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

It’s hard to teach an old dog (me) new tricks, or to remember old ones.

The other night I was working the swing shift, and admitted a patient who I thought may have adrenal insufficiency.  Being the good internist that I think I am, I decided to order a cortrosyn stimulation test.  Being the creature of a habit that I am, I wrote “cortrosyn stim test at time o and in one hour” in the orders, not specifying the amount of cortrosyn.   There poor ward clerk was mystified.  “What do you mean, cortrosyn stim test–is that a radiology procedure?”

Spoiled creature that I am, used to simply typing in “cortrosyn stim test” in the computerized order entry system at the other hospital where I work–and having it spit out the protocol with out me looking up how much and at what times to give the cortrosyn and measure the cortisol levels.  All this got me thinking–do order sets make us stupid?  At my other hospital, where we have a complete electronic health record, we rely heavily on order sets and protocols.  This is all to improve care, but I think I have gotten overly reliant on them.

I had to go look up the dosing nomogram for the cortrosyn stim test.  I had a difficult time getting good results in my computerized search, and ended up asking a colleague, who, ironically enough,was ordering the same test and writing it in the orders.  I wrote out the whole protocol and turned it in to the ward clerk.

Sad as it is, it is probably a good think for me to have to slow down and write out orders. It makes me think a little harder, and that’s a good thing.

I wear many hats, and I suppose you do as well.  I wear my small business owner hat when I run/manage my company, ExtraMD, my doctor hat when I play doctor, and my consultant hat when I head off to multiple meetings that seem to define the EHR consultant world I live in.  Of course, I wear my mother hat, wife hat, Girl Scout leader hat, and the hat that seems to get worn the least–the self hat.

My biggest challenge is going from role to role.  It’s hard to switch gears when going from one area to the next. Here’s what I have learned (so far!):

• there is no such thing as balance. Accept that you will spend more time in any given role depending on the importance/immediacy of the project at hand.  (For instance: when I am seeing patients, everything else, barring outright family emergency, comes second.)
• everything is a project, and projects need to be divided in to action steps. 
• define to-do lists by action steps–example “call” or “email” are proper ways to head a to-do list.  “Decide” is not–you have to figure out what to do to help you decide something–do you need more information, to talk to someone, to get financial estimates? Break the item down into clearly defined verb oriented action steps.
• in meetings, I take notes, and on the side of the page, create “action steps” from my notes.  I have an action journal I got from behance that I love.  I then periodically go through the notes and make sure I have acted on the action items.
• put some items on the back burner, and keep a list of these ideas.  Not all ideas can or should be acted on at the same time.
• realize you can’t think of everything.  I have a good friend I talk to about my small business, and several doctors I run things by.  Still looking for someone to talk to about the consulting gig.

Would love to hear about things YOU do in your multiple roles!

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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This year has been the year of information technology learning experiences.  My web site has undergone a major upgrade (which is still not live!), I bought a new cell phone (a Blackberry, which I love), and one of our office computers suffered a major meltdown complements of McAffee. Here are lessons a non geek doctor has learned (so far!) from the wonderful world of information technology:

1. Pick two of three: good, cheap or fast.  I am trying to get an online reservation system built for my website (www.extramd.com) so our clients can request physician coverage on line.  We started the project in January, with the idea it would be running by the end of February.  It’s still not fully operational.  The person I have doing it is good and cheap, but not fast.  I’m a small business owner, and I trully believe you can only afford  two of the three. I elected for for cheap and good, but I don’t know if this was the right choice.
2. Don’t listen to teenage salesman when it comes to cell phones.  Last December, I listened to a youngster at the phone store, bought in to the hype and bought a Droid phone.  What a mistake.  Nothing on it that was actually useful.  It had all sorts of “aps” you could put on the empty phone, but after I calculated the cost of loading up the phone so it was actually usable, I turned it in for a Blackberry.  Love the Blackberry, hated the Droid.
3. Antivirus programs aren’t that good, especially when they are the cause of a computer crash.  Last month, the main computer my company runs on crashed because of McAffee, the anti viral software the “protects” my computers.  McAffee had just released a new upgrade, and down went the computer.  After two days of trying to fix it, I took it to the computer doctor, who told me the upgrade crashed the computer.  I had just paid to renew McAffee on all the computers.  McAffee says it will make good on the repair bill, and will let you know when/if I get the check.  (My claim is “under review.”)
4. Have some sort antiviral protection however.  Entrepreneur magazine states that one third of small businesses have no antivirus software!
5. Don’t open emails that say “open here for free cash.”  I didn’t do this, but believe it or not, this is a prime way small businesses get attacked by viruses.  Some poor slob opens that email, and in marches the virus.
6. Back up your computer in multiple ways.  I like mozy.com which backs my computers up in to the “cloud”, and I also back up on to a flash drive.  You will still have to go through the pain of resinstalling everything if you do suffer an attack, but it’s better than nothing! A friend of mine had a disc drive failure and it still took her 40 hours to restore everything!

