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?

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…

• Wear your name tag so it’s visible on your right shoulder.  (Now, one of my colleagues feels this draws attention to her chest, but I have no better suggestions.)
• Extend your hand and introduce yourself every time, unless the patient knows you extremely well.
• Always call patients by their last names.  My mother, God bless her, goes ballistic if someone calls her by her first name.  If invited, you can call your patient by their first name, but don’t presume it’s okay!
• Turn your cell phone off during meetings. I eat lunch with a doctor that checks his email on his blackberry while chatting with colleagues and it makes me nuts.  It makes me feel as if what I have to say is unimportant (perhaps it is…)
• Open the door and help patients down from the exam table, especially for those little old ladies! Who wants a broken hip in the office?
• Specialists: don’t treat hospitalists like they are your residents.  We’re not.
• Hospitalists: don’t treat primary care doctors like they are your incompetent interns.  They’re not.
• Be on time.  Every one’s time is valuable.
• Dress appropriately.  What’s with scraggly beards, the pinned together blouses?
• Say please and thank you.  This goes a long way in today’s hyperharried, tweeted, anxious world. Just take the time to be genuinely thankful for something somebody does for you, no matter how small.

So, to that end, thank you for reading this blog post. I would be honored to hear your kind comments!

And thank you to Success magazine for the inspiration!

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The final straw was when I was attempting (thank God for pulmonary!) to intubate a patient in the ICU at Hospital B.  It was horrible, with the patient having massive emesis and desating to anaerobic levels, when suddenly, I got a page.  The nurse  initiating the page reported to me that my patient had a cold sore on her lip, and the family wanted her started on something for it.   At Hospital B the nurse culture is such that nurses page early and often.  It doesn’t matter if the issue is trivial or critical–a page instantly goes out, and the nurse is absolved of responsibility, the family is happy and all is well.

Except that it is not.  Pages need to be used for important matters–as a page can frequently interrupt a critical conversation, procedure or even a critical thought process.  Low level pages create mistakes as we pull our attention from the critical to the mundane.   I propose a couple of solutions, and wonder if others have stories and solutions as well:

1. Nurses text us with requests.  This way we don’t have to leave a critical conversation or encounter to answer a page.  (This is what they are encouraging at Hospital A.)
2. Nurses can assign a “stat code” to a page such as “911″ or “111″.
3. Nurses can leave us a note on the computer.  (At Hospital A, we still use paper charts, and the nurses will tape notes to the top of the chart–like “call Mrs. Sicky’s family” or “please clarify if you want colace–she’s having diarrhea.”)
4. Nurses need to know that it is okay to wait on smaller, less important issues.  This is a culture issue, and while I dearly love the “patient is always first” attitude at Hospital B, it has translated to “MY patient is always first”–which is not necessarily true or even medically sound reasoning.  Other patients come first sometimes!

Thanks for listening.  I would love to know what I can do to make pages less intrusive so we all can keep the focus on the patient we are with.

In the church bulletin I was struck by three prayer requests: one was a request for prayer for a woman diagnosed with stage 2 breast cancer who is now status post surgery,one for a patient in pain from a herniated disk, and the last for a patient that had a knee replacement.

“For God’s sake,” I though, wearing my hospital acquired cynicism like a suit of armor, “what the he** are they worrying about?  That’s all minor stuff.  I can’t believe they are so stressed out they put in a prayer request!”

But then something switched.  Maybe it was the music, or the sermon, or the communion wine, but I lost my cynical coat.  For those families, and the ones I met the past week, what they were going  through was huge, significant and scary.  It might not have felt that way to me, but to them, these were all huge crises, involving a loved one, and with unbelievable stress.  Sometimes, I (we–admit you do it too!) forget what it is like on the other side of the bed, when something really horrific is going on, and it all seems so bewildering and unfriendly and sterile, and most of all, uncaring.

I will try to better, to use the other perspective of the patient and family as well as my crisp, efficient doctor perspective.  I really do care, and I bet you do too.

God bless.

PS: I actually had the communion “grape juice.”

