I enjoyed reading Fun Works - Creating Places Where People Love To Work by Leslie Yerkes. She suggests that encouraging people to have fun at work reaps benefits of increased productivity, creativity and employee retention. Sounds like a prescription for the healthcare system. She's not talking about having fun socializing at work (although this is important). She writes about integrating work and fun into a "culture of fun". There are great stories about Pike Place Fish, Harvard University Dining Services and Southwest Airlines. All these businesses emphasize a focus on their customers' experience, and how satisfying and invigorating this can be for employees. Sounds suspiciously like patient/family-centred care...
I was particularly struck by her comments on taking risks in order to "harness and develop the full potential of employees":
The integration of fun and work requires expansive thinking and risk taking. When we utilize expansive thinking, we learn to 'think beyond the box.' When our thinking expands, we create the room for fun to come into our work. Only then can we embrace the risk of integrating fun and work.
To embrace risk taking means to try new things without fear of criticism, to be able to make mistakes and welcome them as learning, without fear of punishment. To be successful at risk taking, we must overcome our fear of failure; we must be able to bring our whole selves to work without fear of rejection. Once we are successful at expansive thinking, risk taking itself becomes fun.
Nothing great in history was ever accomplished without risk. The risk for great success is the same as the risk for failure - extremely high; the risk involved in producing mediocrity is extremely low. To succeed greatly, we must risk greatly. (My emphasis) Risk is inherent in innovation and innovation is the life-blood of our future. Lead the way into the future - don't follow.
Expand your thinking, embrace the risk of fun and work.
Here's 3 recent blog tweaks. (Tech freaks only...) I had to reinstall the collapse/expand post hack from Hackosphere. I don't know where it went, but it suddenly stopped working. Something I did must have reset the template. I found another version (again, Hackosphere) that takes the reader to a post page when "Read More..." is clicked. I like this feature because...
I'm tracking reader interest using Google Analytics. This is another free Google application that lets bloggers see how many visitors they have, where they live, what pages they read, how long they spend on each page, and lots more information. Previously, if a reader surfed to my blog's main page, they could read recent posts without having to go to that particular post's separate webpage ("post page"). Google Analytics would show that as a visit to the blog's main page but wouldn't tell me what content readers were actually looking at. (Google Analytics is good, but it can't read your mind. Yet.)
Now I should get results on what content is holding people's interest. Why do I want to know? Because it's all about you! If I'm going to spend time writing this blog, I'd like to make it interesting for visitors.
Finally, I added a labels column on the right of the page. It's very simple to do using Edit Template in Blogger. I label most posts into categories/labels, so if there's a certain flavor of post you're interested in, click on that label.
HRH Queen Elizabeth II has a YouTube channel and, according to this story, has very recently "embraced...major technological advances" such as the internet, cellphones, Blackberries and iPods. I think this would qualify her, according to Rogers' innovation adoption model, as a late-adopter of information technology.
She's still ahead of many physician-laggards. It's tempting to ridicule physicians who are reluctant to use electronic health records (I think I just did!) But, for those of us who are keen to promote the use of EHR, we need to understand why well-educated, tech-savvy physicians often resist implementation of EHRs.
(DISCLAIMER: I'm a member of our health region's recently-formed IT Steering Committee so I'm a little evangelical about this stuff.)
I'm already sold on the virtues of EHR: reducing paper clutter, rapid access to patient information, easy transfer of information between care-givers, decision support, less scut work, etc.
But, in order to win over skeptics, we need to provide an EHR system that goes beyond moving from paper to pixels. We need an EHR/IT system that changes the way we can practice medicine.
We need WOW! (Don't try to figure out the acronym - it's just WOW!)
We need to put together an EHR/IT that sells itself - that flies off the shelves. We need the EHR equivalent of an iPod/Wii/WOW (OK, this time it's an acronym - ask a teenage boy).
Our EHR needs to do COOL stuff.
Here's a great NEJM article (c/o Atul Gawande's website) that lists some cool stuff EHR/IT could be doing for us (our patients, I mean!). This article is 4 years old - that's 26 in tech years. We're seriously behind!
Which of these options/opportunities described in the article appeal to late-adopters/laggards? We need to know. We have to ask.
Over the holiday season, I was shopping for a new TV. One salesman wanted to set me up with a 52-inch wall-mounted model. He showed me a football game in high definition. The picture and sound were incredible.
He didn't make the sale.
You see, he didn't bother to find out my needs. I don't watch sports or rent many movies. My kids don't need 52 inches of SpongeBob. The screen had to squeeze into a cabinet recently vacated by our defunct TV set.
If we want to have physicians accept (even embrace, a la HRH) EHR, we (the salespeople) have to find out their needs. How do they practice now? How can EHR make their practices better, easier and safer? What are their concerns about EHR?
