How Doctors Think Outside of the Medical Box

It was a tough week in Pookieville.  I worked all week at one of my favorite hospitals.  I like working there because the specialists I work with are hypercompetent and always willing to help.  Furthermore, they like to chat. Well, they like to chat about interesting cases.

I was particularly challenged this week because I had to think out of the box.  I will not share the details of the case, as I don’t intend this blog to be about medical cases per se.

When I picked up  my service, I  assumed care of a very complicated patient, with a disease process that was appropriately handled.   Unfortunately, there was an outcome that was unexpected and completely unpredictable .  It was also quite serious.  What I want to share is how hard it was to think out of the box, which was what was required.  Medical statistics and medical science can not predict all outcomes, which is when the “art” of medicine comes in to play.

I walked in to the room to discuss the latest bump in the road, and the various treatment options to remedy the latest bump.  Now, before I went in the room to talk to the patient, I had done my home work.  I had reviewed the latest bump in the road with the surgeons, specialists,  the sub-specialists and several of my co-hospitalists.  There was no clear consensus as to what should be done about this problem, just a general agreement that this problem was indeed, a big problem.  Most of my colleagues were glad they were not me, because it felt as if all options were fraught with danger to the patient.  “Glad I’m not the one that has to write those orders,” was the general feeling.

Great.

I explained to the family what the issues were, and that we were now in rock and hard place territory.  I explained that there were no randomized, double blinded placebo controlled studies for where we were at.  I explained the options, risks, benefits and side effects of each option.  I explained that  I had done my home work.

“Do you just fling sh– at the wall and see what sticks?”  One incredulous family member asked.

It must appear that way, when we can’t quote studies, and cite statistics and supply comfort from numbers.  We must appear like idiots when we have to use our experience, and our colleagues’ experience to make a decision when there is no clear cut decision, and when the road is paved with ill feelings and anger at an outcome only God could have predicted. 

But none the less, a choice on treatment had to be made. 

Here is how I made my decision on how to treat the problem:

  1. Identified the problem.
  2. Said “@#%*!”
  3. Asked everyone involved in the case their opinion, including the PharmD, and the head of the department of medicine.
  4. Came up with three options, and picked the one I felt was the safest with the best outcome.
  5. Reviewed options with the patient and family.
  6. Realized that there may be MORE options, once I talked to the family.  (Interestingly, the family was the most creative in looking at solutions.)
  7. Walked out of the room, made more phone calls, and finally came upon the solution that we ended up going with.
  8. Called a renowned specialist at the local University and got the specialist’s opinion, who was in concurrence with the ultimate solution I had crafted.
  9. Went back in the room (a bit demoralized, as I had said there were no other options, but now had come up with one.)
  10. Heard the family’s  intense relief at the more moderate, middle of the road option that we ultimately agreed to implement.
  11. Went for it.

So why I am writing about this?  Because it took me TWO hours to do all of this.   It took two hours for me to think and explore every option, and to finally come up with an option that seemed workable, and the least dangerous.  I took the time because I wanted to do what was best.   It was the family that was most able to think outside of the medical box, and who encouraged me to explore further.

Now, was this the right choice?  Only time will tell, and yes, sometimes as physicians we just have to throw sh– against the wall, and then throw some more, and then consult our colleagues, and then think again to find the answer when there is no right answer.

I just hope that in the future, I have enough time to think out side of the medical box.

How do you think out side of the box?

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The Medicare No Pay, Never Ever List

The Centers for Medicare and Medicaid Services announced 10 hospital acquired conditions for which it will not reimburse.  The no pay rule has been in effect since October 1.  So, with out further ado: (drum roll):

  • “Stage III, IV pressure ulcers
  • Fall or trauma resulting in serious injury
  • Vascular catheter-associated infection
  • Catheter-associated urinary tract infection
  • Foreign object retained after surgery
  • Certain surgical site infections
  • Air embolism
  • Blood incompatibility
  • Certain manifestations of poor blood sugar control
  • Certain deep vein thromboses or pulmonary embolisms.”  (List from AMedNews.com Aug 25, 2008).
  • CMS began to implement the no pay rule October 1, 2008.  Physicians will still be reimbursed for their services, but hospitals will not be reimbursed for their portion of the care.   Now, I don’t know about you, but I agree  some of the events are absolutely “never-ever” events  (retained surgical object, blood incompatibility), but some of the other conditions are out right ridiculous.