There are many more mistakes I’m sure I’ll make, but I’ll learn from them! Hope you can learn from mine!!

Today I was at one of my favorite sites on lifehacks.  There was a blog on the “10Tips to Create a High Performance Workplace”.  Me being the fun loving, efficiency afficiondo instantly started reading the blog.  So here is how my work place stacks up, and why I now have a really great excuse for low performance(!):

• “Clean”–sheesh, the card table with the two computers on it that the ED lets the hospitalists work at is covered with crumbs, coffee cups containing gel like brown material and used tissues.
• “Organized”–no organization here.   There is a stack of order sheets you can root through if you have the time.  Otherwise, it’s easier to print out your own.
• “Uncluttered”–see notes on food ditrius above, not to mention that there is no usable space–it’s all taken up by the computer monitors, the printer, and the random stacks of order sheets.  I frequently put my clip board in my lap ’cause that’s the only place left.
• “Walls painted a color–not white”–Ha, ha, ha.  The only color on the white walls is spatter from mysterious body fluids, whose origin I would prefer not to investigate.
• “Good natural light”–I have yet to be in an ED that has a window.  Were they afraid patients would escape out the windows when they designed the building?
• “Healthy live plants”–the only plants that are in the ED are the ones used for “medicinal” purposes, and they aren’t living–unless they survived their time in plastic baggies.
• “Intersting colorful art”–I guess the wall spatter could be an abstract painting of sorts…but the color scheme leaves alot to be desired.  At least in a primary care office they can put in some color and nice art work. Hmm, maybe primary care does have an upside!
• “Momentos that matter to you”–I don’t carry anything that matters to me in to the hospital for fear of losing it!

Wow, no wonder my brain goes to mush as the environment I work in is chaotic, cluttered, filthy, noisey and cold.  Seriously, however, I wonder if we would have better decision making and outcomes if our work environment was less chaotic (not to mention better behavior by some patients!)  I think a sunny yellow would pep me right up!

I like to fancy that I am a good doctor.  I know I am good at reading, and particulary like to read old charts of the patients I am about to see.  The two hospitals I work at have EMRs, as do lots of the primary care doctors whose patients I help care for.  (No, I’m not going to rant on interconnectivity, although it’s tempting.)

No, today I am going to rant on two things: admission history and physicals, and discharge summaries.  Much can be gleaned from them, and at my two hospitals both theH&) andthe discharge summarey are  part of the EMR, EHR. (I’ve been told to refer to the electronic record as the electronic health record from here on, so I’m retraining myself.)  Anyway, much is to be gained from reading the discharge that your colleague so dilligently dictated or typed.  Like, your patient who had “heart troubles” and had that “normal test” actually had a stent placed and was told to take plavix, which the patient never picked up because it was too expensive. (Admit, you have all had that patient!) So, just from reading a one paragraph summary, you figured out the patient has known coronoary disease, and is at risk for re-occlusion because he had never picked up their plavix.  You look brilliant, but you’re not–you’re just thorough because you took the time to read the notes.

I love being the hero, especially when all I have to do is read the chart.  These days it’s even easier to get reliable information.  In the age of electronic health records, there is no excuse not to know what happened the last time your patient was in the hospital.  So stop you whining about EHRs and look like a hero.  (Now, if we could only link all of our various EHRs together…but that would be Nirvana!)

I’m on an efficiency tear, because my plate is so darn full lately.  I’m loving my EMR consultant gig as EPIC champion, but still do doctoring and run my small locums firm, ExtraMD.

