Leslie Kernisan, MD, MPH
Internal Medicine andGeriatric Medicine
This piece reposted with permission from GeriTech.org.
In another post, I described why it took me almost two hours to sort through the recent hospital records of an elderly patient. The records had arrived in my digital fax queue as a PDF with 159 pages of images of text.
It seems a bit nutty, in this digital age, that so much of medicine is still being done through paper and faxes, but there it is. Most hospitals have EMR systems, but if a clinician who’s not within the hospital system needs medical information, that information usually gets printed and faxed.
What might work better? The most popular plan I hear to solve the problem of independent clinicians accessing hospital records is to create Health Information Exchanges (HIEs).
Health Information Exchange features we need
Let’s assume the HIEs will eventually arrive. How should they function to allow outpatient clinicians to get needed information in an easy and low-hassle manner? The best-case scenario I can envision with a HIE would be an online system that I could easily log into, and that would allow me to do the following:
What’s the best path forward for information sharing and care coordination?
I admit I’ll be surprised — stunned, really — if the HIE, whenever it finally arrives to the hospitals near me, has many of the above features. An HIE is after all enterprise software, purchased not by the daily users, but by administrators or better yet, groups of stakeholders.
Are there alternatives? Some EMR companies, like Practice Fusion, are spearheading a move towards peer-to-peer sharing of medical information. This is a promising idea, but doesn’t help when one is trying to extract information from a hospital.
Another option: that health information sharing among clinicians will be driven by the patient’s control over his or her medical records. Certainly could happen, since connectivity with patients may happen a lot faster than PCP connectivity with hospitals.
Personally I’d welcome this, as I’d like to see patients get to gatekeep most of their medical data, including laboratory data. But I don’t know how close we are to patients getting access to their raw hospital data (and am skeptical that the Blue Button output would cut it, when it comes to clinicians getting the needed info to coordinate care). OpenNotes is a promising start but was just for the outpatient setting — and the patients were mainly in their mid 50s with relatively few medical encounters.
Will patients soon be able to download meaningful hospital data into their personal health records(PHRs) and share with clinicians of their choosing? Only if they demand it.
In a nutshell:
Health information exchanges (HIEs) are projected to eventually allow outside PCPs to access hospital records. Features I hope they’ll include are capacity to easily search and copy the information. Bonus if patients end up able to directly give other clinicians permission to access their medical information.
For more information: in doing a little brief research related to this post, I came across a few good resources for those who want to learn more about HIEs. The National eHealth Collaborative has a report on “Secrets of HIE Success,” which offers insights into how some HIEs have come into being.
But far more interesting and informative to me is Robert Rowley’s series of blog posts on HIPAA and HIE: Part 1, part 2, part 3, and part 4. Love it when articulate primary care docs write about healthcare.
Clinicians and others, have you had good experiences with HIEs yet?
Anees Chagpar, MD
Associate Professor, Dpt. of Surgery
Director, The Breast Center
Assistant Director for Diversity & Health Equity, Yale Comprehensive Cancer Center
Program Director, Yale Interdisciplinary Breast Fellowship
Yale University School of Medicine
Originally published on ASCOconnection.org, the American Society of Clinical Oncology’s professional networking site.
More money, more problems
A few weeks ago, I presented Yale Surgical Grand Rounds focused on “Cost and Quality in Cancer Care.” Amidst the talks in Washington regarding our unsustainable health care spending, and provisions of the Affordable Care Act rapidly taking hold, it seemed appropriate to start to critically evaluate how we spend our health care dollars and the value we receive in return.
The data are not news to anyone. We spend more per capita than any other nation on earth, and yet the Organization for Economic Cooperation and Development (OECD) and the Commonwealth Fund find the U.S. lagging in terms of access, quality, efficiency, and equity of care. How can this be? We spend more than twice the OECD average on MRIs and CT scans, and our unabashed (and sometimes inappropriate) use of these may drive up costs without a commensurate improvement in quality despite innovations in technology.
