Useless Charts & Fresh Eyes in Handoffs

28 03 2011

Last month, I was a speaker for AMSA on their patient safety webinar. This was the brainchild of Aliye Runyan, a fourth year medical student at University of Miami and her colleagues, to expand the patient safety taught to medical students.  They are not alone.  The IHI Open School also virally spreads patient safety training where traditional med schools failed.

My topic was handoffs – and they asked me to talk about it.  I wondered what could I tell mostly preclinical medical students, some of whom may not have even entered the clinical arena about handoffs.  Would what I say be over their head and irrelevant if they had no clinical context?  I was also hoping there were some fourth years on the call who could offer their experience doing handoffs as subinterns.

But, I forgot the importance of fresh eyes, a concept that is sometimes used to describe the one positive aspect of a handoff, that sometimes the best insights come from someone who is not well acquainted with the case.  I had a lot of fresh eyes (and mostly ears) on the call.  In the vibrant Q&A that followed (and continued via email), one of the things the medical students brought up asked me about something I said is sometimes bad in the signouts- TMI? or Too much information.  This often happens when the signout is used to help the primary team track the patient and it loses its function for the receiver.  In hospitals with electronic health records, TMI is often a symptom of “CoPaGA” syndrome, or Copy and Paste Gone Amock.

But, this led to the most interesting debate of the night- why has the medical chart become so useless that people feel they need to use the signout this way?  I was asked to think about this question again later in a meeting with our Epic staff who are working to create an automatic signout system for our residents – they really wanted to know why we needed a separate system.  Since our residents have iPads, why couldn’t they just look at the record?

I had to think about that one.  I said that the chart is a document that is an archive that is most helpful for those people that know the patient.  It is also one large medical bill.  And yes, Dr. Verghese makes excellent points about the iPatient, but the truth of the matter is that the medical record is not all that helpful when you don’t know a patient and you have to make a quick on-the-spot decision.  So, this is why we can’t ask busy residents to pause to look in the electronic health record to answer the clinical question of the moment when they don’t know the patient.  The information there is overwhelming.  Our chief resident had a better answer.  The night resident needs the Cliff notes to answer the question since they weren’t assigned (and don’t have time at that moment) to read the full text.

Of course, handoffs are more than just the written information.   A handoff also has to include a verbal interactive component.  As the implementation of shorter duty hours is looming, so too is a requirement that all residency programs make sure their residents are ‘competent in handoff communications.’   I was asked about this by Dr. Bob Wachter in an interview that was just released on AHRQ Web M&M last week (disclosure – I am on the editorial board).  Because programs are looking for a way to meet this requirement, I have racked quite a bit of frequent flyer miles visiting residency programs.  But, after I give a talk, I know that they may talk about it for a bit if I’m lucky. Once, I actually witnessed residents putting some of the principles I taught them into action shortly after I spoke at their resident report.  However, these moments are isolated and as you can guess, education by itself will not translate into practice change (we could talk to the handwashing people all day about that!).   So, like handwashing, a monitoring plan is also needed and yes, that is also part of the new requirement- that programs actively monitor resident handoffs.

So as we head into July 2011, here’s to more fresh eyes…

–Vineet Arora, MD





How Technology is Changing Medical Education: Match and Residency Training

20 03 2011

This past week was the biggest week in medical education, which culminates in the Residency Match.   It also marked the swsx festival in Austin, featuring the best of technology and entertainment.  So this post is dedicated to commemorating these two seemingly unrelated yet simultaneous events.  The generation that matched are the doctors of the future who are extreme technophiles and not afraid to use it in medicine.  They may even make their career decisions based on them.  On the interview trail, they will often ask whether the program has an electronic health record.   So, as senior students embark into their residency, it seems only fitting to explore how technology is changing medical education.  Since there is a lot to say, I’ll write a follow up on how it is affecting preclinical education but the focus is on the match and residency training here.

Technology and the Match   During the 2011 residency match, social media was in full force, and the internet was atweeting as medical students, schools, and educators were espousing the #MatchDay and #MatchDay2011 hashtags.  Several medical schools actually embraced social media to actively announce where their students were going via Twitter, dedicated blogs, or Flickr (yes Eastern Virgina students wear costumes!).  As students celebrated by announcing where they were going, faculty (including myself) could welcome them into their own program.  Current interns could rejoice that they were that much closer to the end of their grueling internship, except that they were still going to be on call overnight, while the newly matched have restricted duty hours.

Students often wonder about the size and capability of the mega-computer that runs the algorithm that produces the matches.  Unfortunately, this year’s match was marred by a serious computer crash during the precious hours of the Scramble highlighting the worst case scenarios when we depend on technology.  The computer crash also does not bode well for the implementation of next year’s Managed Scramble which will increase the numbers of aspiring residents who will use the Electronic Residency Application Service to apply to programs in the post-Match mayhem that is the Scramble.  In addition, the current debate over the “All -in” plan will require heavier technological capability as international medical graduates will be required to enter the Match (unlike US Seniors, they can accept positions outside of the Match). 

Technology and Residency Training  Technology certainly increases our capability in monitoring resident duty hours and collect evalutions through Learning Management Systems like New Innovations or e-Value.  However, the implementation of electronic health records actually increases time to do work in many cases, which may make it harder to comply with duty hours.  Although decision support can improve quality of care, others worry that overreliance on decision support may result in physicians who subscribe to cookbook medicine and worse, can’t operate without technology.  For example, one program director stated that she was going to resort to a ‘blue book’ exam for residents to demonstrate how to do admission orders using the classic mneumonic ADC VAN DISMAL.

