Oops! Spoke too soon!

Looks like I spoke to soon about bathroom doorknob hygiene freaks. Today's Globe and Mail gives the thumbs up to "fastidious, obsessive germophobe(s)", and finesses a link between sweaty, germ-encrusted gym equipment and necrotizing pneumonia.

The beauty of this article about fitness centre hygiene and infectious diseases is that it is completely generic. The setting for this health scare du jour could just as well have been a restaurant, library or water fountain. Any public place would do, because the writer doesn't mention any actual cases of nasty gym-acquired infections. She quotes a couple of doctors about community-associated MRSA, and name-drops SARS and necrotizing pneumonia, but there's no actual data showing a link between unhygienic workout equipment and anyone getting ill.

Slow news day?

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What's wrong with this picture? - V

Inside the men's washroom next to our office


Missed the garbage can... again!

I wondered what was going on when, regularly over the last few months, there were crumpled paper towels on the floor just inside the washroom door. But I think I've figured it out.

To keep their hands clean, guys are using the towels to turn the door handle. Because there's no garbage can beside the door... on the floor they go.

Bathroom architects take note: put a garbage can beside (or within 3-point range of) bathroom doors. Better yet, no bathroom doors, a la airport washrooms where you walk through an angled entrance that gives visual privacy.

I wonder what these hygiene-freaks do when the washroom has a hot-air hand "dryer" and no towels. Wait for the next guy to come along and open the door, I guess.

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Re-imagine!

"If you don't like change, you're going to like irrelevance even less."

General Eric Shinseki (quoted in Re-Imagine!)

Re-imagine, by Tom Peters, is a book about business, not health care. Yet, all the ideas in it can be applied to health care and how we can change it (and ourselves). Peters' theme is that businesses and individuals need to change radically rather than incrementally (Re-imagine!) in order to succeed (or even survive) in today's economy.

He's looking at life from a business point of view, but if you read this book wearing health-care goggles, it makes incredible sense for changing the way we provide service (yes, service) for our patients (dare I say, clients?).

The book's design makes it a fun read, full of asides and anecdotes. He takes his own advice in imagining a book that goes well beyond rows of text.

At about 350 pages, it's hefty, but I found myself stopping every few pages to ponder his ideas and consider applications to medicine.

I highly recommend this book!

If you want a taste of Peters' style, visit his website and flip through some of his (many) Powerpoint slides.

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World-class presentation by Hans Rosling

This video shows a world-class presentation. Hans Rosling shows off his Trendalyzer software (now sold to Google and being developed for free, public access). His finale is a show-stopper (don't try this at home!).

While the animated slides may not be appropriate for some presentations, the slide of the woman on a bicycle (at 13:23) is a great example of how to make a "Powerpoint" with visuals rather than bullet points.

See his 2006 presentation for background on the Trendalyzer program. Also check out the TED site for other terrific presentations.

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Illuminating the shadow

The CMAJ reports that BC's Fraser Health Region has banned "physician shadowing" by pharmaceutical and medical equipment representatives. This is a significant, often ignored, ethical issue in medical practice.


I've attended Oncology Rounds with a drug rep present and raised a question about his/her presence. I was assured that a confidentiality agreement had been signed. OK, let's say that confidentiality is looked after, then.

But, what about the physicians' ability/willingness to speak freely and openly about their opinion on a patient's care? Multi-disciplinary cancer rounds often require frank discussion about some difficult situations. There may be disagreements about therapeutic approaches. The meeting's purpose is to air those differences and freely debate treatment options.

The discussion relies on a certain "therapeutic detachment", that is, the ability to suggest a treatment option (or withholding of an option) without necessarily believing it's appropriate for the patient. Some physicians may be uncomfortable in sharing their opinion in the presence of an "outsider" who may misinterpret their intent.

This is only one example in the debate about pharmaceutical reps and clinical practice. The Company We Keep: Why Physicians Should Refuse to See Pharmaceutical Representatives offers a broader discussion of the issue. The comments about this paper are as interesting as the paper, and cover the range from those who piously refuse to interact with reps to those who are indignant that anyone would believe that their professional integrity and judgement could be compromised by a rep. (Those of you in the second camp should check out this article.)

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Cool Science!

Check out "Cellular Visions: The Inner Life of a Cell", an incredible animation made for Harvard biology students. It's about the inner workings of a white blood cell. My kids (age 7 and 10) are fascinated by it. They're asking all kinds of questions about cellular biology (although they don't know it!). I can't vouch for the explanation posted here , but it's better than I could come up with.

