Monday, October 22, 2007

Hospital Rounds: Inefficiency By Design

I should preface this post by noting that my experiences are shaded by working at a public hospital that does not yet have electronic medical records. I am not complaining about my workload in particular, but rather the structure in which everyone in the health care field operates in when 'rounding' on patients in the hospital.

A Typical Morning

On many services, mornings are scheduled around some kind of morning conference. For this example, I will assume that I am on internal medicine, Morning Report is at 8:30 AM, and I have three patients to see. The attending wants to round after Morning Report at 9:30. This all sounds reasonable enough, right? However, here is what really happens. The residents, reasonably enough, want to discuss the patients prior to attending rounds, so we have prerounds/work rounds, typically at 7:30 AM, before morning report. I allocate about 30 minutes per patient (15 minutes for looking up results from the previous night, 10 min to see the patient, and 5 min transit time), so this forces me to arrive at 6 AM to see my 3 patients prior to work rounds.

Now, if I were able to utilize that time fully to understand everything that had happened with my patient the previous night and discuss problems thoroughly with my team, that would be great. But no. Instead, I waste most of that 1.5 hours hunting down charts that are being shared by up to 10 individuals who are caring for the patient (nurses, respiratory techs, other techs, consult teams, etc). When I finally find the chart, I have to hunt all over the place for vitals, medications, etc, which may or may not be filed under the correct tabs. Then, I have to read notes other people have left, but there are two problems here. First, everyone is forced to regurgitate the same basic info about the patient, so you have to skim through all of it just to get to the relevant stuff. Second, HANDWRITING: some people just refuse to write legible notes, thereby defeating the purpose of leaving a note. In that 90 minutes, I sadly only get 30 minutes max to actually see how my patients are doing, let alone think and discuss the issues they have.

Why 'Rounds'?

Why do medical students round? There are many ways to teach and practice medicine. There is no inherent need to 'round' in order to care for patients. My history may be a little bit rough, but I believe the idea of rounding in American medical education can be attributed to Sir William Osler and the program he began at Johns Hopkins. Physicians had rounded prior to that, but my understanding was that Osler was the first to integrate medical students and education into this system. And, for decades, the system succeeded and many learned medicine at the bedside. And, I must admit, I learn a fair amount on rounds. However, it is ironic that while the buzz in medicine is all about 21st century technologies and practices, we are still stuck in a 19th century work flow pattern. Remember, when Osler rounded, there were no X-rays to interpret, no EKGs, no other fancy studies. Heck, they barely had blood pressure cuffs. Rounding was an appropriate way to pattern work for the 19th century hospital, but rounds are no match for the information overload that each patient now presents.

A Modest Proposal

Well, perhaps several mini-proposals. Rounds should change to keep up with the advances in medicine. First, there is no excuse for having paper charts in the year 2007. It just makes no sense when nearly all the data that goes into charts is generated by some piece of electronics. Second, why must I see my patient 3 times each morning, yet not really examine them because each time I am in a rush to get to the next set of rounds and/or conference? The med student pre-pre-rounds and pre-rounds should be combined. The obvious criticism is that the med student would not be as exposed to the data and would not be required to think on their own. This is easily avoided by simply ensuring that the residents allow the medical students to examine the patients first and to "lead" the rounds for their own patients. By doing so, the students will have more opportunities to ask questions and have their physical exams directly observed by their interns and residents who can help them do a better job. Lastly, and maybe this is just because I'm not a morning person, can't we just combine Morning Report with noon conference? The "break" at 8:30 seems nice, but all it is really doing is extending the day in a particularly inefficient way by breaking everyone's work flow. Anyway, that's my two cents.

