Archive for the 'Reflections' Category

Between Patients: The Myth of Multitasking

Primary care doctors don’t usually have scheduled blocks of time to read incoming reports, refill prescriptions, answer messages or, what we are told the future will entail, manage their chronic disease populations. Instead, we are generally expected to do all those things “between patients”.

This involves doing a little bit of all those things in the invisible space between each fifteen minute visit, provided we can complete those visits, their documentation and any other work generated in those visits, in less than he fifteen minutes they were slotted for.

If we can’t capture (steal, really) enough time from our scheduled visits, we are still expected to somehow get that work done, but then on our own time. This results in most primary care doctors logging in to their EMRs from home after supper and on the weekends. Mismatched workloads and work schedule are a major source of professional burnout.

Compare this with air safety. Are airplanes scheduled to be in the air all the time, with refueling and maintenance squeezed in only if they happen to land ahead of schedule?

Quickly reviewing a couple of messages, a few lab results and some imaging reports, and then rushing in to see the next patient is an extremely inefficient and sometimes unsafe way of working.

I have likened this to jumping back and forth between baking a cake, balancing your checkbook and mowing the lawn. Normal people don’t work that way. Why do we expect doctors to?

Neuroscience teaches us that there is no such thing as multitasking. We really only do one thing at a time, and every time we switch from one task to another, we expend mental energy and brain glucose. Switching rapidly between tasks reportedly reduces usable IQ by ten points. Maybe doctors in general have IQ points to spare, but why organize our work that way on purpose?

MIT neuroscientist Earl Miller points out that juggling multiple plates floods the brain with cortisol (the stress hormone) and adrenalin (the fight or flight hormone), which prevents clear thought.

And those are the chemicals involved in burnout. In moderate doses, they are known to boost performance, but constant, low levels of them are the biochemical basis for burnout. We all know that.

My ideal way to work would be “protected” time for Results Review and Care Planning, and then, while another doctor does that, give me two medical assistants and double my number of exam rooms for efficient visits where I have already studied the charts and know better what I’m supposed to accomplish.

And, let me do slow visits grouped together, like physicals and wellness visits, and quick visits together, like sore throats, earches, rashes and knee pains. Slow and fast visits require different mindsets and skill sets. Again, comparing with everybody’s personal life, playing ping-pong or whack-a-mole interspersed with practicing or teaching yoga is very unintuitive an inefficient, at least as far as the yoga part goes.

Kind of like scheduled refueling and maintenance for aircraft…

How to Write Like a Dockter

Many physicians have become world famous writers and in Greek mythology, Apollo was the god of both poetry and medicine.

I can personally think of many prominent physician writers I have come across in my reading over the years:

There was the 12th century rabbi Maimonides, Copernicus in the 15th century and the poet John Keats in the 1700’s.

In the late 1800’s to early 1900’s there were Anton Chekhov, Sir Arthur Conan Doyle and William Somerset Maugham.

Examples from our time (or at least mine) are A J Cronin (Dr Finlay) Robin Cook (Coma), Viktor Frankl (Man’s search for meaning), Michael Chrichton (Jurassic Park), the Polish science fiction writer Stanislav Lem, M Scott Peck (The Road less traveled), Oliver Sacks, Frank Slaughter, Sherwin Nuland, Walker Percy and more recently, Mainer Tess Gerritsen.

But you wouldn’t think doctoring and literature are even remotely connected after reading what my colleagues and I are producing every day in our electronic medical records.

In journalism school and writing classes they tell you how to capture the reader’s attention and make your point effectively. They teach how to make the readers feel like they are witnessing real events and experiencing the emotions of the characters of the writing.

In medical charting class, and when using EMRs, the priority is to prominently list the items that are required for payment and compliance purposes.

Evaluation and Management (E&M) reimbursement codes are built around how many aspects of a symptom or a physical exam are documented. Sometimes called “bullets”, each one is usually a separate sentence in the “printout” display of a medical record whereas to the documenting physician they may be a click box. Looking at the computer screen, they are sometimes quick to review, much like the paper forms I used to create for upper respiratory infections, urinary tract infections and physicals etcetera in the days of paper records. But when our computer programs turn these checkboxes into sentences, they look more like “See Spot run” grade-school English than an expert clinician’s narrative.

Here are two screen shots from a clinic a couple of towns north of here:

Writer’s view:

IMG_0354.JPG

Reader’s view:

IMG_0356.JPG

Anybody who tries to quickly read such notes would probably just as soon see the original clickboxes, instead of the stilted English produced by the EMR.

