1st Day Thoughts

Telluride is beautiful – leaving me breathless. First day of programming was packed with goodies. Lots of great discussion – respect for everyone who shared their thoughts – fellow residents, teachers, and patient families. For me, it was my intro to twitter – which I’d signed up for but never used. Check out @edcountydoc which I took to throughout the day with thoughts. Some are shared here.

One tweet that received¬†no love was my tweet on handoffs. We are always so focused on the number of handoffs that we point fingers at the number and poor quality of handoffs as a major reason that errors and patient safety have not improved since work hour restrictions. However, I think this is a correlation and not causation. The thing that never comes up is that handoffs are not usually 1:1. During the day, there are multiple teams on duty. For example, in medicine, there are 6 teams staffed with 1 resident and 2 interns + 1 attending caring for 10-20 patients. At night, there is 1 resident and 1 intern caring for all 6 teams’ patients. That’s 1 resident and 1 intern caring for 60-120 patients.

With this ratio, of course handoffs are not great, as the oncoming team has barely any time to get information as they are being hammer-paged for all sorts of issues – big and small – for the 60-120 patients they are covering. So I think the number of handoffs may be less of an issue when compared with the sheer incongruity in staffing that the handoffs represent.

Furthermore, at least at my hospital, signout consists of individuals manually updating a fancy word document type of program rather than pulling directly from the EMR. If we have technology such as Twitter and Facebook that can automatically pull from hundreds if not thousands of profiles and display that information for a single individual to consume, how can we not have a similar signout / information tracking system for the 60-120 patients that the 1 resident and 1 intern are following overnight instead of relying on pen, paper, and human error?

It’s kind of absurd that despite the amount of money we place into EMRs and healthcare, our technology is still so horrible whereas the free systems I have access to, such as twitter and facebook, are able to attract top programming talent and provide relatively much higher tech systems. Don’t get me wrong – twitter has played an amazing role in some social movements, but why can’t the same kind of talent, dedication, and creativity be applied to EMR systems?

Other random thoughts:

Transparency leads to better “outcomes” for patients, families, and providers. Despite being a lawyer, I feel strongly that we need to take tort out of adverse outcomes in medicine, which would inspire greater transparency. Think about this – how crazy is it that we have a bunch of lay people who do not understand medicine (judge + jury) deciding how much patients should get. It results in many cases where patients who were harmed get no compensation, many cases of unequal reimbursement for the same harm, and a lot of wasted $ and time on the part of the legal system. Perhaps we should create a “no fault” or automatic compensation system such as those set up for those who suffer adverse outcomes from vaccines and save the legal system for punitive damages and criminal charges when true negligence occurs or when individuals blatantly flout the standards and rules that have been created. This type of system would hopefully encourage more transparency, leading to faster resolution and compensation for patients/families and more openness and willingness to learn from adverse events so that future harm is avoided.

Another interesting thought – as physicians/healthcare providers we often forget to close the loop with families – we spend so much time thinking and discussing conditions, ordering tests, analyzing results, and thinking more. However, we do not incorporate families into the decision process and our thought process enough. More importantly, we often do not explain what tests were run and what this all means. Often it’s just a “everything’s ok” with a thumbs up gesture and we discharge our patients because we feel that our work is done – we have thought through everything and it is safe for the patient to go home. All of this is good and well, but it leaves the patient and families out of the process, with little understanding of what transpired. Yet in residency, at safety net hospitals, where we are so pressed for time, this part of closing the loop often takes the hit, because it is not traditionally emphasized as an important part of our job.

One last thought. We forget that it takes us years to get an understanding of the complex medical system – intern, resident, fellow, attending, consult, primary team. Yet although we introduce ourselves as, “Hi I am Dr. XYZ, title” we never really sit down with our patients and explain how all of these roles fit together. This results in confusion for the patients and families – who is in charge, who do I talk to when I have questions, why are these guys asking me the same question that I just answered for that other doctor in the white coat. etc? We need to do a better job for our patients – perhaps a chart diagram where patients can put doctor pictures or doctor cards that outlines their roles and arrows or explanations next to each box – think World Cup trading card/sticker book with doctor cards as individual trading cards/stickers. It’s not enough to collect individual trading cards/stickers. One then needs a way to organize it so that it all makes sense!

Ok enough random thoughts from Day 1. Was able to go for a job/walk – jalk, representing the relative amount of jogging: walking. Had some good pizza last night and got to hang with my fellow residents = a good time. Got some sleep and now looking forward to day 2!

P.S. Follow Twitter hashtags: #tpser10, #patientsafety, #ptsafety, #meded, #gme

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