I was eating lunch in the doctor’s lounge when I heard a young doctor harassing his secretary via phone. He sounded so self centered and paternalistic that I wanted to smack him with a news paper like one would do with a naughty puppy. He was doing stuff like raising his voice, and using words I can’t use in this blog.

I understand that we get angry.  But talking civilly to each other and our office staff needs to be a requirement.  It’s just not okay to vent your spleen onto a hapless office worker, no matter who has caused your ire to rise.  Unfortunately, it seems that it is more and more acceptable to use swear words and disabuse others in the work place.  However, if we are trying to build a better practice, not using expletives, calming down, and keeping our traps shut might just do the trick.

So to that end, I offer up the swear word I use (don’t laugh!).  I started using this when my daughter was born, in an effort to clean up my then potty mouth.  It actually did the trick, and I swear much less frequently, and never at work.

So when you are really, really angry, you may say, “Oh Poopy Dogs!”

Let me know how that works for you.

As we all know, multitasking is a myth.  The human brain can not truly multitask–it can only hold one thought at a time.  As most attending physicians and all resident physicians know, a pager slows you down.  But how does it slow us down, and why is it dangerous?

When we are doing multiple tasks, we do none of them well.  That may be okay if you are knitting and watching TV, but when trying to manage a complicated case, interruptions can be deadly.  Take, for example a simple page, like the one I got yesterday, “Dr. So and So is not answering his pager?  Is he here today?”  Simple to answer, but what are the results?

1. I can’t complete my thought process, and it takes twice as long to get done what I was doing.
2. I forgot what I was doing, or planned to do.  I had to reorient myself to the complicated patient at hand and re-immerse myself in planning a diagnostic and treatment strategy.  Studies have shown that within 15 seconds of considering a new problem, we will forget the old problem.
3. It took me time to  get back in to the deep thinking mode that this very complicated patient required.
4. Multitasking leads to inattention blindness: we are so taken with one task we are inattentive to the other task, and ta da! mistakeville!  (Hmm, where could Dr. So and So be?  Is his pager battery dead?)
5. Multitasking leads to “task saturation”–becoming so engrossed in one problem that we forget the bigger problem at hand, that requires clear focus.  (Oh yeah, I was just about to move Mr. Very Sick to the ICU, but got involved in dead batteries!)

So how to fix this?  Sometimes, I deliberately do not answer pages instantly.  If I am in with a patient or putting orders in I will not call back right away.  I do look at the pager so I know where the page is coming from.  (For instance, I sometimes delay calling the ED back, as I know there is a physician on hand to handle emergencies.  I usually call the ICU back right away.)  However, this still requires me to look at the pager and figure out the level of importance, distracting me again.  Lastly, hospital groups, if they are busy enough, should have a designated admitting doctor, one that is not rounding.  Rounding, taking calls from the ED, and farming out admissions is a clear recipe for multitasking disaster.  Yes, I know, it’s the culture, but maybe it’s a culture whose time has come and gone now that hospitalists are busier than ever. 

It would help to have pages routed through a nurse practitioner, as some groups do.  In addition, it would be nice if I could get the nurses to assign a priority number to their pages.  And lastly, are all these pages necessary?  How about a formal study on how many errors pagers cause, and what kind of errors?  Motorola could fund it.

And yes, while I wrote this, I was interrupted three times–in twenty minutes–at home.

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Here are the “5 A’s” as developed by the Brown School of Medicine  (I have added my notes in parentheses):

• Agenda: attend to the patient’s agenda, and then explain your agenda of helping the patient change an unhealthy behavior. (Note: I would prefer a visit JUST to address the unhealthy behavior but…)
• Ask: what does the patient know about the behavior, it’s health risks, and does the patient have interest in changing the behavior? Have they tried to change before? What’s worked or not worked?  (Note: then listen!)
• Advise: tell the patient you strongly advise a behavior change. Personalize why the patient should change, and discuss short and long term benefits of change.  (Note: this should be the shortest section of the entire encounter!)
• Assist: address patients feelings about change, and address barriers. Discuss steps to be taken to change, and provide support.  Provide information for the patient to take home, and other resources if you have them. (Note: the website suggests written information be given if available. This may be okay, but I advocate a DVD in addition, if available.  More on this in a later post.)
• Arrange follow up: reaffirm the plan and then arrange for a follow up visit or phone call.