Back to the real writers among us – here is how Abraham Verghese explains the deep connection between doctoring and writing:

“I’m really struck by how much of what I learned in medical school has helped me to be a writer, and how much of what I learn as a writer helps my thinking as a physician. They are very parallel disciplines. When you take a patient’s clinical history, what is that but a story? What makes a good doctor is that he or she takes the story down well, sees the links and makes the connections toward a diagnosis. That’s also what writing is about.”

I guess that’s why, after a long day with my patients and my highly structured EMR, I like to sit down in my den next to the horse stalls with a completely blank screen in front of me and just tell stories.

Caught Between two Paradigms

In the very near future, clinics like ours will be paid according to how well our patients do medically, or at least according to how consistently we provide certain medical tests and interventions.

This includes frequency of diabetic blood tests, foot exams, eye exams, prescriptions for heart and kidney protective medications, achievement of pre-set targets for blood pressure, body mass index and immunization rates, and other measurable “quality indicators”.

But paychecks for medical providers as well as short term financial viability of clinics like my Federally Qualified Health Center depends, besides Federal grants for being open in the first place, almost entirely on the fixed revenue we receive from every face to face encounter we have with patients.

If I spend an extra ten minutes with a diabetic to help him quit smoking and avoid a heart attack ten years from now, I don’t bring in any more money than if I send him out the door with a pat on the back and “see you next time”. But if I cut his visit short and see his grandson for a sore throat, I generate as much income for us as I would have done for a lengthy visit with his newly diagnosed diabetic wife. Any face to face encounter generates the same revenue, no matter how short.

My productivity target clashes with my quality targets. I am constantly balancing between them. And so are physicians everywhere, even if non-FQHCs get paid per Relative Value Unit (RVU), which rewards them to a degree when patient visits are longer and more complex.

In the old paradigm, a physician is only working when he or she is face to face with a patient. The new paradigm claims the importance of reading and being aware of incoming reports from hospitals and specialists, conferences with nurses and care managers, review of population health data and planning future interventions.

But right now, those are money losing activities. How many organizations have the courage, and the deep pockets, to do right now what will hopefully be paid for some time in the coming years?

So, in reality, doctors skim over their incoming reports or sign them off unread. Nurses and care managers read them and enter diagnostic details and new medications prescribed by hospitalists and consultants in each patient’s EMR, but the busy providers don’t have enough time to talk in depth with the care managers whose chart entries take as long to read as the outside reports would have taken in the first place.

We struggle to find the time to talk to our patients, and rely on others to communicate with them. When we work that way, information can get lost or distorted, so we risk making tangential or inappropriate clinical decisions. A patient calls back reporting to the medical assistant or receptionist that they are not better from their antibiotic and the physician prescribes another one, when the real message may have been that they are only 75% better and most likely will be fine in another day or two. So resources are wasted, unnecessary treatments are prescribed, and opportunity for patient education is lost. All because we are too busy to gather the clinical information that we have the training and experience to collect.

It is obvious that this incongruence between paradigms is a setup for physician burnout, but on a bigger scale it also makes me wonder about organizations. Can they experience burnout too?

I read somewhere about the causes of burnout:

“Maslach, Schaufeli and Leiter identified six risk factors for burnout: mismatch in workload, mismatch in control, lack of appropriate awards, loss of a sense of positive connection with others in the workplace, perceived lack of fairness, and conflict between values.”

All of today’s healthcare seems to fit this description. We must go forward, or even back, but we can’t stay too long where we are right now.

The Dunning-Kruger Effect

“The fool doth think he is wise, but the wise man knows himself to be a fool.”
– Willam Shakespeare

I learned about the Dunning-Kruger effect at a medical conference recently. It certainly seems to apply in medicine. So often, a novice thinks he or she has mastered a new skill or achieved full understanding of something complicated, but as time goes on, we all begin to see how little we actually know. Over time, we may regain some or most of our initial confidence, but never all of it. Experience brings at least a measure of humility.

IMG_0331.JPG

Just the other day I finished a manuscript for an article in a Swedish medical journal with the statement that, 38 years after my medical school graduation, I’m starting to “get warm in my clothes”, as we say in Swedish.

I think the Dunning-Kruger effect applies not only to people who are in the beginning of a career in medicine, but also to people who learn about it for purposes of judging its quality or efficiency or of regulating or managing it from a governmental or administrative point of view.