So for my sake, as well as yours, here are some efficiency hacks I found:

1. Answer the phone. Sounds pitiful, but I looked at my phone as it was ringing and almost didn’t answer it because I knew it would be a tough call. I sucked it up, and got the difficult conversation done, and saved myself the call back and the inevitable phone tag.
2. Corollary to above rule: emails are not always the most efficient way to get things done.  In my mind, emails begat emails.  Email is great for yes/no questions, but down right ridiculous for extended conversations that need to take place by phone or in person.
3. Make a to do list the night before. Yes, I’ve said it before, but do it!
4. Each day, think, “If there is just one task I need to do today to make today successful, what would it be?” Then go do that one task.
5. Don’t go to meetings if you won’t add anything/you won’t get anything from the meeting.  It’s okay to say no.
6. Impose time limits on discussions.  I was at a meeting where there were 150 items to go through (not kidding here!) Finally I suggested the group limit it’s discussion to 5 minutes per item. If we couldn’t decide what to do after 5 minutes, we moved on.  We actually had a time keeper to keep us on track. It worked.
7. Do NOT multitask!!! Do not be distracted by shiny objects! Focus on one thing at a time!
8. Don’t mindlessly surf the Internet.  (Hey, I was looking for tips on efficiency when I was surfing!)
9. Be happy! No, I’m not suggesting eating brownies from the  local baked good marijuana store.  Happy people have more energy and make less mistakes.
10. Take a break when you are overwhelmed.  When you get so buried and frustrated, you make mistakes and slow down. So, paradoxically, taking a break is probably just the ticket.

Alright, send me your efficiency hacks–c’mon I need all the help I can get!

I don’t know how you feel about pain management, both acute and chronic, but articles like the recent one in Annals of Internal Medicine(“Opioid Prescriptions for Chronic Pain and Overdose” 1/19/2010, vol 152, #2, pp88) don’t make it even easer.

Basically the article said that 3% of adults are on long term opioids, and that the older the patient and the higher the dose, the higher the risk of overdose.  Add benzos in to the mix, and the risk goes up even higher.  Additionally, the highest chance of accidental over dose is upon initiation of the drug.  The situations that I think are potentially dangerous are the times you have a Little Old Lady right out of surgery, on her valium for sleep (“I’ve been on it for years, Sweetie!”) who now needs narcotics for her hip replacement. And yup,  the orthopods want you, trusty hospitalist, to manage her pain!

I hate PCAs. I really hate PCAs and Little Old Ladies.  (I don’t however, hate Little Old Ladies!)  So whenever possible, I nix the PCAs and try to convert patients on to oxycodone (no acetaminophen–I like to dose that separately), and occasionally on to ms contin with oxycodone for breakthrough.  The only issue I have with this is that nursing staff can get really busy and not get the oral analgesic to the LOL on time, and the pain level sky rockets, and LOL ends up with a shot of morphine or dilaudid.

So what to do?  Anyone know of slick tricks around this so that the  Little Old Lady has her pain managed with oral medications delivered on time?  (By the way, is not a rap on the hands of nursing–I just want to be realistic!) Let me know how you manage pain in this vulnerable population!

The do one thing differently experiment yielded mixed results.  First of all, for complete disclosure, I didn’t get through them all.  (Should I have titled it: just do something different?)

Monday: use phone more and email less. A huge success. I got more done by walking the dog and making calls then by sitting in front of the computer plunking out messages.  I intend to this more, and continued to do it this week as well.

Tuesday: plan the day ahead of time.  Mixed results.  I think I wasn’t specific enough: e.g. “from 9am to 10 am, meeting, 10 am to 10:30 emails” probably would have been better.  I found I didn’t get through the things I planned because I ran out of time.

Wednesday: look for ways my assistant can do more.  Again mixed results. Sometimes I got so busy I didn’t have time to figure out stuff for her to do–which would have saved time! (Truly pathetic, I know!)

Thursday: investigate tweetdeck. Didn’t get to it.  See excuses under Tuesday and Wednesday.

Friday: look at getjar.com for apps for my black berry to improve efficiency.  Roamed the site, but didn’t find anything helpful.

And how are your experiments going?

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.