    My colleagues and I have come up with some ideas on how to respond to this latest demonstration of government “efficiency.”  We have proposed “buttocks rounds”, where the wound RN examines every patient’s behind and charts presence/absence of pressure ulcers.  We thought it especially important to do this on those 35 year old youngsters we are obligated to admit for chest pain.  We also thought that perhaps we could have a “fanny cam” to take pictures, so our documentation would be impeccable.  We advocated noting that all patients had decubs at admission, but the hospital administration shot this one down.

    Our next suggestion was that every patient, no matter what, should have an admission urine analysis, to document presence/absence of infection.  There could be a little check-in kiosk where the patient signs in, hands in a credit card for the hefty co-pay, and pees in a cup.  The patients could even dip their own urine, and record it on their check in information to speed the process up and decrease labor costs.  Additionally, we thought surveillance ua’s would be helpful in all patients with urinary catheters, probably daily.  Got to nip that e. coli in the bud!  We also considered putting a mandatory quinolone on every order set for patients with catheters, but became concerned when we realized c. diff may soon be added to the no pay list.  It may be worth a try for now, though!  Too bad about the cost of all those extra ua’s.

    As to falls, I have little to offer on prevention of the noscomial hip fracture.  Our hospital uses bed alarms (frequently it requres a doctor’s order, though), and of course we can always get a sitter.  (However, all the hospitals where I work discourage sitters secondary to cost.)  Occasionally we try to get family members to stay with the sun downing patient,  but they rarely do.  Now that Granny is in someone else’s care, they will give some sage advice, like “Don’t use ativan, or haldol, or ambien or seroquel, because Granny gets really nuts with those.  And don’t restrain her either.  Bye.”  They then hurry to the car for their first meal out in months.  Who could blame them? 

    CMS is planning on expanding the no pay list to ambulatory settings, nursing homes and home health agencies in 2009. 

    I am always in favor of intelligent uses of government regulation, but someone missed the boat.  What do you say we make some fanny cam rounds at CMS?

    PookieMD Airlines: How aviation check lists apply to medicine

    I am married to an electrical engineer that loves to fly around in a small airplane.  Because I hang out with him, I’ve been forced to observe the intricacies of not crashing into other planes and landing safely.  I’ve learned a lot.

    Pilots have a check list for everything.  Plane manufacturers include an entire book of checklists for every contingency, from take off, to landing, to what to do if there is an emergency.  ( It is a BOOK, mind you!)  My husband straps the needed check list to his leg and goes through it every time we land or take off or preflight.  He actually LOOKS at the list, touches each instrument and taps on the applicable gauges.  It is not a passive process.  Hence my hubbie and I have logged over 1000 hours safely in the cockpit of our tiny plane.  (Don’t look at me.  I don’t know a dang thing about flying.  I just kiss the ground when we land.)

    Why do we physicians not utilize more check lists as we go through our day?  The medical profession has been (reasonably) stubborn on adapting algorithms and treatment pathways, arguing that each patient is different and no one algorithm can apply to every patient.  But from a patient safety stand point, I will side with the check list every time.  When a patient goes to the OR a check list is utilized, and when a patient is transported in one of the hospitals where I work, there is a “ticket to ride.”  Why don’t we have some simple checklists for ourselves, listing important but (sadly) forgettable to do items for each patient?  Now, some hospitals have an EMR that will generate order sets, but they are usually not as robust as they could be, and frequently only cover one disease state.  These order sets are good, but incomplete, and  lead to “drop offs” on treatment plans.  Hence the need for the check list.

    When one of the hospitals I work at transitioned to order entry, I had to develop a check list that I carried around with me, because going back and forth between multiple screens is onerous.  It included the following:

    • Order labs for next day (first screen)
    • Review current meds (screen #2)
    • order new meds (screen #3)
    • order radiology studies (screen #3)
    • make sure note is entered in the EMR (screen #4)
    • review labs (screen #5)
    • read other doctor’s notes (screens 6 and more, each note a different screen)
    • review radiology studies (screens 7 and 8, depending on if you actually looked at the image.)

    It’s quite easy to drop the details we internists live for.  Seems silly, but given it was a new EMR for me, I had to develop a system to make sure my work flow was preserved and important information and procedures were addressed.  Most of us used check lists as medical students, and then gave up the habit as we grew more comfortable with medicine.   You don’t have to have a check list for everything, but it’s helpful when you are encountering a different situation then usual, like the new EMR I described. 