Hard sell won't work with physicians. At the first hint of something being forced on us, we circle the wagons and become as stubborn as mules (among other cliches). Administrators planning to implement EHR must sincerely engage physicians in the process.
If anyone needs to take advantage of Google's online Calendar application, it's my friends Paul (an ophthalmologist) and Pam (a psychiatrist). Check out their daily schedule in this Star-Phoenix column, "Hectic hockey parents".
If they leverage the power of online scheduling, they could probably fit in a 6th child.
Not Santa Claus... Your surgeon! The World Health Organization is beta-testing a Surgical Safety Checklist as part of their "Safe Surgery Saves Lives" initiative. You can see the elements of the checklist here.
It's purpose is to improve communication between OR team members and avoid preventable errors during surgery.
Saskatoon Health Region's (SHR) already has a policy that a similar, somewhat shorter, checklist will be reviewed immediately before each procedure in the operating room. Our checklist is read out by the OR nurse and includes:
Confirmation of the patient's name
Confirmation of the surgery planned (including which side of the body is to be operated on)
Review of any patient allergies
Asking the surgeon whether perioperative antibiotics are required
Make sense to do this? No-brainer, right? I'll bet if you've never worked in an operating room, you just presumed that some kind of "pre-flight check" was standard procedure.
Well, it is now, but it's only recently adopted. And not wholeheartedly accepted.
Surgeons are a very conservative bunch. And we tend not to like ideas that come from outside our community. Especially if the new ideas are perceived as being extra work for not much gain. SHR's preop checklist policy certainly fell into that category, at least initially. (I admit to being an early skeptic.)
Probably the best judges of how this policy is accepted by surgeons are OR nurses. In a completely arbitrary and invalid survey of OR nurses (read: gossip in the lounge), I found that surgeons' attitudes to the preop checklist varied widely. Some surgeons accept the policy and actively participate in the procedure. Many ignore the checklist as it's being read out. (One colleague commented to me that "it's a nursing procedure, not for surgeons.")
A few surgeons actively deride the checklists. I overheard a surgeon who mocked the nurse reading the checklist, saying "C'mon, I know you have to do this, but do you really think it makes any difference? Like I don't know what procedure I'm going to do on this patient?"
Well, doctor, check out the comments in these recent blog posts regarding wrong-side surgery and preop checklists in general:
Suture for a living (The final paragraph says it all: Most important is for everyone involved to be engaged in the process...) More than Medicine (Think how much effort/anguish could have been saved by creating a system to prevent these mistakes.)
And, if you're still not convinced, watch Tom Shillue's standup comedy bit about wrong-side surgery.
He makes it sound ridiculous. Because it is ridiculous.
Every member of the OR team should be actively involved in the preop checklist process. Maybe we should include one other person: the patient. I don't mean that the patient should listen and confirm the checklist in the OR - that would be impossible if they are sedated or asleep.
Instead, patients (families, caregivers, etc.) could be made aware that this is SHR's policy. They can be informed of this as part of their preop orientation. They may choose to confirm with their surgeon that he/she will make sure that the policy is followed during their surgery.
The surgeon may then choose one of these responses:
Yes, certainly. I believe this is an important part of the system we have put in place to ensure your safety while you are in our care.
What a load of crap! Do you really think that reading out some bureaucratic garbage is safer than my years of surgical experience? Either you trust me or you don't!
I was listening to some rap music today. Not that I had a choice - it was coming out of a Jeep four miles away. - Nick DePaulo
I was listening to an elderly lady's medical history and vital signs today. Not that I had a choice - it was coming out of a paramedic student four metres away. The young man was presenting his patient's medical history to his supervisor and an ER nurse. I had nothing to do with that patient, but the student's booming voice gave me an earful of her life story. Everyone else in the ER, including patients and their families, could hear him clearly.
The thing that bothered me most about this situation was that no one called him on it. Neither his preceptor or the nurse suggested moving into a more private location to have this discussion of confidential information. Their acceptance of this potential breach of privacy validated this behavior for the student.
Certain hospital environments make it difficult for staff to preserve patient confidentiality. Crowded, multi-patient areas such as ERs, recovery rooms, critical care units and 4-bed rooms (yes, we still have them at my hospital!) are particularly challenging.
For example, when patients are brought into the recovery room after surgery, it's critical that the OR nurse and anaesthetist inform the recovery room staff about the details of the surgery, the patient's medical history and current condition, as well as plans for the immediate post-operative period. This is done in a room where patient beds are separated only by a thin curtain. And it's sometimes done in a loud voice, in order to be heard over other conversations and the noise of monitors and other equipment.
I can hear the excuses and objections now. "You can't expect us to leave the room to sign over a patient. I've got to watch 3 or 4 other patients." Or perhaps, "We're using medical jargon anyway. Laypeople wouldn't understand what we're saying."