Monday, October 08, 2007

Top Ten Tips for Patients

While I am no expert on the patient-doctor relationship, it seems to me that many patients would benefit from a simple introductory handout that explained to them the nature of the patient-doctor relationship and what their rights and responsibilities are. Based on my experiences, here are ten tips (in particular order) for patients to help them get the most out of an office or hospital visit:

1. Bring Your Meds - It is simple really. You are in pain, you come to see the doctor, they prescribe you medication to relieve your pain. When you come back the next time to see the good doc, the least you could do is bring those medications (or some record of them) along. Why? There are several reasons. First, doctors do not always remember what they prescribed, and the records are not always accurate. The best record is what you are actually taking. Second, if you are seeing multiple doctors who prescribe you different medications, it is important for each doc to know every med that you are on. Third, by bringing the actual meds in, the doctor is better able to gauge how much you are actually taking and prescribe you an appropriate dose / # of tablets.

How to achieve this? Again, it is very simple: put all of your medications in some kind of bag at home. When it is time to see the doctor, bring this bag along with you. That's it. That is all you have to do - you don't have to memorize names or doses of meds. Just bring 'em along.

2. Ask for reports - Any time a doctor runs a test on you (X-ray, CT scan, sends a sample to pathology), they get a report back with the results. Ask for copies of these results! It's your health, and your test, that you likely paid for. You might as well know the outcome, right?

3. Bring your reports - See #1 and 2 above. This applies if you ever see a new doctor.

4. Wear underwear - This applies more to the hospitalized patients. If you are conscious, in no acute distress, and have no problems directly in your groin area, feel free to keep your tighty whites on. No, really, we insist. Okay, so I know as physicians, it is important to fully examine the patient and this is important on day 1. However, on Day 5 for a patient with chest pain, I am not really concerned with their scrotum. While 'going commando' is always a bit of a thrill, you should not do so because... uh... umm... you'll get scrotal cellulitis. Yea, uh, that's it.

5. Go home - Again, this is more for the ambulatory hospital patients. If you are not acutely in pain and you are just waiting for a test that is of little diagnostic value, you can leave. As my upper level resident pointed out today when I asked him why we did not restrain an agitated patient who was trying to pull his IV, hospitals are not jails. As a patient, you have the right to leave. To do so, you must sign a form that says you are leaving "against medical advice" or AMA. Of course, this sounds ominous, but in some cases, it is actually to the patient's benefit to leave AMA. Why? Well, in some cases, physicians practice CYA (cover your ass) medicine in which they order a bunch of pointless tests that take forever to come back. During this time, the patient is just sitting there, waiting to catch something from the hundreds of sick people around them. If you are feeling well, and the tests can be done as an outpatient, well.... go home!

6. Ask questions -Pretty self-explanatory. If you don't ask questions, you'll never know. At the very minimum, you should know the name of your diagnosis, and what it means, and what the doctor is doing to treat your condition. Write the diagnosis down, and then later, look it up online. Educate yourself using trusted websites online (WebMD, MedlinePlus, etc). Do NOT bug your doctor with every crazy 'miracle cure' you read about online though.

7. Learn English - Sorry, that may be a little harsh, but the more you know (of English), the more you'll know about your disease, and the healthier you'll be. Sigh, I realize, I am writing this in English so if you don't know it, this will be lost on you, but still, gotta say it.

8. A "medication" is anything that you put in your mouth that is not food/water - Just because you got it from a nutrition store does not meant it cannot affect your body like something you got from the pharmacy.

9. Short, simple answers - The more extraneous things you say, the less doctors hear. The doctor is like Sherlock Holmes, and they are trying to figure out why are you in pain. When answering their q's, try to focus on the basics like: what, when, where, why, how (the "who" is hopefully you). Like Joe Friday would say, "Just the facts, ma'am."

10. Smile! - Doctors tend to be tired and grouchy sometimes. However, it is hard for us to be mad at a happy patient. If you smile, your doctor is likely to smile back. In fact, anyone would: it's simple psychology. Doctors are visibly nicer if the patient seems nice. This is not ideal, but it is true. You should see some of these disillusioned residents when they encounter a pleasantly demented 85 year old grandmother...


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