the process.  (I was speeding, and had no remorse. Give me the ticket, and I’ll keep my kid alive, thank you.  What was funny was when I finally stopped in front of the ED and my husband zoomed in carrying my daughter, the police officer said, “You know, ma’am you were speeding.  I could understand it if you were a doctor on the way to an emergency, but you were just bringing your kid in.  She’ll be fine.”  I  didn’t say a word.)

Anyway, we did the whole drill, with a second epi shot in the ED, steroids, pepcid, benadryl, blah, blah, blah.  She was fine and we finally made it home.  I was a wreak, but she was fine.

So last week, we were at her doctor’s getting a check up.  I asked if they had gotten any notification from the Emergency Department about the visit.  Nope, no record sent to the PCP. And yes, I clearly identified who her PCP was during the visit to the emergency department.

ARGH! What does it take to have us communicate effectively and efficiently with each other???!!! Peoples lives are on the line, and we have to do better!

PS: For those with nut allergies, ground walnuts are hard to see in cookies.  Ask you neighbors about such things when they bring you baked goods.  (It was a bad mother moment when I let my guard down and let Tweenager Daughter eat the cookie with out asking about nuts!!!) Be careful out there!

The hospitals where I work have 30% of the patients that have “no PCP”.  That is an astonishingly high number, and is probably not a valid number–patients may not know who their PCP) is, or nobody asked, or it was just easier to hit “No PCP in the computer”. But so what? Why should you care?

Because it really, really matters from multiple stand points if the patient has an identified primary care physician.  It matters because:

• Patients that have an identified primary care physician have a place to go after discharge to get on going care.
• As highlighted in JAMA May 5 edition, heart failure patients that get follow up with in 7 days of discharge have a 10-14% lower risk of readmission or mortality.  If you don’t have a primary care physician it’s hard to get early follow up!
• Hospitals will soon get “dinged” for readmission of Medicare patients with in 30 days.  If the hospital doesn’t find out who the primary care physician is, they just raised the risk that the patient may be readmitted.  It behoves the hospital (and hospitalists/hospital physicians!) to find out, identify and communicate with the outpatient physicians regarding follow up care.
• Physicians, both in and out of the hospital care because we want practice good medicine.

So, clearly, from a patient, physician and hospital perspective, having an identified primary care doctor who will manage care after discharge is paramount for the health of the patient, and the finances of the hospital.  (Let’s call it like it is!)

So what needs to go on at the discharge process?

• Communication between “sending and receiving” physicians (the discharge summary!)
• Medical reconciliation
• Follow up plan outstanding tests and ongoing problems
• Preparation of the patient as to what to expect next
• Signs and symptoms of worsening conditions.

How well do we do with this?  PCPs complain constantly that they don’t get discharge summaries in a timely fashion, or at all. This directly effects follow up of outstanding issues and problems.   Medical reconciliation is fraught with mistakes, especially with fragmented record keeping.  Lastly, the discharge instructions to the patient are frequently misunderstood or incomplete.

So here’s what needs to be done:

• Hospitals must start by ramping up efforts to identify and document who the PCP is.
• Hospitals must identify and implement easy ways to get discharge summaries and other reports to PCPs in a timely fashion.
• Hospitals and hospital physicians must find ways to reconcile medications through out the hospital stay, recognizing the most dangerous medication hand off is at discharge.  Avenues to be explored include fax, interconnectivity of systems/interoperability of systems, phone calls, emails etc.
• Hospitals and hospital physicians must establish processes to verify understanding of patients of discharge instructions of follow up plans.

Get out there and make it happen!

I went to a noon lunch and learn given by my medical malpractice carrier, and the speaker reminded us that most patients have a 5th grade understanding of medical jargon. He told us to tailor our conversations and handouts to this level of understanding. I had heard this before and have tried to use this as a guide in my conversations with patients.