Most of us use this outline, in some form or another, but my sense is that we tend to be heavy on the advising and light on the asking and follow up.  This type of patient may benefit from group visits.  Send in your success stories and techniques!

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Gladwell notes that “plane crashes are much more likely to be the result of an accumulation of minor difficulties and seemingly trivial malfunctions…The typical accident involves seven consecutive human errors.”  He states that in a typical crash, the weather is poor, the pilot is stressed, the pilots are hurrying , the pilots are tired, and the pilots have not worked together before (italics mine.)  Gladwell relates that the seven errors are not usually due to lack of knowledge or skill.

Yikes.  How many times are we seeing patients when we are stressed, hurried, tired and we don’t know who we are working with (the patient or staff), and we have “poor weather” e.g. a sick or complicated patient?  Too many.  So what can be done?

Following are lessons from Gladwell, but applied to medicine:

• If you are the “pilot in command” listen carefully to what those around you are saying.  “First officers” (nurses, therapists) may be too subtle in their hints that something is wrong.  (My favorite:  “Dr. Pookie, I don’t know what, but something is wrong with Patient Dunno Wuzwrong.”  Arrgh!  This is a patient I always go see, because I know there is something wrong but never know what I will find!)  Gladwell notes that those who are equals but placed in a second in command position tend to speak more obliquely than those in command.
• If you are the “first officer,” speak succinctly and directly of your concern.  (“Patient C. Opdier has a respiratory rate of 34, and is tiring out. Please come see him, as I am concerned he will arrest.” Got my attention!)
• Ask for help when the situation requires it.  Gladwell details a complicated flight where the pilot in command involves all  the commercial pilots on board (a total of 3 others) in landing a plane emergently.  The pilot effectively used every resource he had to get the plane down safely.  Trying to tackle a complicated situation without help leads to plane crashes!  (Hmm, what about the attitude that was emphasized in residency: “I can do it all with no sleep, no food and absolutely, no help!”)
• Speak clearly.  When you in an emergency, or critical situation make it clear what you need, and when.  As a female physician I have struggled with this, but have learned to be more assertive, especially with subspecialists.  (Me: “Dr. Amazing Cardiologist, I need you to come see Mrs. Killip now as I think she needs to go to the cath lab.”) 
• Slow down.  Recheck the information you are getting and make sure it fits the situation.  (Especially chilling is the story of KAL 801, in which the plane crashes into the side of a mountain after a series of missed communications and ignored information.)
• Get some rest.  (Right!  If someone can cure my early morning awakenings when I ruminate about patients, my husband’s job, the economy, my kid, my dog, my garden…I will become a better doctor!)

Read Outliers.  It is worth buying the book for the chapter titled “The Ethnic Theory of Plane Crashes.”

1. “Your right to make health care decisions.” Brochure, 7 pages.
2. “Remember your hero book mark.”  Patients were supposed to write the name of a caregiver they really liked on it to remember the caregiver in the future.  Surprisingly, my name was NOT filled in by dear Hubby.
3. “Notice of Privacy Practices”–HIPPA junk, 8 pages long.
4. “Need Help Paying for Your Health Care”–4 pages.
5. “Welcome to our hospital” –from the CEO. One page, single spaced.  Now I know who he is–and I’ve worked there 8 years!
6. “Our mission”–from the CEO.  One page single spaced.  (Do I care?)
7. “Stop smoking” –2 pages.  (My husband doesn’t smoke.)
8. “Make your health care safe”–2 pages.
9. “What if I have concerns about my care”–1 page.
10. “Is it a side effect or Allergy?”–1 page.
11. Hospital admission agreement, small type single space one each for pre-op and surgery, total two pages.
12. “Important Health Care Decisions” one page, signed by God knows who.
13. One folder with a pretty picture of a helicopter on it to hold the 31 pages of “important material.”

I didn’t include all the paper work for discharge.  Sheesh, who reads all this?  And can’t we do better?  How much of this is government mandated, “best practice” mandated and out right unnecessary?  This is not the way to  make health care more transparent, this is the way to make health care more confusing.