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

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!

As a hospitalist, I hate direct admits, especially from doctors I don’t know well.  The direct admits always seem to get called to me at 4:45, just as the busy clinic doc is wrapping up, and I’m throttling up for the admitting race. The clinic doc will call us with the patient info and ask us to go on faith that the patient is stable.  Cases that make me queasy and reject the patient as a direct admit:

• chest pain–I don’t care if the EKG is normal. Don’t ask me to direct admit a patient to tele, with the potential that they are having an acute coronary syndrome.  If the doc is concerned enough to admit someone with chest pain, they deserve a timely eval, something that may have to wait for several hours until I get to them.
• the physician hasn’t seen the patient, and is calling in based on a lab, or a report from a visiting nurse.  (I see this a lot with anemia–the patient will have a low hematocrit, and the PCP will assure me the patient is “stable.” How can you know the patient is stable if  you are not looking at them?)
• marginal vital signs.  Again with the assurance that the patient looks fine, “they not septic!”  Ha, I say.  My criteria is that a patient must be stable enough to wait two hours in a hospital bed before someone sees them to be a direct admit.  I will ask the PCP if the patient meets this criteria. 
• hypoxia–I hate admitting “stable” hypoxia.  If they are that stable, why do they need  to be admitted? I see this with chronic COPD patients on oxygen who are going up on their oxygen requirements.  The PCP will assure me that they are not in extremitis from their COPD exacerbation or pneumonia, but it takes a lot to convince me.  This type of patient can go down hill fast, and you can’t under rate breathing!
• TIA evaluation.  Patients like this may need a rapid CT scan and neuro exam before I am certain it’s “just a TIA.”

So why do PCPs direct admit? For a good reason–it saves the patient a lot of money and hassle not to have to go through the ED.  I’m all for cutting down costs, but only on verifiably stable patients.  I know that a direct admit gets labs and study results a lot slower than a patient in the ED.  Therefore, a direct admit patient may have treatment started much later than a patient that comes through the ED. This may be acceptable in very stable, slightly ill patient, but for many patients, the delay in diagnosis and treatment can lead to an extended stay and increased morbidity.  So, no, when I question the PCP, I’m not a lazy bum, I’m actually on medically solid ground.

My suggestion: develop a rock solid criteria for direct admits.  My proposed rules:

1. No chest pain or hypoxia direct admits.  Don’t care how stable the PCP says they are.
2. No one with marginal vital signs–and I get to be the arbiter of this.  If I think the patients is not stable enough, then they aren’t. It’s my name (and malpractice!) that is on the line, so, sorry, but I rule.
3. PCPs must have the patient physically in the office.  No one can get called in from home after a lab done yesterday, or last week, or last month.
4. Cellulitis is okay.
5. Social admits are okay.  Why waste all that ED time and money?  This is the one case I really think IS a direct admit.
6. No mental status change evals as a direct admit. C’mon, would you do that to your mom?

Lastly, my friendly PCP, I’m right there with you trying to take good care of patients, in a timely and cost effective manner.  My world is a little different than yours, and I hope you understand I’m not argumentative–I just see patients a little differently, and in a different time frame than you may.

As I pull myself out of my post holiday over fed stupor, I have a bunch of random items floating in my head.  Most of them have to do with my business, ExtraMD, but quite a few have to do with the process of practicing medicine.

Okay, that’s clear as mud.  I’m such a ruminator it’s amazing I don’t have a cud.  What I’m trying to say, is that I frequently review events and try to figure out what I can do in the future.  It’s a more constructive form of worrying, which I have down pat.  Here are some questions I am pondering, along with questions that have been asked of me:

• How can an EMR mimic work flow?  More specifically, why do most of us still think better on paper, and what can be done about it?  (Quite a few docs have asked said, “You know, I do a note on the EMR, and then can’t even remember what I wrote.”)  I don’t know if this is because we all trained on paper–leave out the puppy training/paper analogy! Perhaps the physicians currently in training that grow up with an EMR won’t have this problem.  Thoughts?
• How can I build more loyalty from the physicians that work for my company?  The last two months have been filled with prima donna behavior from them that has left me cringing and apologizing to our clients.  All from some of my best doctors that usually give me no problems at all!
• How can I recruit more physicians into my company that will help my company grow?  Entrepereneur magazine suggests I ask the potential candidate for his/her vision of their role in my company.  I really like that, as I think most candidates would not have a vision beyond the paycheck.  I’m not cynical, I just know that I have  not been rigorous enough in shaping and sharing a vision.
• Why do some consulting physicians intimidate me? And how can I muster up?   
• How can I find the time to do the things I want to do both professionally and personally?