I think many people outside medicine think “how hard can it be” and then proceed to imagine ways to change how trained medical professionals do their work.

But the Dunning-Kruger effect is also a particular problem in rural primary care. Newly trained physicians, PA’s and Nurse Practitioners are asked to work in relative professional isolation with full responsibility for sizeable patient populations. Unlike the hospital environment, primary care practices seldom have time earmarked for teaching and supervision, and there is little feedback given to such new providers. There is also very seldom collaboration and communication about specific patients or cases. We probably get more feedback from our specialist consultants than we do from the providers in our own clinics, because we are all busy with our own patients.

So, how does a new clinician avoid the newbie hubris Dunning and Kruger describe? Seek out potential mentors and ask them to be yours, start a case conference at your clinic, read the leading journals, NEJM, JAMA, BMJ, The Lancet and ones like them, and read about the history of medicine and the old masters.

And consider honestly how often a brand new driver should expect to instantly do better than the person who taught them, parent or driving instructor.

A medical license is in no way proof of mastery of the art of medicine, it is only a license to begin practicing, in a very literal sense.

Alarm Fatigue

I missed a drug interaction warning the other day when I prescribed a sulfa antibiotic to Barton, a COPD patient who is also taking dofetilide, an uncommon antiarrhythmic.

The pharmacy called me to question the prescription, and I quickly changed it to a cephalosporin.

The big red warning had popped up on my computer screen, but I x-ed it away with my right thumb on the trackball without reading the warning. Quite honestly, I am so used to getting irrelevant warnings that it has become a reflex to bring the cursor to the spot where I can make the warning go away after a quick glance at it. Even though I have chosen the setting “Pop up drug interaction window only when the interaction is severe”, I get the pop up with almost every prescription.

Today I went back to Barton’s chart and looked at his interaction screen.

With the Bactrim DS no longer there, the first of the red boxes was a major interaction between his 81 mg aspirin and his Pradaxa (dabigatran) – two blood thinners are more likely to make you bleed than one. That is basic knowledge, even common sense.

The next red box was a moderate interaction between his baby aspirin and his lisinopril. Theoretically, higher doses of NSAIDs can interfere with the blood pressure lowering properties of ACE inhibitors. That is very basic knowledge, too.

The third red box, another moderate interaction, was between the aspirin and his steroid-bronchodilator inhaler. Theoretically, steroids and aspirin can increase the risk for stomach irritation and supposedly, the pharmacologic effect of aspirin may be decreased by the inhaler.

After these came several warnings labeled “extreme caution” and some that were “not recommended”. The scrolling seemed endless, so I printed out the warnings instead. They filled eight pages. I counted 61 “extreme caution” warnings, from metoprolol and diabetes to the poor man’s steroid-antifungal cream and his diabetes. Beta blockers can, at least theoretically, decrease the tremors and other warning symptoms of low blood sugar, and oral steroids can raise blood sugars, but a mild steroid cream doesn’t do that.

There were 32 “use cautiously”, many of them quite tangential, like the blessed fungus cream and Barton’s history of hepatitis C.

On the last two pages were the dietary warnings, including not to swallow your atorvastatin with grapefruit juice, or to mix your pain pills with alcohol.

I hate to sound uppity, but no amount of pop-up interaction alerts or other forms of “decision support” can replace basic medical education. In Barton’s case, the only warning I needed was the one about his dofetilide, which he gets from his cardiologist, and the antibiotic I wanted to prescribe. The aspirin-Pradaxa interaction is common sense, and the baby aspirin-Symbicort interaction is nonsense. And if I were to even read through the eight pages worth of precautions and “use with caution”, I would have doubled the 15 minutes it took to assess and document his infection in the first place. Or I could have listened to a tutorial about evaluating lung sounds – how much coaching do the EMR designers think we need?

So, here is my suggestion: Make these warnings behave like some computerized card games – let users decide based on their skill level whether to get all the warnings or only the critical ones that are not generic class effects we all learned in pharmacology class. Because when everything is a red alert, alarm fatigue sets in and all the warnings are wasted.

It reminds me of the story about the boy who cried wolf…

Quality Medicine: Showing the Math

Medicine is a lot like grade school mathematics. The days are long gone when instantly knowing or quickly arriving at the right answer was enough. Now it’s all about showing your calculations. Process is everything. It’s almost like having the right answer doesn’t matter anymore.