Well, yes, I understand the constraints of the work environment. But if we're committed to respecting our patients' privacy, we should at least try to solve this.
If you're a healthcare worker in one of these hospital areas, ask yourself these questions:
- Do I keep my voice quiet when discussion patient information in patient care areas?
- Where possible, and safe for my patient, do I insist that private information be discussed away from other patients and staff?
- Do I model ethical behavior to students and trainees?
And, most importantly:
- How would I feel if I were the patient? Would I want my personal information made public without my expressed permission?
I wonder what people think when they hear us bellowing patient histories across a crowded ER. Does it affect their confidence in our professionalism?
But, back to the paramedic student. What should I have done? Point out what he was doing? Suggest they find a private spot to discuss the case? Probably. But, I didn't know any of the people involved and they didn't know me. I couldn't think of a tactful way to raise the matter without them mentally labelling me a nosy, know-it-all, arrogant physician. So I did the next best (or perhaps, better) thing.
I mentioned it to one of the senior ER nurses. She has an easy, personable manner and I thought the comments would be well-received from her. She agreed that the problem was too common in the ER and that she would mention it to the student.
I love when someone else does the dirty work. Read More......
Wow! I had no idea how many blogger docs were out there until I started poking around in Medicine 2.0. But what's with the anonymity? I agree with Jay Parkinson - if you're a professional and have something to say about your profession, why not put your name on it? If it's controversial, be ready to support your opinion. If it's offensive, don't post it. Sooner or later, you're going to get outed. It just depends on how badly someone wants to find out who you really are.
I cringed recently while reading a post on Urostream, by keagirl, an anonymous urologist from "A Big City, USA". I generally enjoy this blog, but this time, she lists various euphemisms used in office notes to disguise what she is really saying about a patient.
Use these puppies at your own risk, keagirl! If one of your patients asks for a copy of her records, how will you explain what you meant when you called her "challenging and loquacious". Maybe you could bafflegab her, but what about her lawyer? A judge? Professional review board? Especially when you've published a glossary on the internet.
Since starting to use Skype last month, I'm still very pleased with the service. I made 2 discoveries last week. First, Skype's customer service seems very good. I had a glitch using Skype on my laptop. (Of course, it turned out to be my mistake, but let's not dwell on that.) Their online help desk sorted out my problem within 24 hours.
Second, I found out that Skype shows your Skype username to people with call display on their phones. That explained why, over the last few weeks, when I've called some people on Skype, they seemed suspicious of who was calling. I indicated it was "Dr. Visvanathan calling with test results", but they didn't seem to believe me. They were expecting to see my full name on call display. (My Skype name is "kishorevis".)
One patient who I eventually reached after several attempts told me he had seen "kishorevis" on his phone and was a bit puzzled. A resourceful chap, he googled it and Plain Brown Wrapper was at the top of the result list. He saw my picture/profile and solved his mystery. Perhaps a sneaky way to publicize one's blog!
Beware if you're in the habit of choosing "naughty" usernames, especially if you're using Skype for business. First impressions...
Last week, each one was stuffed with this memo. Don't get me wrong here - there's nothing wrong with the memo. It's useful info. But, once I've read it...
There are about 100 mail slots in the lounge. All of them get the memo, even the ones for doctors who have retired or moved. (Why do we still have those slots?) The garbage can fills up pretty quickly on memo day.
The holidays are particularly hard on the forests. Today was a 3-memo day.
Earlier this year (I believe it was during the Easter paper blizzard), I called the admin assistant responsible for these memos and asked if the information could be sent out by email. Just set up an email group and press 'Send'.
Think of the savings: Paper, ink, delivery time, less garbage to haul.
C. The "Squeegee kids we'd like to meet" feature in Maxim magazine?
Answer: None of the above. This is from... ... the Canadian Medical Association Journal!
No lie. Here's the whole ad from the October 9 issue.
Testim is a testosterone gel marketed to men with low testosterone levels. You get the gist of the ad: If you didn't answer the ad's quiz with "C", maybe you need to smear a little Testim on your hypogonadal self.
This is not the type of ad you usually see in a medical journal (note that, in the actual journal, the ad is in full, glossy color and much more, uh, life-like). No doubt an attention-seeking ploy by the marketers.
And, attention they got.
Check out these letters in the December 4 CMAJ (under the title "Advertisement". You need to open each PDF. Sorry, that's the way CMAJ is set up).
Some readers were upset that this ad, demeaning to women, they say, appeared in a medical journal (or anywhere, if I understand some of the letters). I agree with their point and that this isn't appropriate for the CMAJ, despite the protestations from Paladin Labs.
But, would it be disingenuous to suggest that the ad is also demeaning to men? The message to men is that, if you don't dissolve into a drooling, hormone-fueled, horn-honking mess when this woman appears in your car windshield, then there must be something wrong with you.
