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.