Avoiding needless tests is a necessity, duty
I told the story of a very elderly patient of mine, who had gone for a routine screening mammogram, which found a speck of calcifications which were further evaluated with magnification views and a biopsy before she was referred to me with low-grade DCIS for surgical considerations. We had a very frank discussion – although she was certainly healthy for her very advanced age, with hypertension as her only comorbidity, one had to wonder about the natural history of her disease and whether this would ever progress to invasive disease that would threaten her quality or quantity of life. As she contemplated whether or not to pursue surgical extirpation of her disease given our conversation, I considered why she had a screening mammogram at her age, with little to no evidence of the efficacy of mammography in this population. A recent New England Journal article noted significant overdiagnosis, and the paper published in JAMA Internal Medicine estimated annual screening-related expenditures associated with mammography in the population over the age of 75 to be $410.6M.
But it’s not just the fact that our duty as citizens should force us to be good stewards of health care resources. It’s our duty as physicians to avoid needless tests that could add to potential morbidity. Beyond that, one cannot underestimate the effect of the financial impact of cancer treatment on the quality of life of our patients. Bankruptcy levels continue to rise in this nation, and the #1 cause (accounting for 42% of all bankruptcies) is medical expenses — that’s more than job loss, credit card debt, avoiding foreclosure, preventing loss of utilities, student loans, and car payments combined.
We must stop the madness
We need to stop the madness –- stop ordering metastatic work-ups on patients with early-stage breast cancer; stop doing routine MRIs even on patients planning to have bilateral mastectomies; stop doing a CBC and complete metabolic profile on every patient who walks into your office “just because”….we need to practice more rational evidence-based medicine; and our professional organizations like ASCO need to support these choices with guidelines like its “Top Five.” Soon after I gave the talk, a few people showed me the Time magazine article that came out the same day (how serendipitous was that?!). The same song, with a different verse… We can no longer choose to ignore the issue, for if we don’t step up to stop the madness, others will stop it for us.
Reposted with permission from futuredocsblog.com
One of the most interesting conversations that I had last year was at the ABIM Foundation Summer Forum Open Space Sessions. The ABIM Foundation Summer Forum is a summit of thought leaders and experts representing healthcare organizations, policymakers, patients, payers, doctors, and trainees who come together to tackle a major problem in healthcare.
As I returned home, I reread some of the literature I have become acquainted with on why we (humans) don’t communicate as well as we should. Using this framework, it’s worth considering why doctors and patients may not communicate as well as they should. Drawing from the knowledge communication literature when an ‘expert’ is communicating to a ‘decision maker’, two distinct problems can arise:
How can we get around these problems? Well, improving a conversation requires training on all sides. Patients can also be coached to take a more active role in their care. However, healthcare personnel also need to be prepared so that their newly empowered patients are not an unwelcome surprise. Physicians and other healthcare personnel need to be trained in how to speak to patients about difficult decisions in a sensitive way. One model curriculum we can learn from has been developed by oncology fellowship directors and is called OncoTalk. One of the key tenants is the principle of NURSE, which describes how to respond to patient emotions during complex decision-making.
Of course, the age-old question is can you teach empathy? Well, according to one recent study, empathy wanes throughout medical school. So we should, at the very least, try to at least preserve it.
Garry Choy, MD
Department of Radiology
Massachusetts General Hospital, Boston, MA
One of the heralded traditions in medicine is “rounds” where physicians communicate, share, teach, and discuss clinical cases or the latest research. When we first conceived a network of social media sites in healthcare and specifically radRounds in 2005, we wanted to bring radiology online, to create a site that connected physicians and healthcare providers around medical imaging.
Today, we have over 11,000 members and growing. We have users registered from nearly every country in the world which has radiologists. We have over 6,500 cases online - for instance, our most popular image has been viewed over 15,000 times.
Creating a Community
radRounds’ success is encouraging, but it’s the collaborative networks and relationships the site has helped establish which is the most satisfying. We’ve successfully built a reliable online medical imaging tool, and true to our vision, we’ve done much more than that: we’ve created a medical imaging community.