And you should be medicated.
Anyway, I particularly like the response from Paladin's VP, Sales and Marketing, Mark Beaudet, who stays on message and insists that everything is on the up and up.
"We did physician focus groups, for goodness sake!" (I'm paraphrasing.) Where? At a stag party?
Well, M. VP, you're the Marketing professional. We'll just have to see how this ad plays out for the rest of the campaign. You are sticking to your guns and carrying on with the campaign, aren't you?
Deirdre Bonnycastle from the University of Saskatchewan College of Medicine hosts this edition of Medicine 2.0 Blog Carnival, focusing on medical uses of technology.
The yellow sheet clipped to a notice board is an X-ray requisition.
Anyone see a problem with that? While on rounds this morning, I noticed that this ward has the practice of posting their X-ray reqs like this. I presume it's so they're easy to get at when a porter comes to transport the patient to the X-ray department. Whatever the reason may be, I suggest they rethink this practice.
Anyone walking by can read what's on the req, including the patient's name and details of their medical condition. Would you want your private information displayed like this?
Here's a dodgy business plan: Give away your best services for free.
But the folks at Google (stock value $714 US) seem to be making a go of it.
Makes no difference to me, as long as they keep the free, online applications coming.
Of the long list of apps Google provides, the ones I use daily are Documents and Spreadsheets, Blogger and Calendar. And don't forget the granddaddy - Google Search.
All you need to use these apps is a Google account (free) and internet access.
Because these programs are online, you can access them from any computer with internet access. The files live on Google's server, which is probably about as safe as it gets. (If Google's servers crash, it's one of the signs of the Apocalypse.) Data security/confidentiality is another matter. I wouldn't be comfortable storing sensitive information or patient data online.
Documents is basic word-processor. It doesn't have all the bells and whistles of Word, but you can export the text to Word if you need to do some fancy formatting. You can share documents online and invite collaborators to edit the document.
I usually start writing drafts on Google Docs so I can keep working on the document whether I'm at home, at the office or the hospital. I'll export to Word later, if I need some more advanced features.
And it's free.
Google Spreadsheets is handy for data entry. I'm keeping track of some data on referrals from family physicians as part of our Advanced Access project. I enter the data at the office, then access it at home if I want to add it to a blog post.
As with Documents, you can share information and collaborate online. Here's a demo. For an explanation of the data, see this Advanced Access post.
I chose to use Blogger for Plain Brown Wrapper because it was easy to get started and simple to make posts. And free. I don't want to mess around with HTML or setting up my own website, so Blogger fits the bill. It's not quite as flexible as some blog engines, but it's great for a beginner like me.
We've been using Google Calendar at home for the last 2 months, since my wife got a laptop. It's terrific for keeping track of our family's busy and ever-changing schedule. We have 4 children and my wife and I both work.
Our old paper calendar was a mess of appointments, soccer games, school concerts, garbage pickup days, etc. Calendar keeps everything neat and lets me review the evening's schedule from the office during the day. There are multiple views (day, week month, 4 day agenda) and every person's activities are color-coded for easy reading. You can collapse everyone's activities onto one calendar, or just pick one person's schedule to view.
In the new year, I hope to implement this at our office to track physician's holidays. Our group has 9 urologists and we currently list our holidays on a paper calendar. If I want to add some holidays, I need to find that calendar to make sure there are not too many doctors away during the week I want off. The calendar usually lives in one doctor's office, but it might be with my office manager, our on-call scheduler, or with another doctor. It can be a nuisance to track it down.
With Google Calendar, everyone can access the holiday schedule simultaneously, from home, office or hospital.
The beauty/curse of the Internet: All your sins come back to haunt you. The latest edition of the CMAJ contains the annual Holiday Review, a collection of medical spoofs. This reminded me that I made a contribution about 10 years ago. I see it's available online, so I might as well come clean about it.
I got into a little trouble over it. People have different senses of humor and medical care is a tricky thing to joke about.
By the way, after this "article" was published, I received reprint requests from several physicians in Europe and Asia. (This was before on-line journals. Yes, I am that old.) The article was listed in the journal index under "Incontinence" without any indication that it was tongue-in-cheek.
O.K. Maybe I'm going overboard with this drippy-hands thing, but here it is again.
This cutlery has been washed and laid out to dry right underneath the paper-towel dispenser! I know I dripped all over them when I grabbed some towel.
This is in the kitchen of the OR lounge. Yes, the Operating Room, where they're supposed to know a little something about contamination, proper handling technique, etc. Sheesh!
Well, yuck. Someone's left their drinks under the paper towel dispenser! Which is fine if you don't mind someone dripping soapy water, hair and general effluvia into your cola. I know I'm trying to cut down on effluvia.