    I encourage you to add to your history and physical check list the following things:

    • Prophylaxis: e.g. have you written for GI prophylaxis (if warranted) and DVT prophylaxis  (don’t forget that DVT is now one of the  medicare “no pays”)
    • “Treatment plan discussed with patient and family, and they are in agreement.”
    • Note the time spent with patient and coordinating care.  (A must, for billing.  Heck, have this tattooed on your hand if you can’t remember it!)
    • Pressure ulcer present/absent at _____________(location).  (I have a skin category in my physical exam and include the pressure eval here.  Pressure ulcers that develop during a hospital stay are another Medicare no-pay.  More on that in a later post.)

    One of my hospitalist colleagues uses the following check list at discharge, necessitated because the EMR we use makes us go between several screens and logins:

    • write discharge summary
    • write discharge orders
    • send note to PCP
    • set up follow up
    • write scripts

    Useful primary care check lists would be:

    • State of undress for each exam:  (female pap: the full Monty, male: off with the tighty whities for the prostate check, diabetics: off with their shoes and socks!)
    • Check list clipped to chart as to what screenings are done at what age, or in each room.
    • Check list on cabinet door detailing what items go in each cabinet.
    • Check list at discharge for assistant to review: does patient have scripts, referrals, test info, and know when to come back.
    • List of items your front desk staff needs to check at each check in (check address, insurance card, HIPPA).
    • List of items your assistant needs to check as they room the patient (chief complaint, allergies, meds etc.)

    When I wrote this post,  I considered making a “write post” check list, which would include looking for typos.  It seemed like a good idea, but I wuz too bzy so I didn’t have tim to go threw my list witch wud have reminded me to make sur I didn’t have no tipos.   

    We can learn a lot from the world of aviation.    Should we have a check list for Code Blue/COR-0?  Nah, we’re physicians, we know it all.  Besides, the guidelines will change in two years anyway.

    Flaps up!

    Don’t Recoil: Marketing Your Practice

    Yes, we will talk business today.  No more fluff on being efficient, knowing where the speculum is, and handing out tricolor business cards.  Let’s get to the meat of it: YOU CAN’T SEE PATIENTS IF THERE IS NO ONE TO SEE. 

    Sadly, many practices have a dearth of patients.  How could this be?  Some are located in physician dense areas  ( or is it dense physicians?),  where competition is fierce for patients, others are in a location with out a lot of patients, while others have not gotten the word out.  Getting the word out will be the focus of today’s highly opinionated, some what educational post.  (In all fairness, this is not JUST my opinion.  I actually DO research these topics!)

    So, here are a list of free, cheap, inexpensive and expensive marketing ideas that you should try in the laboratory of your practice.  (Yes, you need to have the Edison mindset–experiment!  You can’t build a light bulb the first try.)  I freely use examples from marketing ExtraMD, my company.  (An example of see one, do one, teach one, but hey, we’re doctors, it’s what we do.)