We have been able to facilitate collaborative discussions around cases, the formation of new friendships and professional contacts, new research collaborations, and the education of radiologists globally. Our users, typically Radiologists who are devoted to teaching and keenly interested in healthcare social media, use the website to share cases, view educational videos, browse our comprehensive CME event calendar, discuss hot topics, find jobs, and connect with other imaging professionals.
radRounds’ Place in the Future of Medicine
The future of medical will hinge on physician collaboration through online platforms like radRounds. With the new movement towards patient-centered medical homes which tap into a medical neighborhood and rely on evidence-based practice, radRounds and sites like it will be key to fostering digital communication and teamwork between physicians.
As we work to expand into other specialties (construction for psychRounds, dermRounds and oncRounds is currently underway), it is with the conviction that physicians practice better medicine when they connect and collaborate with their peers. We’re helping physicians tap into the wisdom of the collective medical community and that’s not only a powerful way to practice, but a necessary one.
Visit http://www.radrounds.com and first browse some parts of the site such as our vast teaching file and case section without becoming a member yet - see if radRounds can enhance your professional practice, education, career, research, or business goals. If you like what you see, we invite you to join radRounds. Let me know if you have any questions, email me at email@example.com.
Alice Ackerman, MD
Department of Pediatrics
Virginia Tech Carilion School of Medicine
Reposted with permission from Dr. Ackerman’s blog.
There should always be ONE right answer to any problem in medicine. Patients should be able to seek advice from a qualified physician about their symptoms and get an answer. If they present the next doctor with the same symptoms he or she should offer the same advice as the first.
Most physicians, especially the experienced ones, know that for many patients, ONE right answer isn’t necessarily clear. That’s when it becomes important to be a physician who can say “I don’t know,” and help find the right answer for the patient and their family. None of us can know everything. But we can strive to be certain that we know what we don’t know, so we don’t get caught up in making assumptions, and jumping to conclusions. Or, worse yet, telling patients that the symptoms they report in themselves or their child are not real, because they don’t meet our expectations.
I have been impressed (not favorably) that many physicians, faced with a child or adult with a perplexing illness, or set of symptoms, will tell the parents, after a sequence of negative or unrevealing tests: “there is nothing wrong”, or “there is nothing I can do for you.” While the latter may be true, is that where the physician’s responsibility ends? I am much more favorably inclined toward my colleagues who say: “ I don’t know the answer, so I am going to consult with colleagues around the country”, or ”I am going to refer you to someone who is a super specialist in this area”, or who will help you to get an appointment with someone you may have found on the internet, or through parent support groups.
But what if there still is not ONE absolutely clear and convincing answer?
What if things are still muddy enough that there is room for debate? Lets say a child is diagnosed with a rare disorder, that may have many different manifestations. What if the symptoms the child is having are not to be found in any textbook or journal article describing that specific disorder?
That is where judgment comes in.
Physicians should be looking at everything they know, everything they can discover about the disorder, and looking at the specific needs of the child, and then work in concert with the family to determine the best path. Will that be the ONE RIGHT PATH?
But the path needs to make sense in the current time, with knowledge that is available. That path may change with time, as more is learned, or the symptoms evolve and change.
So, what if I have two (or more) sets of experts who disagree with each other on how to proceed? For me, the answer is relatively simple: I defer to the choice an informed family has made as to the preferred path. Remember, the family knows their child better than any of us ever can. They know the subtleties of that child’s behavior, and how it changes with perturbations of the illness. They may be able to detect signs of illness before there are any OBJECTIVE findings.
We should listen. We must listen.
Do I always know what is right?
But I always strive to know what I don’t know, and to listen to all sides of such an issue. My role might be to sit with the parent and ask them questions about what they understand about different options, to help clarify their opinion. What if I disagree with a plan in place? I have to do what I feel is in the best interest of the child; but defining BEST INTEREST is often problematic. It needs to take into consideration more than strict medical issues. It needs to include family values (not physician values), quality of life, social considerations, and more. This is one example of the ART of medicine.
If you are a health care provider, I would love to hear your thoughts on this matter. If you are a medical educator, or learner, let me know how you think this aspect of medicine is best taught. If you have read this post, and you have an opinion, PLEASE share it.