On the ward, I notice that boxes of exam gloves are often left next to the sink, under the towel dispenser. Nothing says "I love you" better than a box of dripping wet plastic gloves.
You remember what I think about RateMDs, right? I hadn't checked my listing for a while, so I took a look recently. Two comments from November made me cringe. They aren't negative comments . In fact, they're downright flattering. Yet, they make me uncomfortable.
Please don't think this is false modesty. I appreciate a genuine compliment as much as anyone. I want to do a good job for my patients and I enjoy hearing that they've had a positive experience.
But, I live with myself all day and I'm aware of all the times when I don't do a good job. Being impatient with someone's questions (see comment 1/9/07), taking too long to return phone calls... it's a long list. Maybe it's perverse, but compliments often highlight those failings. (Or should I call them "opportunities for improvement"?)
But, hey, if you're planning to compliment me, don't worry that I'll be upset. Just go ahead and flatter me. I'll deal with it.
Canada Health Infoway promoted electronic health records (EHR) in the Globe and Mail this weekend (online here). CEO Richard Alvarez says Canadians should "demand" EHRs. If the public only knew how ridiculously wasteful the current system is, "demand" would be putting it lightly. I've explored the concept of muda in my Advanced Access blog, but here's some examples of wasted time, energy and money from one day in my practice.
7 a.m. hospital rounds: 4 patients to discharge after prostate surgery. Same instructions written out manually on 4 charts. An electronic system would allow routine orders to be bundled together and added to a patient's digital chart with a single mouse click. (Please let me log into this system with a fingerprint or retinal scan. Don't make me go through password purgatory!)
A man with blood in his urine needs a kidney ultrasound. I fill out the requisition and indicate the clinical problem. Hope the radiologist can read my handwriting. Once again, common tasks should be automated.
8 a.m. Seeing a man with a kidney stone. He had an X-ray done yesterday in his home town, 1.5 hours away. I have a verbal report, but his doctor didn't send the films so I can't review the study myself. Our new PACS (on-line X-ray storage system) went live last week, so I can access any films done in Saskatoon, but it doesn't give province-wide access yet. I have to repeat the X-ray in order to make a diagnosis and recommend treatment. Muda tally: Waste of his time, my time, X-ray technologist's time, extra dose of X-rays and cost to the taxpayer.
10 a.m. Elderly man referred to see me because he's having difficulty passing his urine. Family doctor's letter is, shall we say, brief. No indication of other medical history, medications, allergies or results of previous tests. I ask about his medications. He's on a blue pill and a little white one. No idea what the names are. Helpfully, he says that his doctor should have a record of all his pills. No doubt his doctor does. A universal EHR would mean I could access all his history, medications and test results instantly, saving time and reducing chance for mistakes or faulty memory.
11 a.m Review lab results received today. We use an electronic medical record program in our office. (It's basic, but is a huge improvement over hunting through paper charts.) Our health region's lab has its results in electronic form. Sounds like a match made in heaven, huh? Hey, Lab, why don't you just electronic those results right over to us?
Well, they can't. Actually, they can, because they do it for other doctors' offices in our region, but they can't do it for us. I've asked several times and the reason seems to be that they don't have the proper (insert random, unconvincing technobabble here) for our program and we'll just have to wait our turn to get connected. It's been about 2 years now.
In the meantime, they fax us the results and we scan them into our system. It's a crazy Rube Goldberg machine. Not only does this waste my staff's time, there's a huge opportunity cost. Because the lab results only exist in our system as scanned pictures, the system doesn't really "know" what the results are. We can't follow results (such as PSA levels) over time without having to manually enter every single result. We can't search for abnormal results. We could be doing so much more with this information.
These examples are just about shuffling data around. That's peanuts! An EHR could harness computer-assisted decision-making, show current evidence-based best practice, alert me to medication interactions, help patients be more informed and involved in their care, the list goes on...
It's holiday potluck time in the X-ray department! Everyone sign up to bring their favorite dish.
Umm, Shelley, I'm going to pass on the pumpkin dump. It looks delicious, but my doctor told me not to eat anything that sounds like a trick you play on the groom after he passes out at his stag party.
Is Jay Parkinson at the leading edge of innovative medical care? Or is he a cherry-picking, cream-skimming squeegee-doc? Whatever your opinion, it's fascinating to see the media attention around this newly-minted doctor's unorthodox practice model. First, visit Dr. Parkinson's website. Even if you find yourself skeptical about his practice model, you have to agree that the website design absolutely nails it. It's uncluttered, engaging and absolutely true-to-brand.
While you're there, check out "The News". This story went viral when Dr. Parkinson started his practice in September. The Wired article is a nice, brief summary. The Chicago Tribune has an interview with the doctor, but the comments posted afterward are very interesting. Dr. P gets into a posting slap-fight with some other docs. Nasty. (I liked it!)