I’ll be thinking about answers to these questions and post on them.  I’d appreciate your insights as well!

I am a fanatic about discharges.  Of all the hand offs we do in medicine, this one seems to be the most dangerous, with discharge medications being the road side bomb of hospital medicine.  A recent article in Archives of Internal Medicine examined the effectiveness of a pharmacist performing medication reconciliation, patient counseling and education and then making a follow up call at 72 hours.  The study examined ED visit and readmission rates at 14 and 30 days, and found no difference between intervention and control groups.

Important highlights of the article:

• one fifth of patients were found to have omitted medications.
• a phone call after discharge reduced readmission risk at 14 days, but the benefit of a post discharge call is not well defined–some data has shown a post discharge call leads to higher utilization of health care resources!  (Perhaps these calls identify other issues that require clinical follow up…)
• only 43% of patients were reached with a post discharge call, so the phone call data is limited.
• the article doesn’t mention how many medications were on the medical reconciliation at discharge.
• it took the pharmacist 87.5minutes to perform the reconciliation and “other discharge activities.” There is no way a discharging physician could spend this much time.  The article doesn’t mention what exactly the pharmacist was doing in these 87.5 minutes!

My (unscientific!) take away: patients with long medication list, lots of changes including stopping old medications and starting new ones, are at the most risk of errors and medical mishap.  These patients are probably older, have limited eye sight and hearing, and may not comprehend the changes.  Additionally, they may be on narcotic pain relievers, “sleepers”, and antidepressants, as well as a plethora of beta blockers, anticoagulants and oral hypoglycemics.  I think that this group of patients deserves their medications to be combed through with a fine tooth comb, and reviewed and reconciled with the family, the patient and other caregivers.  AND, for pity’s sake, the primary care doctor has got to be kept in the loop!  I would like to see a study that focuses on the elderly, and those who go home on 5 or more medications, as well as those on coumadin and diabetes agents.  I bet we would see a large improvement if these patients were the ones studied to examine effectiveness of pharmacist medical reconciliation at discharge.

Anyone interested?

 The November 23 issue isn’t on line yet.  Here’s the citation: “Impactof a Pharmacist-Fracilitated Hospital Discharge Program: A Quasi Experimental Study”, P.C. Walker, PharmD, et al, 2003-2010.

The November Mayo Clinic Proceedings has a feature article on “Armodafinil for Treatment of Excessive Sleepiness Associated with Shift Work Disorder: A Randomized, Controlled Study.”  The cliff note version: taking armodafinil makes the user more awaken and less likely to fall asleep during shift work, along with improving memory and attention.  (For details go read the article!)  In an accompanying editorial, Dr. Steven Rose wonders if such drugs should be used by resident physicians  He sites a push from the Institute of Medicine to further limit resident work hours, and examines the usefulness of a drug like armodafinil in residents.

Yuck.

Health care workers and “social service” workers represent the largest percentage of night shift workers in the United States.  They have higher rates of car crashes, depression and cardiovascular events than their day time counterparts.  What does the American pharmaceutical market, and by extension, the health care industry do?

Tell it’s workers to take drugs to “enhance performance”!  Mark McGuire are you listening?  You should have been a physician, where you would have been lauded as a test subject extraordinaire!

I’m going to be blunt here–this is totally screwed up!  Instead of figuring out ways to help residents, and all of us that work grave yard shifts,get more rest, and decrease the AMOUNT of shift workers needed, we are told to take drugs so we can stay awake longer on the job, and not crash our cars on the way home!  Dr. Rose points to the example of fighter pilots who are rigorously counselled and examined when they use armodafinil on long missions.  Do you think residents, and “nocturnists” will be counselled and followed clinically if they take armodafinil?  Heck no!

What example does this set? Just go ahead and take a pill to stay awake, another pill to sleep, another pill not to be depressed, another pill to have sex!