I was paging through the Annals of Internal Medicine, and there at the back are summaries of articles that can be given to patients.  (I’m not sure why you would want to give a patient a summary of a double blind placebo controlled randomized study, but just in case you do, Annals has it for you!) Anyway, there was a sheet you could tear out and give to patients summarizing “Cost-Effectiveness of Different Types of Evaluations Before Sports Participation in Young Adults.” I quote the paragraph entitled, “What is the problem and what is known about it so far?”

In the United States, sudden death in young people participating in competitive sports occurs at a low rate. Previously unknown heart disease is the leading cause of these deaths. Major medical organizations recommend that young athletes be evaluated for heart disease before they participate in organized sports. The American College of Cardiology and the American Heart Association recommend a medical history and physical examination, with further testing if history or examination is abnormal.  The European Society of Cardiology and the International Olympic Committee recommend including electrocardiography (ECG); this test records the electrical impulses of the heart and provides information about abnormal heart rhythms and other heart conditions.”

Wow. You’d have to be some fifth grader to make heads or tails of that paragraph! If I was a fifth grader, I could care less about the American College of Cardiology and the American Heart Association, as well as the European Society of Cardiology. I might care about the Internal Olympic Committee, if I envisioned myself as the next Lindsey Vonn, but other than that, the entire paragraph would mean nothing to me.

Should I send Annals the hand out from my malpractice insurer to help them make hand out sheets that are actually readable?

Imagine, you are the pilot of a 747, getting ready to land the plane at LAX (pilot speak for Los Angeles International Airport), your ear phones are strapped on, you are talking to the tower, verifying your landing instructions, going through the check list, lowering the landing gear, adjusting the fuel mixture, and just as you throttle back–

“Excuse me, captain, but the passenger in 12B really needs to go to the bathroom even though the no smoking sign is on.  Is that okay?” 

Pilots have the sterile cockpit–a situation in which, if the plane is below 10,000 feet, only conversation directly relevant to flying is allowed.  The rule was developed because take offs and landings are the most likely time a crash will occur, and take offs and landings occur below 10,000 feet. Simple enough, and it saves lives.

Physicians need a sterile cock pit.  I speak as a hospitalist, but I imagine many specialties would benefit as well.  What are mission critical times during my day? For admissions, I would say writing (or typing!) the H&P is the most critical time, followed by order entry (or order writing.)  For discharges I would say medical reconciliation is the most critical time.  For rounding, I would again say order making followed by the “plan” part of the SOAP note.

Wouldn’t it be nice if we could have a “cone of silence” or sterile cockpit in which we could think and perform these critical functions? Wouldn’t it be nice to have all pages delayed for a set amount of time (say, 20 minutes) until we are through with our critical tasks? (Does such a pager exist?) I’d still be willing to get Code Blue pages, but can’t the other stuff wait?  (Mr. Smith’s constipation for example.)  Nurses at my institution have a “no talk zone” around the pyxis to help decrease medical errors, so why are physicians any different than pilots and nurses?

They aren’t.  It’s a cultural issue.  Page early and often needs to be replaced with “page urgently when appropriate,” and an understanding that physicians need to be able to think uninterrupted to make good decisions and give good patient care.

Medical decision making grows more complicated daily.  Before we can even focus on the problem at hand, we have to synthezise data from many diverse sources–we use the old fashioned tools of listening and talking to patients and families, then log in to computers to obtain more data, view radiology images from yet another system, and call colleagues to discuss what we know or don’t know.

Whew.  Just the data gathering is complex, not to mention the actual decision making!

In a fun but scientific twist I offer a solution–give a doctor a bag of candy and we’ll make better decisions!

Our mental attitude effects how we make decisions.  If we are in a negative frame of mind, we tend to close down to other diagnoses and solutions, focusing on the obvious.  Furthermore, we are less likely to think in depth and go beyond the problem in front of us.    We are also less likely to engage the patient.  A body of work has been published, examing how affect effects clinical problem solving.  If a physician has a positive frame of mind, he or she is more likely to perform a deeper analysis of the problem, be more organized in the thinking process, and arrive at a correct decision faster!