If you ask a patient with a given symptom, like tremor, lameness or a skin eruption, only a few questions and then conclude that they have a rare disease you happen to have seen before during your years of training and experience or read about in your diligent study of the leading medical journals, you get paid next to nothing. If, on the other hand, you ask a hundred questions and examine them from head to toe and then decide to refer them on to someone who knows more than you do, you can charge a bigger fee, at least a 99214 instead of a 99213.

We get reimbursed for complexity that is sometimes a result of incompetence. That is one definition of value in health care delivery.

These days, quality in healthcare is also measured in “outcomes”; how many people comply with our recommendations by eating better, quitting smoking or exercising more. Or at least whether we documented that we told them to.

Of course, you could talk about more things in greater depth in your precious fifteen minutes together if you didn’t also have to document everything you touched on in a Byzantine electronic record better suited for billing than patient care. But, if you didn’t document it, it didn’t happen.

Diagnostic accuracy doesn’t figure prominently in the quality literature, only sometimes when it comes to missing heart attacks and cancer, but in my world, primary care, you can still achieve great quality scores from documenting sometimes meaningless housekeeping tasks like annual microalbumen tests for diabetics, even if you don’t manage to decrease the kidney damage.

Good quality measures are ones that are easy to collect and manipulate statistically. But does a good and tidy measure convey better quality?

We are still stuck in the Deming manufacturing mindset. But people are not machines and diseases are not manufacturing processes.

Do we ask how a teacher managed to inspire a young student to become a great scientist? Do we demand an explanation of how a priest brought a distraught parishioner from the brink of suicidal despair? Do we ask how Da Vinci held his paint brush when he painted Mona Lisa’s smile? Do we value an athlete with “good” technique more than one with good scores?

I think our health care quality debate has a myopic view. We are often ignoring the big picture and the real purpose of caring for the sick. That’s because healthcare is a business now…

EMRs: It’s the Interface, Stupid*

The reason we all struggle with our EMRs is simple: It’s not so much the underpinnings we object to, but the “User Interface”. And the User Interfaces of EMRs are awkward, to say the least.

UI is the look and functionality of the screen.

For example, if I have an imaging report in my inbox and want to do something about the result, say look at the previous scan the patient had six months ago, let the patient know it was okay, add a new diagnosis to the problem list, arrange or check the date of the followup visit, send a copy with a question or comment to a specialist, look back at what the blood work showed, prescribe or stop a medication, or check a reference website like UpToDate what the best treatment is for what the scan shows – how many clicks does it take to do any of those things, and can I still see or at least get back to the report I just received as I do any of those things? Why don’t I have every single option for what to do with the result right there on the same screen as the result itself?

That’s the essence of our frustration.

Even more basic, and I have lamented about this before, can I read the scan, lab report, consultation note or whatever it is, in one view without scrolling, enlarging, clicking or standing on my head?

If you have only fifty reports to go through every day, and each one takes even just over a minute instead of fifteen seconds to go through, like a paper report used to require, it may not sound like a big deal, but that means about 40 minutes more per day, hardly ever built into your clinic schedule, for that task alone.

Documenting a physical exam with abnormal findings in a structured way, not free texting or speaking, can involve innumerable clicks to get to the findings you need.

For example, click on ENT, then EAR, then scroll down to TUNING FORKS, then scroll to WEBER, scroll to LATERALIZED LEFT, go back to RINNE, and scroll down to POSITIVE or NEGATIVE LEFT and try to remember if bone conduction greater than air conduction is positive or negative because that’s not the terminology you use.

What if the physical exam could be documented by pinching your fingers to zoom in on a touch screen with a body and just pointing to the body part in question and having all the options literally at your fingertips?

If video games can do it, why can’t EMRs?

Just look at these two pictures, courtesy of Bangor ER physician Dr. Jonnathan Busko, and imagine…

IMG_0287.PNG

https://www.linkedin.com/pulse/dont-let-your-ehr-tail-wag-patient-care-dog-jonnathan-busko

*(It’s) “The Economy, stupid”, is an American idiom from the 1992 Clinton-Bush presidential campaign, a phrase coined by Bill Clinton’s campaign manager James Carville to keep the candidate focused on the most important issue(s).


Enter your email address to subscribe to this blog and receive notifications of new posts by email.

Bookmark and Share

Mailbox

contact @ acountrydoctorwrites.com
© A Country Doctor Writes 2008-2017. Unauthorized use and/or duplication of this material without express and written permission is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given.