Pathetic! Let’s look for ways to use fewer night time workers, such as 4 hour shifts, automation, etc.  Let’s not create a bunch of pill popping physicians forced to do so because they are residents, or hospitalists, or ED MDs.  The last thing we need is a bunch of pill popping docs!

Note: at the time of this posting the online version of the Proceedings didn’t include the November issue.  Look for it in your mail.

I’m done with H1N1, but I fear it is not done with me.  Last week, rounding at my hospital, I felt like I had been transported back to the days of the plague.  Everyone wore masks, and outside each room were signs with warnings like “Droplet precautions!”  Carts stood beside each room, filled with masks, gowns, blue gloves, hand sanitizer and plastic stethoscopes.  The entry ways of the hospital are manned by “greeters” (ala Walmart!) who don’t allow anyone in under the age of 18, and ask potential visitors about flu like symptoms.  Those visitors deemed too young, or with flu symptoms, are sent away and not allowed in the door.

The Emergency Department is over run with those who are sick, or not so sick, with flu.  We go to meetings nearly daily on flu updates, and our hospital has a “control center” to deal with flu.  I received the H1N1 vaccine via nasal mist, but many of those required to get the shot because of age or having small children have not yet received their vaccine as my hospital has run out of shots.

We are also facing shortages of masks, gloves, gowns and antiseptic wipes.  According to the infection control nurse specialist, we are doing too good of a job wiping off surfaces with the wipes–the supply is going too fast.  Masks and gloves are part of a “strategic reserve” stock piled and allotted by the government.  So is tamiflu, which is more tightly controlled than narcotics at this point.  We are short on gowns, because the gowns were automatically loaded on the isolation carts, and so we all started putting them on when we saw them on the carts.   “Can’t you read the signs?” Asked one my ID colleagues.   Yes, we responded, but which do you believe–the sign that says wear a mask and gloves or the cart fully loaded with gowns?

They removed the gowns.  They can’t seem to decide what type of masks we should have: sometimes it is the N95, with special respirators, and now lately, just simple surgical masks.

The ones that seem to get the sickest are the young people–those 20 or 30 somethings.  They get sick quick, and end of “tubed and paralyzed” with in hours as one of my more grim colleagues puts it.  We wonder when we will run out of ventilators.  The good news appears to be that these youngsters get better after spending some quality time on the vent–about 1 or 2 weeks.  One of my non-medical friends was shocked–”That’s horrible!”  I, on the other hand, was delighted that they lived.

Be careful out there.  Wear your mask, use the hand sanitizer, and pray for spring.  And boy, do I wish I had bought stock in Purell!

photo of H1N1

Last night I ditched my tennis team practice and instead went to the Colorado Foundation for Medical Care “Launch of A Community Health Endeavor” meeting on how the community can/should reduce re-admissions to the hospital.  As you are hopefully aware, the CMS (Centers for Medicare and Medicaid Services) has mandated that the amount of re-admissions of medicare/medicaid patients must go down–approximately 20% of these patients are readmitted in the 30 days following their hospitalizations.  One of the hospitals I work at has been chosen to be part of a pilot study on decreasing re-admissions; CMS has picked 14 areas with in the country to take part in the initiative which CMS is funding.

There was a fair amount of finger pointing by some parties, a lot of talk, some power points, brochures and introductions, but not a lot of concrete planning.  I suppose it is early yet, but I was hoping we could get down to concrete tasks rather than the usual “it’s broken and has to be fixed.”  There was a panel discussion which contained the chief medical officers of the two hospitals involved, the director of the Center to Improve Care of the Dying from GW Medical School in Washington, D.C., a professor of medicine from the U–an expert on “care transition intervention”, two state representatives, a community liaison, and the chief medical officer of the Colorado Foundation for Medical Care.  There were no hospitalists on the panel.  The physicians on the panel were not “in the trench” physicians, but rather CMOs or University Professors.