An interview on HIStalk summarizes his business plan.
Dr. Parkinson restricts his practice to 18-40 year-olds - a notoriously healthy age group, no matter his protestations that they do get ill. He also plans not to perform pelvic exams, no doubt for medicolegal reasons. (Difficult to carry a female chaperone with him as he zips around New York on his scooter.)
But, wouldn't a full assessment of a young female with lower abdominal pain usually include a pelvic exam? Perhaps patients need to be pre-screened to see if they fall into his preferred pathology-demographic as well as his preferred age range. (He also talks about practicing preventative medicine. Umm, Pap smear, anyone?)
The media has made much of how radical a departure Dr. Parkinson's practice is from mainstream medicine. The problem with his idea is this: It's not radical enough!
Dr. Parkinson, your plan is too generic, too easy to copy. What distinguishes you from any other Tom, Dick or Sally (yes, Sally - Pelvic Exams R Us!) who wants to give it a shot? If it is a viable scheme, then copy-cats will be popping up like weeds. New York's streets will be thick with Vespa-mounted Docs-in-a-Box, racing each other up high-rise stairs, desperate to over-service the worried well.
In business, imitation is the sincerest form of bankruptcy.
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.
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.
"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.
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.
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.)
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?
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.
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.
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.
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.
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.)
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.
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.
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.
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.
I was at a conference over the weekend and patient confidentiality was not on the agenda.
Several speakers used CT scans or other materials in their presentations which clearly displayed the patient's name. In one case, the patient was not only identified, but also his medical condition was discussed in detail. This presenter was from the US, so it seems unlikely that anyone in the room would know that patient, but that's not the point, is it?
A Canadian speaker identified a patient by his initials only, but then went on to indicate that the patient was a retired physician. He went so far as to give his specialty. We know the locale in which the speaker practices, so there may have been other physicians in the room who could put this information together and recognize the patient. Once again, details of his medical history were revealed.
Both speakers are teachers at renowned medical schools. Time for a refresher course, professors!
This is photo from the OR change room, but I've seen the same sign in many places around the hospital. I understand the problem: Laundry bag too full = heavy weight = back injury. But is this sign the best solution?
Rather than relying on people not to overfill the bags, we need to change the system so they can't overfill the bags. How about using smaller bags? Of course, the bags will need to be changed more often, or more bags need to be in place so laundry doesn't overflow onto the floor.
See the previous "What's wrong with this picture?". There's a pattern here. I'll keep an eye out for other examples and report back to you.
Today I experienced a sweet technologic convergence that would make any propellor head weep. Last month, we (finally) got wireless Internet access in the OR. A few of us had already been plugging in cables so we can remotely access our office server, but wireless is soooooo much more convenient.
When I do a clinic at the hospital, I may see up to 20 people. Traditionally, the evening before the clinic, I would make notes from my office computer records to jog my memory about each patient's situation. With wireless Internet, I can have access to my office records live from the hospital. I don't need to make my notes the night before. That saved me 15-20 minutes at the end of a long day.
We also decided to try out Skype's VOIP unlimited calls in North America for about $30. We make lots of long distance calls, so this could save us plenty of money. Today, I tried it out with a USB headset/microphone plugged into my laptop. Excellent sound quality. So far, Skype works great.
So today, I had my computer sitting on the counter outside our clinic room, live access to our electronic medical records, Skype to return any calls from my out-of-town patients, and my PDA running voice recording software to dictate letters which I would download to our remote transcription service.
This is a door at one of our local health facilities. By the presence of the fancy electronic lock, you might imagine that there's a reason to keep unauthorized personnel out. Alas, the door doesn't reliable close on its own, so we're relying on people to remember to pull the door closed manually.
Here's the other side of the door. No sign! So if you're on the way out, you won't be reminded.
Shouldn't the sign on this door read: Attention: Maintenance! Please fix this door. (?)
The Saskatchewan Surgical Care Network (SSCN) is “an advisory committee to Saskatchewan Health dedicated to creating a more reasonable, fair surgical system for all Saskatchewan people.” I’m the urology representative on the Surgical Services Subcommittee. Our most recent initiative is to improve men’s experience when diagnosed with prostate cancer. We’re looking at several aspects:
Initial diagnosis (from the initial primary care visit to prostate biopsy) Access to treatment Education about prostate cancer diagnosis and treatment
The first piece we’re going to work on is education. Our Prostate Cancer Education working group’s first meeting on October 2 included representation from:
Urology Radiation Oncology Patient support/advocacy Provincial and regional health Hospital foundation Nursing education
The main chunks are content and delivery. We want to make the information widely accessible, taking into account varying levels of literacy and access to technology. Even though the final delivery may be using various methods (written, DVD, internet), I’m interested in developing the material using a collaborative, online model a la Wikipedia. I think this approach will help address several problems with producing patient education material.