    1. Set the tone from the moment the patient walks in, to the moment they leave.  Word of mouth is huge in the doctor business.  Your receptionist needs to actually LOOK AT THE PATIENT AND GREET THEM BY THEIR LAST NAME, before handing them 27 forms they must fill out with a scratchy pen.  (Could ya’ spring for some decent pens?)  You, dear doctor, must BE ON TIME , say the patient’s name, listen intently, and come up with an understandable treatment plan.  But wait–we are not done yet!  Your trusty assistant (or you, depending on how your office runs) must make sure the patient knows what the plan is, has the needed ‘scripts, and knows when to return.  Helping the patient find the check out desk is a nice touch.  How many times have I wondered through a labyrinth of an office, trying to find a way out, and ended up in the bathroom?
    2. Avail yourselves of your friendly colleagues.  Go out and meet the docs at the urgent care clinics, and specialists at your local hospital.  While you are at the hospital, introduce yourself to the ED docs.  HINT: the nicer you are to the ED, the nicer they are back! (Really!)  Let all of these people know you are taking new patients, and hand out cards.  Introduce yourself to the hospitalists.  Just last week, I met a nice nephrologist who gave me her card.  She had a great niche in that she spoke Spanish.  Guess who I called on my very next Spanish Speaking Only (SSO)  ICU patient?  Guess whose cards I passed out to my colleagues?
    3. Send thank you notes to physicians that send you patients.  Everyone likes a thank you note.  Include that fancy tricolor business card.   Yes, I walk the walk.  ExtraMD’s nifty assistant just sent out thank you cards to our clients.
    4. Have a website.  It is a necessity in today’s hyper connected world.  Even the sadly computer challenged ExtraMD has one.  In this day and age, patients are savvy and will check you out on line. Make sure your website lists your hours, days, experience, the patients you want to see, which insurance you take, and has some nice pics of you and your staff.  Not to have a website is archaic.  Get with the 21st century!  You can get a website going fairly easily and at a reasonable cost if you shop around and ask colleagues who they used to design theirs.
    5. Speak the language.  If you are in a community that speaks a language other than English, and YOU speak that language, make sure that’s on your web site.  Unfortunately for me, no hablo espanol, which would be a huge asset in the region where I practice.  Sprechen Sie Deutsch?
    6. Make sure your hours are accessible.  What are you thinking, closing at lunch?  Have a late lunch (if any) and the working folks will love you when they can get in at lunch. They will tell their friends and so on… Also consider extended hours a couple of times per week, opening early and closing late. 
    7. Get famous. Seriously, a lot of docs write columns in the newspaper, or do radio programs.  Select topics that are interesting, and applicable to your wannabe patients.  You could be the next Dr. Drew!  (Hmm, is that a good thing?)
    8. Get your name on the hospital website.  Make sure your name, practice name, and practice address/info is listed on the hospital website where you have privilege’s.  Patients will search these databases to find a physician.
    9. Introduce yourself to the medical staff office at your hospital.  Leave cards, brochures and chocolate.  (Don’t laugh, chocolate sells!)
    10. Press the flesh. Consider doing some meet and greets at health clubs, sponsoring a kids sports team, or giving a free talk at the local senior center. 
    11. Consider fliers, and direct marketing post cards.  I list this last, because this is an expensive way to go.  I must note, however, that post cards have served ExtraMD well.

    Other key points: develop a marketing plan, and a budget.  Track what works and what doesn’t.  Some stuff will surprise you, other sure bets will stink up the place.  Let me know what works for you and I’ll post it here.

    Good luck!  Keep doing the valuable work you do, and know that you really do make a difference in the world!!!

    How To Listen So Patients Will Talk

    I wish that in medical school and residency we had spent more time learning how to communicate.  We finish training stuffed with knowledge (think a brat on a grill!) but are horrible at distilling that knowledge to help people.  As a hospitalist I have tried to hone my interviewing skills, but feel that I could use some improvement.   Here’s my own two cents on how to interview a patient  (of course, I’m a doctor, I’ve got an opinion!):

    1) Read the chart before you go in.  I have gone back and forth on this, wanting the patient to tell me what was wrong in their own words, but finally have settled on, “Hello, Mr. Hurting, I understand you have had chest pain (or warts, or whatever) for the past two days (weeks, months, decades…).  Could you tell me more about it?”  I have started doing it this way, because, when I used to say, “Hello, Mr. Hurting, what brings you to the ED today?”  inevitably I would get a wisecrack like, “My wife.”  or “The ambulance.”  I’m hoping my chart reading before hand makes me look smarter!  (I have a personal theory that if I had a British accent, I would appear smarter, but that’s a whole different blog.)

    2) Please slow down, and don’t interrupt the patient.  Let them get their spiel out, before you jump in with the questions.   Try not to turn the interview into an interrogation.

    3) Review the medication list (the med rec, which I think is your best friend!) every time, using trade and generic names.  Many patients will know one or the other, but not both.  Hopefully you will not encounter the dreaded, “I take the little peach pill” scenario.

    4) Try to answer the following questions:
    –what is my diagnosis –(why am I sick?)

    –what will happen next?  (What tests, treatments, other specialists?)

    –when will I be informed of the test results?

    –will it hurt?

    –when will I get out of here (the hospital)?

    –and of course, when can I eat?

    5) For pity’s sake, introduce yourself and shake hands!  (I know, this post is slanted towards hospitalists today.)  Give the patient and family a card.  I occasionally give my pager number to so called “needy” families.  I find that they take comfort knowing they can get hold of me, and seldom abuse this.  I must note that some of my colleagues frown on this.  (“We don’t do that,” one of them said frostily.)

    6) Always ask, “Do you have any other questions or concerns you want to share with me?” before concluding the interview.  I also tell patients and families how they can get hold of me.  (“Ask your nurse to page me.  We have someone here 24/7.”)

    Please feel free to share your suggestions.  My communication skills are a work in progress, and I bet yours are too!