Wouldn't you have loved something cool like this to get you engaged in freshman biology?

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The Lost Art of Persuasion

I picked up a freebie copy of SOHO business magazine to have a look at "The Lost Art of Persuasion", an article on sales presentations. It's an "advertorial" for the author's book on the subject, but it has some great ideas on how to improve your presentation style. The article isn't on the online version of the magazine, but it's available verbatim on another site.


Can health professionals learn from sales and marketing techniques? Aren't we trying to impart serious information rather than influence a decision about what brand of widget to buy? A lot of us have been brainwashed into thinking this.

There's a stereotypical format for presenting medical/scientific information. It's formal, dry and serious:

Here is my hypothesis, these are the methods I used to test my hypothesis, these are the results of the testing, and these are the conclusions I have drawn from the results.

Here is slide after slide giving the exact words coming out of my mouth.

Is anyone out there still awake?

It's an unusual presentation that breaks out of that dreary mold.

And that's my point! If you attend a scientific presentation where the speaker engages and excites (surprises!) the audience with something (anything!) different, you remember that presentation. You talk about it. That speaker influenced you.

If uninspiring presentations are a part of the medical/scientific culture, how will we improve? Who will show us a different way? Check out Presentation Zen for links to videos of some inspiring presentations (of course, it's the presenters who are inspiring). The speakers demonstrate many of the techniques from Paul LeRoux's article.

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Dr. Dressup and nose hair

I recently gave up wearing ties to work, so I was interested in the Globe and Mail article about appropriate attire for physicians. Looks like anything goes, within the boundaries of clean and neat.

I have never worn a white coat at the office (much to the chagrin of my father, an old-school general surgeon). The "image consultant" gave the OK for that degree of informality, but for some reason would still like cardiologists to wear a white coat. As far as I can tell, a white coat's main function is to provide plenty of pockets. It's certainly not for better hygiene.

Physicians of the excessive-facial-hair persuasion (you know who you are) should check out the comments on nose hair.

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What's wrong with this picture? - IV

Operating room scrub sink


Soapy water makes stuff slippery?! If you're getting the hang of "What's wrong with this picture?", you know where I'm going with this.

Don't try to change behavior with signs; change the system! How about some non-slip mats on the floor in front of the sinks? What about getting rid of soap and water altogether? Use antiseptic lotions instead.

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Link love

Thanks to Sam Solomon at National Review of Medicine for adding PBW to Canadian Medicine's blog links.
Type rest of the post here

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Yes to Skype!

Two weeks ago, one of my partners suggested we start using Skype at the office for our long-distance calls. Gold star to you, doctor!

Skype is one of several VoIP services that let you place phone calls over the internet. You need a USB headset/microphone connected to your computer and a Skype account. You can call from your computer to another computer for free. If you want to call from your computer to a telephone (handy!), you have to pay. Well, if you call $30 a year, "paying"! (Unlimited calls within North America.)

We spend many thousands of dollars a year on long-distance calls, as many of our patients and referring physicians live outside urban Saskatoon. If Skype works for us, we'll be saving plenty.

I've been using it for the last week and it has been very good. There are the occasional calls with poor quality, but almost all the calls are crystal clear. I've also occasionally found that the system doesn't always let both people talk at once and there are sometimes voice delays. These are the exception, however.

Also, I can use Skype wherever I have my laptop and a wireless network. I can make long-distance calls at the hospital (or from home) without having to bill the office calling card.

I'm going to continue the trial for a few more weeks, but so far, Skype gets high marks.

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Twice in a week!

Being in the national news, I mean. Not the other thing that is good twice a week.

Advanced Access in Saskatoon made the front page of the National Post last week. (Sorry if this link dies in the future.)

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Realpolitik

Just so you have the context of this post, I originally intended to post it on my HQC Advanced Access blog, following the recent Saskatchewan provincial election (which shut down any potentially politically inflammatory communication for the duration). However, perhaps it's a little too politically spicy for HQC, so here it is on PBW.

I'm back! Sorry to abandon you for a few weeks, but our provincial election rules prohibit propaganda. Any organization linked to the government (including health regions and this blog's sponsor, Health Quality Council) had to put the lid on anything that smelled political for the duration of the campaign. What do they think I could possibly say that could be considered subversive?


How about this: Advanced Access is the saviour of Canada's public health care system!


OK, it's no Communist Manifesto, but I sincerely believe it.


When proponents of privately-funded health care point out the failings of our system, long wait times are their major argument for creating a parallel delivery system. They assume that the present situation can't change; that it's inevitable to have these access problems.