Similar education projects I’ve been involved with laboured over the material for months, resulting in a monolithic product (usually a pamphlet or brochure) that can’t be easily modified. Even though we had reviewed the pamphlet many times, there would invariably be a forehead-slapping moment when we’d say “We forgot…”
Also, when the information is aimed at patients, it’s difficult for health-care professionals to know what content is appropriate. Is the information relevant? Have we assumed too much regarding prior medical knowledge? Are we presenting the information at a suitable literacy level?
Here’s my suggestion: Break the information into small segments (e.g. explaining the prostate biopsy, prostate anatomy and function, radiation treatment side-effects) and produce a brief, draft presentation on each topic. Post these presentations on the internet, using Youtube (for video) or Slideshare (for Powerpoint). Invite anyone and everyone to comment on them. (An email to a prostate cancer support group should get this rolling.) If the segments are brief, it’s easy to modify them with the requested changes. Once we’re confident that we’ve covered the necessary information, we can consolidate the segments into one presentation (for use on a DVD), or leave them separate on a website so users can more easily access the particular topic they’re interested in.
The most important part of this is Ready… Fire… Aim! Forget about the interminable planning and editing. Let’s get some product out there and rely on the real experts – our patients – to help us refine it.
Yesterday, I had a phone call from Jay Mercer. He's an Ottawa family physician and leader of the CMA's physician website project. He read my post about our Urology Associates website, and saw my request for ideas on what content we should include. He had some great suggestions on how other physicians have been using the Mydoctor websites. I'll be testing these out on my practice website.
I'd like to supply information for referring physicians as well as patients. In particular, I'm interested in an online tool that will standardize referrals for common conditions and remind physicians what information and testing will be useful before their patient's visit with me. Jay also mentioned that there is a contest next month for the most improved website. Seeing as we're starting from zero, we should have a good shot at the prize!
How about helping me out with some of your ideas... Maybe we could split the prize?
I received an interesting consult this week. It read "I think I'll let this man describe his own symptoms to you."
I sometimes get referral letters that carry brevity to the extreme: "BPH" and "ED" come to mind. One referring doc occasionally sends a one letter consult: "P". I don't know if he means "prostate problems" or "difficulty P-ing". I'm sure this brevity is meant to be witty.
But, this is the first time I've received a referral that essentially said "Surprise!" A referral letter doesn't need to be lengthy, but it should convey a few essentials such as the nature and urgency of the problem, past medical history and pertinent test results. From this, I can decide how quickly I need to see the patient and what other tests I should be arranging for her.
In Saskatchewan, it's not unusual for someone to drive 3 or 4 hours for their consultation with me, so I try to coordinate necessary testing to take place on the same day as the office visit with me so as to spare patients extra trips. If I don't have the necessary information in the referral letter, my patients pay the price (literally).
Adequate information in a referral letter also lets me schedule a suitable appointment duration. Our usual visits are booked for 15 minutes. If I anticipate a more complex problem, I'll book from 30 to 60 minutes.
Consider another patient I saw this week. This man's family physician sent a referral letter indicating a complicated problem that had been going on for over a year. He detailed previous treatments and pertinent test results. From that letter, I could tell that 15 minutes would not be adequate, so I booked 45. At the end of the visit, the man asked me how long I usually spent doing a consultation. I explained that I would usually spend 15 minutes, but that his doctor's thorough referral letter prompted me to arrange a longer visit. He replied that this was the longest time he had spend with a doctor and seemed quite pleased not to be rushed through the visit.
He was satisfied. I was happy not to feel rushed (I hate to keep my next patients waiting). All the necessary test results were available, so I didn't have to track down results and then phone the man with my final opinion. Efficient!
Thank you to my family physician colleagues who routinely send appropriate information in their referrals. The time you spend composing that letter saves time and expense for your patient, and makes their visit with me more productive and satisfying.
Our practice website is up. It's extremely bare-bones, but it's a start. We're using the "Websites for Dummies" template supplied by the Canadian Medical Association business management group, Practice Solutions. We thought it best to go with something simple rather than be stuck trying to manage a complicated website on our own.
Now we need content. What would you like to see on a physician's website? Here are our initial thoughts:
Office hours
Location and driving directions with links to a map
Information about common procedures (for us, cystoscopy and vasectomy)
I've got comment moderation enabled on the blog. Translation: If you leave a comment (please do!) after any of the posts, Blogger emails it to me and I have to OK it being published. I wanted this option so as to delete unwanted spam and inappropriate language (you know who you are, potty-mouths).
Previously, I would get the email on my PDA (Palm Treo 650) while I was out and about. I then had to find Internet access in order to allow the comment to be posted. But today, I had a minor breakthrough! The Treo 650 has an Internet browser called Blazer. I haven't used it much as it always seemed very slow. I got an email today about a comment under "1-800-How's my doctoring?". Clicking on the "Publish it" link in the email took me to the Blogger log-in page where I can access this blog and authorize the comment. Sweet!