More interestingly, just like email and internet has made it possible to conduct business 24/7, the remote access of electronic health records makes it possible to work from home, after you leave the hospital.  This may come in the form of ‘epicstalking’ as our attendings and residents refer to it – the process of ‘following a patient’ by looking at the labs and studies through virtually logging in to the hospital’s electronic health record “Epic” from home, long after departing the hospital.  Attendings can use epicstalking to ensure that the hospitalized patients are receiving the therapies that are indicated and that the residents are presenting all the information (in essence a form of supervision).  However, residents often epicstalk to try to check to see what is going on with the patient they have handed off and gone home, a time when they should be resting.   With shorter hours, will more work be transferred home?  It is possible, and how this time will be counted in residency duty hours is still anyone’s guess.

In the meantime, maybe a consult to the supersmart Watson can help us tackle these problems? 

Also, stay tuned for part 2 which will look at technology and medical student education.

–Vineet Arora, MD





Nature vs. Nurture in Medical Education: The Case of Student Bedside Manner

13 03 2011

Sir William Osler at the bedside

Believe it or not, it’s been a major news week about the soft stuff in medicine, bedside manner.   First, a Time magazine story about a new study showing that patients cared for by physicians with greater empathy had better diabetes control.  That study comes on the heels of an editorial in the New York Times written by a patient (who also happens to be a science journalist and an outstanding writer) with mitral valve prolapse who graciously volunteered herself to be examined by preclinical medical students learning to do the physical exam and lived to vividly document the experience for all of us.  As she eloquently describes, some students seemed like naturals, whereas others were awkward and clunky.   

These articles add more fuel to the fire for the most hotly contested question in medical education – Can you teach these behaviors?  One on side, you have the nature supporters, saying that the role of admissions committees is to screen these behaviors out.  The nurture supporters say that these behaviors can be taught and its medical schools responsibility to do so.  While it is true that some pathologic behaviors need to be screened in admissions, the question for most students is more refined—is it true that some students come in ‘empathetic’ and others are just hopeless oafs that can’t empathize with patients?  Well, it was refreshing to read Number Needed to Treat blog written by a medical student who says the NYT article was eating away at her soul…She nails it by saying the following:

“Almost every single med student I know is, in fact, an affable person. Yet it doesn’t always come through in the exam room.”

Why is this so hard?  Well, it is not easy to learn how to do a physical exam while also forming your bedside manner.  Our students have to pass a national standardized exam that requires doing the over 100 step “head to toe” physical exam.  As a ‘dinosaur’, I never had to take such a test. I’m not even sure what all the steps are but have asked my colleague, Dr. Farnan, who runs our Clinical Skills program for medical students who informed me of all the points and that they are to be memorized.  Let’s be honest- most of our faculty could not do this without referring to a cheat sheet.  If they had to memorize it for a test, they may even come across robotic and unempathetic at first. 

So, what does this mean for students’ bedside manners while they are learning?  Well, mental capacity is finite.  Workload has been well described as a construct that includes the mental and physical challenge of the work.  For complex tasks, it is important to consider how much ‘spare capacity’ one has after the ‘primary task’ is dealt with.  Elegant studies have shown that experienced physicians are BETTER at performing a secondary task than novice physicians when both are doing the same primary task.  Why?  The experienced physicians have more ‘spare capacity’ to deal with the second task.  

So what is the primary and secondary task in interviewing a patient?  Well, the primary task is learning the physical exam and how to take a history.  As we celebrate this week’s residency match, the job of medical school is to produce physicians that can perform these basic functions during residency training.  While our medical students acquire these skills, of course some will be naturals, and therefore have more spare capacity to key in on their bedside manner.  In contrast, others may struggle with basic skills and have difficulty with both.  The majority, however, will first initially put all their mental effort into learning how to do a history and physical, leaving little ‘spare capacity’ for bedside manner.  Is there hope?  Yes, as these students get better at taking a history and physical, they will be more at ease.  This will then free up the necessary spare capacity to be continuously cognizant of their bedside behaviors.  Consistent with this philosophy, one school has had success actively reinforcing bedside manner skills while prerounding during the third year clerkship.

This progression is important, and highlights the learned art of medicine.  This was articulated beautifully by our recent keynote speaker, Dr. Joel Schwab, for the Gold Humanism Society senior student honorees.   On the subject of being humanistic, he said that he THINKS about the landmark article on etiquette-based medicine every time he sees the patient and he follows the 6 steps –

  1. Knock on the Door (wait permission to enter)
  2. Introduce yourself (with name badge on display)
  3. Shake hands (wear glove if needed)
  4. Sit down (smile if appropriate)
  5. Briefly explain your role on the team
  6. Ask the patient how he or she is feeling 

While working at a free clinic last Saturday, I too thought about this article for every patient I saw.  The first year students I was working with came from a variety of medical schools in Chicago and were volunteering their Saturday to do this.  I had no doubt that they all cared about the patients.  But, I did notice that they were taking time to think very hard about the chief complaint, figure out the right questions to ask, and how to present it coherently.  So, the role of medical education is to make sure that doing a history and physical becomes second nature for our students, and that thinking about bedside manner becomes the primary task.

–Vineet Arora, MD








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