But, how would a privately-funded system guarantee access to services? By using industrial methods of matching supply and demand, AKA Advanced Access! That's just good business.


You tricky M.B.A.'s! You know that managing supply and demand properly is the key to eliminating wait times. So why don't you put your resources into doing this in the public system rather than undermining it with a privately-funded one? Provide incentives for physicians and health regions to implement Advanced Access. Train project managers to implement the principles of clinical office redesign, and make their services available at no cost. (It's working for us... thanks, Karen and HQC!)

How much money would go into creating the infrastructure of a parallel, private system? I’ll bet if we took a fraction of that amount, we could significantly improve wait times through appropriate management. (Note: I’m not a professional economist and so am entitled to make blatantly unfounded claims like this.)


Ideological fights waste time, energy and resources. We can improve our current system. Lobby for Advanced Access in physicians’ offices, CT scanners and surgical wait lists. If you’re already involved in improvement projects like this, then spread the word. Encourage your co-workers to get involved.


If you support a parallel, private system, then you're a bad, bad person. But, you can probably be rehabilitated. Comrade.

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"Sorry about this slide" redux

PBW hit the national press! My griping about Powerpoint presentations got mentioned in "Death by Powerpoint" (National Review of Medicine).

There's some great tips from Dave Paradi on tuning up presentations. Also, check out Art of Speaking Science (courtesy of a comment from Lisa B. Marshall).

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Yes, it's annoying... so what?

I had 2 medical students with me yesterday at my cystoscopy clinic. One of them raised an interesting point about Internet-savvy patients.

One of the patients about to undergo cystoscopy had done some homework. She had Googled "cystoscopy" and read up on the procedure and possible complications. She had also spoken to some family members who told her about other complications (including some that just weren't applicable to the cystoscopy procedure).

We talked about the cystoscopy and some common complications like blood in the urine, burning urination for a short time afterward and the small chance of getting a bladder infection. I also corrected some misconceptions she had about the procedure and possible adverse events. The procedure went fine.

Afterward, one of my students commented that it must be annoying to have people research a medical condition or procedure, but not really have the background, education or context to let them understand which information is accurate or pertinent, and which information is misleading.

I know exactly what she means. I admit to having cringed mentally when someone arrives for a consultation, hauling a file folder full of print-outs, cross-referenced with colored Post-it notes. But, I'm learning to use a mental trick to approach such a situation more positively (see the post "Switch" in my Advanced Access blog.)

After all, my job is to gather and interpret information for people. Being a surgeon, I also do procedures and operations, but any physician's main job is to be a data processor. And, I should be doing it in a way that makes sense to my patient and helps advance their understanding of their condition.

It really should be the patient's choice. Sometimes that means a 77-year-old retired farmer telling me "You're the doctor. Just do what you think is best." Other times, it means spending an hour with a 50-year-old business man reviewing the latest studies on how to treat his enlarged prostate.

My main point was: Embrace the idea of an informed patient. When someone walks into your office with reams of research, tell yourself "Great! Here's someone who's interested in their own health. They trust me to help them wade through the thicket of information that is the Internet." Be prepared to schedule an additional visit so that neither of you feels rushed. Don't be alarmed if you don't have all the answers to their questions ("specialist" doesn't mean omniscient). It's more important to know how to find the answers.

It looks like the Internet is here to stay. Better get used to it, doc.

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What's wrong with this picture? - III

Doctor's parking lot - Nov. 8 12:10 pm



Doctor's parking lot - Nov. 8 15:23 pm
Different car

To be fair, even though there was no visible handicapped sticker on either car, it's possible that the drivers were handicapped in some way. I mean, other than morally.

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Practice website puttering

I've been gradually working on my practice website. It's template-based and so is pretty simple to use. On the other hand, it's template-based and so has limited capabilities. As such, I was pleased with myself when I figured out a useful way to work around its limitations.

The website template (courtesy of Mydoctor/Canadian Medical Association) includes a way to show a Yahoo or Google map to your clinic location. I wanted to show maps to several local hospitals, radiology clinics, etc., but the template won't do that.

I could put a long list of links on the site, but that clutters up things. I started by putting a list of links in a Word document and then uploading that to a page on the site. It turns out that the template converts Word documents into PDFs. That would be fine, but the links wouldn't work on the PDF page. A little Googling revealed that links on Word docs (generated on a Mac) don't survive conversion to PDF.

The fix: Upload the Word doc to Google Documents, convert it to PDF and upload that file to my practice website. The links survived that translation. Now I have a single link that gives Yahoo maps to various healthcare facilities.

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