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.

Family Practice and Internal Medicine physicians wanted to join ExtraMD, Denver’s local locums.  ExtraMD, in practice for 7 years, specializes in placing FP/IM physicians in short and long term assignments in the Denver/Boulder area.  ExtraMD covers family medicine and internal medicine clinics, urgent care and hospital medicine groups.  Benefits include flexible schedule, ability to have extended time off, and the ability to work in the situation of your choice.  Please do not apply if you are not boarded, and don’t have malpractice coverage.   Physicians who value interesting clinical work, balanced with home and family life should apply.  Slackers need not bother!

Who qualifies?

Must be board certified family medicine or internal medicine physician.

Must have Colorado License, DEA and proof of malpractice.

Must be committed to the flexible schedule and mind candy that go along with fill in work, and who honor their commitment to work and family.

Must have ACLS if doing urgent care or hospital medicine.

Signing bonus: to applicants that commit to working 10 shifts with ExtraMD.

Reply to info at extramd dot com.

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?

Please join me in remembering a great icon of the entertainment community. The Pillsbury Doughboy died yesterday of a yeast infection and trauma complications from repeated pokes in the belly. He was 71.

Doughboy was buried in a lightly greased coffin. Dozens of celebrities turned out to pay their respects, including Mrs. Butterworth, Hungry Jack, the California Raisins, Betty Crocker, the Hostess Twinkies, and Captain Crunch. The grave site was piled high with flours.

Aunt Jemima delivered the eulogy and lovingly described Doughboy as a man who never knew how much he was kneaded. Born and bread in Minnesota , Doughboy rose quickly in show business, but his later life was filled with turnovers.. He was not considered a very smart cookie, wasting much of his dough on half- baked schemes. Despite being a little flaky at times, he still was a crusty old man and was considered a positive roll model for millions.

Doughboy is survived by his wife Play Dough, three children: John Dough, Jane Dough and Dosey Dough, plus they had one in the oven. He is also survived by his elderly father, Pop Tart.

The funeral was held at 3:50 for about 20 minutes.

If this made you smile for even a brief second, please rise to the occasion and take time to pass it on and share that smile with someone else that may be having a crumby day and kneads a lift.  

Thanks Dr. A for sending this on–humor is the glu(ten) that holds us together!

The so called Edwin Smith Papyrus, a 16th century B.C. manuscript, written in ancient Egypt script,  describes the treatment of 48 traumatic injuries, like those suffered in battle and pyramid building.  Edwin Smith, an American living in Egypt, bought the manuscript in 1862, and it eventually made its way to the New York Academy of Medicine.  It details the physical exam, treatment and prognosis of various traumatic injuries.  It is logically organized, working from the head down.  (We can’t read past the torso, as the papyrus breaks off.)

Among the recommendations:

• honey and moldy bread to cure infection (?early penicillin?)
• raw meat to stop bleeding
• immobilization of head and neck injuries
• use of sutures to close wounds
• use of papyrus to document illnesses (early charting system!)
• how to set a broken jaw.

As to prognosis, the author of the papyrus categorizes  ailments into one of three  prognosis: “An ailment I will handle,”  “An ailment I will fight with” and “An ailment for which nothing can be done.”  The latter must have applied to case 31–a description of paraplegia, in which a patient is “unaware of his arms and legs” and a loss of bladder control is noted.  The papyrus notes that this is secondary to a spinal cord injury.

The papyrus is logical and organized, but if all else fails, there is an magical incantation to be used, noted in case 9.  For a look at the papyrus, and it’s translation as well as explanations and more facts, visit the National Library of Medicine.  You can actually “unroll the scroll” from start to finish, and read along.  Have fun!

• We prefer stories to statistics.  Hopefully, we physicians are more focused on evidence based medicine, but there is the adage that we are only as good as our last (complicated) case.  This can also be described as availability–our estimate of the probability of something being true based on how well we remember similar events.
• We seek to confirm rather than to question our beliefs.  In other words, we look for information that confirms we are right.
• We don’t appreciate that chance and coincidence can shape events.  I don’t know how much this applies to medicine, as events usually aren’t coincidental.
• We over simplify.  Who doesn’t? Everything is so darn complicated!  I do wonder if there is so much information and options in medicine that it is too complicated for us to understand, so we instinctively try to simplify to better understand and manage problems.  We arrive on a particular diagnosis and this is the anchor.  We then adjust this anchor based on further information. However, we typically fail to reevaluate and underestimate the probability of a disease even when we have further information.
• We misperceive the world around us.
• Our memory is inaccurate.  Medicine is very much based on what you know, which is based on what you remember.  However, given the explosive rate of growth of information, perhaps as former Google CIO Doug Merrill points out, maybe it’s time we turn from memorizing information to becoming proficient on searching and finding relevant information.
• We classify data based on “representativeness”–e.g. in our experience, does this patient represent a patient with a certain illness?   This works when a disease is common, but fails when the disease is rare, the patient is atypical, or our previous experience was atypical.

If, at the minimum, we are attentive to these filters we place on our thinking, our error rates should go down.  And just for fun, check out the latest JAMA (June 23/30) article entitled “Adherence to Surgical Care Improvement Project Measures and the Association with Post0perative Infections.”  This article shows some errors in common thinking–especially over simplification!

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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!

How does your hospital measure up? Here’s a partial list of outstanding items that hospitals/providers must:

• Institute adequate level of nursing (!)
• Management of ICU patients should be by critical care docs.  (Much disagreement in the literature about this one!)
• Have active participation by pharmacists in medication dispensing, use and monitoring
• Use standard abbreviations (I think we all had this beaten in to us!)
• Clearly document Patent’s “COR” status.
• Implement processes to prevent pressure ulcers.
• Implement DVT prophylaxis protocols — surgeons are you listening?!!!
• Monitor patients with renal insufficiency
• Do surgery on the right patient, and do the right surgery, and do the surgery right!
• Clean your hands.

Okay this is a summary.  But, truly, how well are we doing?  My hospital could use a little improvement on a couple–the COR status and the DVT prophylaxis, not to mention appropriate staffing by nurses.

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