Here are the general points that were made:

• Medication reconciliation is onerous to all, and the primary care physician doesn’t enough time to reconcile a med rec from a discharged patient.
• There needs to be a standardized form for all transfers.
• Hospitalists don’t pay for themselves, and make transfers even harder and more complicated.  They have some value however in that they are “enthusiastic” about making changes.
• Patients should have a Personal Health Record, (PHR), whether it is paper or electronic.  (No word on how we will access this–?from a memory stick?  Do I hear “computer virus”?)
• Nursing homes receive patients from hospitals/hospitalists “all the time” with out receiving proper discharge paperwork and medical reconciliation.
• Hospitals/hospitalists do not prepare patients for “the next care situation.”  One physician panelist asserted that hospitals and hospitalists “lie” to patients about nursing homes to get them out of the hospital.
• The way to fix all of this is by “Care Transition Coaches.”  These are non medical coaches are charged with visiting the patient in the home or nursing home.  They are to make sure the correct medications are being taken, and incorrect medications are NOT being taken, check that the patient knows who to call for problems (not necessarily the PCP), and that follow up appointments are made and that the patient has a way to get to them.  Additionally, Care Transition Coaches are to role play with patients so they know when to ask questions or bring up concerns at the follow up doctor visit.  (Example given: when following up with the cardiologist, the patient should not wait until “the door handle moment “to tell the doctor they are short of  breath when they lay down.)
• “Care Transition Coaches save $300,000 per coach.”  (Please do not ask me for the data on this number as I don’t have it!)

Hmm. The take away for me:

1. Transfers do indeed need to be standardized.  (I have ranted on this before.)
2. Medical reconciliation is paramount.  (I have ranted to hospital administrators on this, and am told it costs too much to do it effectively!)
3. We have got to do better at calling PCPs and SNIFs.  (And vice versa!)

As to the health transition coach: I’m not so sure.  I think the better solution is SLOWING DOWN HEALTH CARE.  Make it so we have time to contact each other, explain things to the patients, and review with the family what is next.  I don’t know that introducing yet another person into the mix –the “coach” is the answer.  I do believe that having the time to effectively communicate with patients, families and other care givers is!

And you? What do you think we should do to fix this problem?

I love science, and miss doing research.  I try to run mini “experiments” and thought you might enjoy the latest.  I decided that after each admission interview, after I did the obligate H&P questions, the exam, the outlining of the treatment plan, the answering of patient/family questions, I would ask one last question to the patient.

Here was my question:

What one thing can I do for you right now that would make you feel better?

I also vowed that I would do what it was the patient requested if it was reasonable and within my power.  I figured I would get a bunch of baloney requests, like, “Can I get some of that dilaudid for home use?” and “Cure my cancer,” and “Send me home.”

Surprise, cynics!

Here were the responses:

• Can I get something to eat?  (Yes, we got him a sack lunch in the ED.)
• Can I get something to drink? (Yes, I got him a cup of ice water.)
• Can I go to the bathroom? (Yes, I got the nurse to unhook him and take him to the bathroom.)
• Nothing, I feel much better already. (Wow, those ED docs are good!)

All of the responses were along these lines–requests to help out with simple needs.  There was no sarcasm from the patients, and no absurd requests.  I was able to comply with all of them, except for the patient who had to be kept NPO because he was waiting for a procedure.  I told a couple of people about the experiment, and one nurse had a very insightful comment:

“Isn’t it sad how far we get away from meeting our patients’ basic needs?”

Yes, it is sad, and I will continue my little experiment.  Sometimes, I have to ask the nurse for help, as providing physician level care is a priority, but on the other hand, didn’t I take an oath to help people? Apparently, it’s the little things that bring the most relief.

I am an avid reader and a rabid anti-tobacco being.  I have been extremely frustrated at my attempts to get patients to quit smoking, and to change their behaviors to healthy ones.  I recently finished the book Influencer: The Power To Change Anything by Patterson et. al. which examines how people and societies change.  I decided to look at smoking cessation, using an intervention review from the Archives of Internal Medicine (see “Smoking Cessations for Hospitalized Smokers”, Vol 168, No. 18, Oct 13, 2009 pp. 1950-1960 by Rigotti et. al., ) and evaluate it through the lens described in the book.

Hope that makes sense.

Vital behaviors: Patterson et al say to change people’s behavior we must clearly define what behavior we want change and provide a substitute behavior.  Usually there is one or two behaviors that are vital to change.  In this case the vital behavior is stopping smoking.    The Archives study looked at people who stopped smoking, verified (mostly) by salivary cotinine levels. The study found that the most effective intervention was hospital counseling and followed by for one month or greater post discharge support.  The length of follow up was key–as it seemed it took that at least a month to establish a replacement behavior.