I've already experimented with "mobile" posting directly from my PDA but this "discovery" makes the whole works mobile. Not impressed? Well, you were warned - this was for gadget freaks only!
I shamelessly plugged Plain Brown Wrapper in my Advanced Access blog. If you surfed over from Health Quality Council, welcome! I hope you'll poke around a bit. I started up PBW to support my patient satisfaction survey project (see below), but I found that blogging is mildly addictive. I'll still be reporting our progress with Advanced Access on the HQC blog, but I wanted to explore some other areas and try other schemes. I'm grateful for all of you who are loyal readers about Advanced Access, and I'd like to tap your experience and expertise in this blog. Please leave comments and suggestions after any posts that catch your interest.
Physicians who know about RateMDs are rarely neutral about it. Physicians who don't know about RateMDs... well, watch out, docs!
RateMDs is an online information exchange where anyone can anonymously post comments about a (North American) physician. There are similar sites for rating lawyers, high school teachers, university profs, etc.
RateMDs sparked my online patient satisfaction survey. Here's why:
Physician rating sites have existed as long as there have been physicians. These sites used to be called coffee row, the backyard fence, and your cousin's friend who knows someone who knows someone. The information was there, but was informal and relatively inaccessible unless you were "connected". Now, the Internet makes everyone connected, and they're sharing information.
Browse through RateMDs (c'mon, you know you want to), and you'll see why some physicians are upset about being rated. There are some pretty frank comments. Some may be accurate and deserved. Others may be vindictive and slanderous. We have no way of knowing. Perhaps looking at the pattern of comments gives a reliable picture of each physician's demeanor. I'd like to think so, but comments and ratings for individual physicians vary quite widely in some cases. One person with a vendetta could leave multiple posts slagging the doc. A physician could salt his own page with glowing praise.
There are weaknesses with the RateMDs model, but the idea is here to stay. I think we should embrace the idea, improve the model and turn it to the benefit of our patients. After all, what physician doesn't want honest, frank feedback on his or her performance?
Ha, ha! Of course, I'm being facetious! I'm a lot more comfortable not hearing about my weaknesses and bad habits, and I'm sure many other physicians feel the same way. If I know my performance is substandard, the logical and professional response is: try to improve. And that means... Change! Before physicians decide to ask for feedback from our patients, we need to commit to making the changes that the responses suggest.
I want to solicit patients' opinions about my performance, but I also want to draw on their experience and insight to make constructive suggestions on how I can improve. To that end, I made my own post (April 17, 2007) on RateMDs encouraging people to comment on how I can improve my medical practice.
As you see on my RateMDs page, there haven't been many responses to that request. As such, I decided to start my own personal rating service. I'm requesting patients to take a web-based survey about their experience in my office. In the spirit of openness, I'll post a link to the survey responses on my blog.
How can you be sure that I haven't polished up or even completely faked the survey results? Right now, you can't. But, I welcome any suggestions on how I could set this up so I can't be accused of fabricating results. (At the moment, I feel I need to review the responses before posting them just in case a patient has included private personal or medical information that should not become public knowledge.)
10 surveys went out on last Tuesday and Wednesday. 3 responses back. Here's the link to see the results. I was hoping for a 50% response. I'll try more surveys tomorrow and Thursday.
FYI: At question 3, if the patient answers that the appointment was made by the specialist (me) as a scheduled recall visit, then the survey skips question 4 about how long they had to wait for the appointment.
I don't like having to scroll through yards of posts to find one of interest. I prefer the expand/collapse ("read more...") buttons found on many blogs. I discovered that Blogger doesn't have that function, so I've tried adding a hack to the template. Thanks to Hackosphere.
Hope I don't pay the price for messing around with HTML that I don't understand.
I went to a great Grand Rounds presentation this morning. Controversial topic, good discussion, lots of ideas for further investigation. Only one thing marred it for me - the Powerpoint Phrase of Doom:
"Sorry about this slide."
PPD is usually followed by "This slide is a little busy" or "I know this doesn't show up well". Here's what you are really saying with PPD:
I understand the principles of appropriate construction of audiovisual aids.
I realize that this slide does not satisfy those principles.
I couldn't be bothered to redesign this slide to make it more valuable to you, my audience.
The old 35mm acetate slides were expensive and time-consuming to create. Audiences were more accepting of poorly-designed slides, understanding that you couldn't just whip up a new one at a moment's notice.
Powerpoint changes that. Presenters have complete control of slide layout and can edit right up to the moment the presentation starts (and even on the fly during the presentation). Too much information for one slide? No problem - break it up into 2 slides. Or 5. Digital is free!