Surprisingly, a similar study showed that giving a physician  a bag of candy, categorized as a small act of kindness, placed the clinician in a more positive frame of mind and inproved decision making. So what to do if no one is handing out bags of chocolate? Simply thinking about a good friend, or a favorite pet was also enough to shift frame of mind toward positivity and better decision making.

It may seem silly, but give it a whirl. I’ll try it out this week and let you know.  In the meantime, of course, you are welcome to send chocolates my way.  I am particularly partial to chocolove chocolate bars–the dark chocolate with raspberries

PS: tomorrow I’ll update you on the mixed results of the “do one thing differently” experiement of last week.

If you’re a typical doctor, you are constantly reading.  The doctor business seems to select for those of us that love to read and learn.  Recently, I felt that a lot of what I read wasn’t sticking–my brain was like rubber and everything just bounced off!  I have been rereading Love is the Killer App, by Tim Sanders, and his chapter on knowledge was striking–yes it finally stuck to my brain!

He suggests that we should read constantly (got that down!) but not just read, but consume and digest.  He says to highlight relevant sections, and write important points on the front cover.  He also suggests we talk about what we read, and that the more we talk about the book, the more we will learn, and the more able we will be to share our knowledge.  He suggests that we hang out at bookstores (truly one of my most favorite places!) and fill our plates with all sorts of books, searching for titles based on key words from topics we are interested in.

Sanders also instructs us to try and find the “Big Statements” of the book–those sentences that summarize and crystallize the message or lesson of the book.

My personal bent is to carry around an index card and highlighter (one that is not dried out!), and make notes on the index card and highlight the heck out of the book. Later on I file the card.  I keep a bunch of blank index cards in my brief case for this. (I have to hide the cards at home because Tweenager Daughter is always taking them!)

So, don’t just read–consume voraciously and digest throughly!  It’s what the doctor ordered.

Quote of the day: “If a man is called to sweep the streets, he should sweep streets even as Michelangelo painted, as Shakespeare wrote poetry, as  Beethoven composed music.  He should sweep streets so well that all the host of heaven and earth will pause and say, ‘Here lived a great sweeper who did his job well.”–Martin Luther King, Jr.

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…

The new year brings the January slowdown, in which patients don’t come to the office for appointments because of many reasons–most of them financial.  Lots of patients have huge deductibles, and will have to pay for every bit of their health care until it is met.  Other patients are tapped out from the holiday season, and are now looking at big debt.  So how do you encourage patients to come in and get the health care they need?

For new patients, make a big deal of the first appointment.  Send out a packet ahead of time, with your bio, as well as information about your staff, office info (where to park, hours, services), and forms to be filled out.  Include  payment policies. Also include a health “tip sheet”–e.g. reminders that exercise, prudent diet, proper medical care and non-smoking offer big health dividends.  (Yes, dear readers, of course you should already have all of this on your website!)  Include your card in the packet.

For established patients, send a reminder post card, and emphasize the necessity of continued medical management for continued health.  Make the postcards up beat, and again offer a health tip.  You don’t need to do postcards every month, but January is an especially good month to get everyone started on their new year’s resolutions!  Postcards should include contact information so patients can easily make appointments!  You should always have staff call and remind patients of their appointments 24-48 hours ahead of time.  There are automated ways to do this as well.

Consider offering something free–a noon seminar on healthy eating, or ways to include exercise in a daily routine.  One of the most fulfilling seminars I did was a diabetic teaching seminar, complete with lunch and samples.  I paired up with a nutritionist, and a drug rep bought a light lunch for the group.  It brought huge kudos and loyal patients in to the office.

Make the experience enjoyable.  Your receptionist should greet patients cheerfully, your office should be neat with up to date magazines, and for pity’s sake don’t keep patients waiting!  Have the patient make their next follow up appointment before they leave the office.

Develop a quarterly newsletter.  This is a chance to send out information on medications, immunizations, new staff, and encouraging news.  Newsletters are a way of attracting the type of patients you want to see in your office–and beginning to build a practice that you love.

Make it happen!