Belief in change: people will change their behavior if 1) they think it will be worth it and 2) they can do what is required.  Patterson states that people are more likely to change if they have some personal experience demonstrating the need for the change.  As the study notes, being hospitalized can be experienced as a reason one should stop smoking.  Patterson notes that just telling people to change a behavior, or telling them to read about changing a behavior won’t produce the desired results.  (So quit lecturing and passing out slick pamphlets!)

Make the Undesirable Desirable: patients love to smoke, and are addicted to nicotine.  It’s a tough sell to get addicts to quit.  Frequently, it becomes desirable to quit only AFTER a devastating event–such asa hospital admission for MI.  (Interestingly, cessation was most effective in those with cardiovascular events, and least effective in those with cancer.  I guess once you are diagnosed with cancer, the cat’s out of the bag.)  The undesirable became desirable after patients experienced a devastating consequence.

Personal Ability: the study doesn’t go in to what counseling methods were employed.  One would assume that active strategies such as linking smoking cessation to personal values, distraction, distancing etc were used.

Harness Peer Pressure: the book advises using peers to create change.  Enrolling the family in support is likely to be helpful, but not included in the review.  (How many times have I tried to rally family members to help the patient quit?  I have noticed that smokers run in packs–making this pretty tough!)  However, the strength of the study comes in the fact that the intervention that worked was a hospital counseling session AND greater than one month post discharge support either in in person or over the phone.  (Efficacy of phone vs. face to face contact was not examined.)  It would be interesting to explore email support. The post discharge support likely was a form of social support and peer pressure.  

Design Rewards and Demand Accountability: One of the most powerful sections in the book is the section on rewards.  Intrinsic rewards are the most motivating, and big rewards for small behavior changes can actually diminish the behavior.  In smoking cessation, it is impossible for clinicians to demand accountability.  The rewards for stopping smoking are more money (less spent on cigarettes!), greater health, and improved outer appearance.  These are mostly intrinsic rewards.  However, clinicians can remind patients of  these rewards and encourage change.

Change the Environment: people will respond to changes in the environment–e.g. taxing the heck out of cigarettes.  This is not a direct intervention but a societal interevention, and practically the easiest intervention of all. 

So what did the study find?  People were most likely to stop smoking if there was a hospital counseling session, longer than 15 minutes, and over a month of post discharge support.  Adding nicotine replacement therapy increased quit rates, but not a statistically significant change! Anything less than a month worth of post discharge support didn’t help, and any hospital intervention with out post discharge support had no effect on quit rates.

Take home message from the study and the book: start with a hospital intervention after a patient experiences a personal consequence from smoking, follow it up with over a month worth of post discharge support, involve the family (peer pressure), point out intrinsic rewards and change the environment (tax those cancer sticks!)

One of my coworkers accused me of being a geek because of my tool box.  Now, I admit, perhaps I look like a refrigerator repair man, but GEEK? So, just to show you all that I am not a geek, I will tell you what is in my tool box when I round at the hospital.

I carry a clipboard/box. The top is a clipboard, that flips open so I have a storage box underneath.  I clip my rounding list to the top, and stick a couple of pens inside, and wear my stethoscope around my neck.  I loathe white coats, so only wear one if I haven’t had time to iron a shirt.

But, what’s in the box?

• My smart phone with my emails, phone numbers, calendar, task list and list of my passwords.  (Good grief, how many  passwords do we all have?!)
• Extra pens with the good grips. (Forget stick pens!)
• Picture of Daughter, (now that I think of it, why don’t I have a picture of Hubby?) 
• Money for emergency cappucinos.
• A copy of  Pharmocopaeia, and Sanford.
• The latest ACLS protocol cards.
• A list of phone numbers for consultants on a laminated card.
• Business cards that I hand out liberally to patients.
• A yellow sticky pad–you never know when you will need one.
• Chapstick.
• Mini toothbrush and paste–for brushing after that emergency cappucino!
• If I’m at the hospital that doesn’t use an EMR, I stick in a bunch of our preprinted progress notes and H&Ps.

Geek?  Heck no, I prefer to think of myself as the Girl Scout of hospitalists–prepared for anything!