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

I’m back from a well needed vacation. I skied my little heart out, had dinner out with family and friends, ate lots of pot luck dinners, went to a musical, and am finally refreshed.  Boy, did I need the break! It was getting so bad that I had to psych myself up to go to work every morning before vacation.  That’s pathetic.

I did have time to indulge my thirsty brain in some books.  Here is what I read:

Switch–How to change things when change is hard, by Chip Heath and Dan Heath.  More on this tomorrow.  It’s a must read, and I gave it to someone I work with as a peace offering after I made an idiot of myself.  He loved it, and we smoothed things over.  This was inspired by reading the book, and caused me to think about how I had been approaching the huge change my hospital will be undergoing.  Buy the book, read the book, highlight the book, share the book!  I will post on it for tomorrow’s book club.  It’s applicable to just about everyone, no matter their field/specialty.

Drive–the Surprising Truth About What Motivates  Us, by Daniel H. Pink.  Basically, rewards don’t motivate, so don’t bother.  I’m only half way through, so can’t comment any more.

And lastly, Making it all Work, by David Allen.  This is more from the GTD (getting things done) guru.  It certainly inspired me to get back to my list making.

It’s nice to be back! Would love it

Surfing the net aimlessly, I came across the following from Care Practice:

“We offer 24/7 Urgent Care and House Call services with an On Call Doctor available after hours and on weekends to meet patients that require Urgent Care services. Our office is open and staffed 365 days a year because patients don’t determine when they get sick.

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.

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 received a request to sign the following Letter to the Editor that will appear in the Denver Post on Saturday, March 14 edition.

“Doctors feel the consequences of unavailable or unaffordable health insurance every day. Uninsured and under insured patients forgo needed care, turning treatable conditions into complex and expensive health care events. Many can’t get insurance due to pre-existing conditions or over-priced individual plans. Our fragmented health insurance system creates administrative burden for patients and doctors alike, but does little toward improving quality, communications, or overall health in America. Our patients are seeing double-digit insurance premium increases and sky-rocketing deductibles.  More and more they cannot afford to come to the doctor.

Delaying health insurance reform would unnecessarily perpetuate lack of access to health care, financial hardship, and suffering. We urge passage of federal health care reform legislation immediately and call for continued executive evaluation and creative legislation until all Americans have access to affordable quality health care.”

Would you sign this? If you want to sign, go to http://bit.ly/aY9IuW.

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?

It was a busy night at my local hospital.  I spent a lot of time in the ED, and the pager was in status.  The hospital I was at is a large tertiary hospital, and receives transfers from small mountain clinics that send us stuff like chest pain (easy) and hypertensive urgency/renal failure/barfing patients (hard.)  We get patched in to the Tiny Mountain Clinic Doctor, who gives us the skinny, and then we banter a bit about treatments etc, and then the helpful “connect” ombudsman arranges transport.

All good, so far. Except when the mountain doc wants to talk to me right as I am transferring a crashing patient to the ICU.  The helpful connect ombudsman calls me, and tells me that the Tiny Mountain Clinic Doctor needs to talk to me.  “I’m really busy,” I say, “I’m moving a patient to the ICU.  Can I call you back in 10 minutes?”  The helpful ombudsman agrees.  (BTW, our conversation is recorded, and we have all been warned to be polite as the powers that be will slap our hands if we are not.)

I’m busily assessing my patient, trying to get the transfer orders done, when the pager goes off again, not 5 minutes later.  It’s the helpful connect ombudsman.  “Tiny Mountain Clinic Doctor needs to talk to you,” she says.  Needless to say, Tiny Mountain Clinic Doctor takes first priority, even though I already said I would call back after the fire I’m putting out is taken care of.  (After all, we are being tape recorded!)

Oh how impatient we are.  But sadly, oh how impatient I am as well!  Could I just have a minute to think?

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!

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.