We can only learn by sharing our thoughts, and by listening to how physician behavior affects our patients, their families and their colleagues. Please help our community learn by leaving a comment.
Reposted with permission from Dr. Campbell’s blog.
In the satirical novel The House of God, author Samuel Shem writes about experiences as a medical student at Harvard. In the novel, many famous quotations are used that have been passed on from generation after generation of medical students and residents. Some slang terminology is also referenced and characters are created to illustrate the qualities of certain types of students. One particular student that is found in every medical school class is the “Gunner”. The Gunner is a term used to describe a hyper competitive medical student who is motivated by performance and grades and will stop at nothing to succeed. Almost every medical school class in the US has a couple of students with this character trait. All of us who have trained in the past can still remember who these students were in our own classes. Sadly, a Gunner feels no remorse about climbing over others to achieve success on the medical wards when being evaluated by attending physicians. A Gunner never learns how to work well with others and, although performs remarkably well on exams and evaluations, is often left without essential skills for success in medical practice.
Teamwork is essential to success
Last week in the New York Times, Author Pauline Chen writes about the inability of the current medical education system to “fail” students with poor interpersonal skills and the inability to work with a team. Now, more than ever, teamwork in medicine is essential to success. In the article the story of a bright, young medical student is detailed. This young student is able to ace all of the written exams but isolates herself from classmates, treats nurses and colleagues with disrespect and is unable to accept constructive criticism. The attending physician supervising the student laments that he is unable to “fail” her due to the fact that there are no objective evaluations in the medical school grading system to deal with important attributes such as bedside manner, communication skills and interaction with nurses and colleagues.
Medicine today is a team approach
In my opinion, this story illustrates a major flaw in our medical education system. We have a responsibility to students as well as future patients to help create doctors who are not only brilliant diagnosticians and clinicians but are also compassionate, caring and able to easily work with others. No longer is medicine practiced by the Physician in isolation. Today, medicine is centered around a team approach. Nurses, physician extenders, social workers and physicians all work in concert to produce excellent patient outcomes. Healthcare reform has now mandated certain (sometimes arbitrary) quality measures and it is only through a comprehensive team approach that these can be achieved and (more importantly for the government) documented. Nothing productive has ever emerged from a negative confrontation with nurses or colleagues in a hospital. We must reward students who display the ability to work well with others and effectively communicate with staff. More importantly, we must teach students how to readily accept and respond to constructive criticism and continually self evaluate.
The future’s best doctors will be team players
Certainly, proficiency with test taking and knowledge acquisition is essential to creating a successful, effective physician. However, a physician who is able to work well with teams and communicate effectively with non physician support personnel is just as essential. We must develop a system put that actively strives to teach and evaluate these important interpersonal skills in medical school. Once students are advanced to internship and residency, these bad habits are much more difficult (if not impossible) to break. Competitiveness and striving for excellence are still important qualities in medical students. However, compassion and concern for others may be even more rewarding in the long run.
Arlen Meyers, MD, MBA
President and CEO
Society of Physician Entrepreneurs
In a few short years, social media in healthcare has grown from a curiosity to a major component of care and business processes. Every segment of the health system, including payers, providers, patients and industry are using social media platforms to connect with each other, patients and customers in an effort to reduce costs, improve quality, increase access, improve the patient experience, increase market share or drive revenue.
While the return of investment of the use of social media is difficult to pinpoint, there are definite potential benefits including the ability to spread the word about your products and services, increased referrals, visibility to patients looking for information and health content, and operational efficiencies in your practice. The main issue is the investment required: know- how and time. Is it worth it?
In my view, considerable benefits flow from learning how to use social media and spending a small amount of time each day using it. Here are 10 things that I’d suggest if you are considering a social media campaign on a shoestring:
The short amount of time and effort you put into your social media campaign can yield impressive results. You’re going to “like’ what happens when you do.
Owner and Consultant in Arts and Clinical Learning
What does it mean to really see a patient?
This question drives the work of ArtsPractica, a medical education consultancy dedicated to improving the skills of diagnosis with arts learning. I have explored this question in collaboration with expert diagnosticians and in the arts.
Seeing is about longitudinal skill development, multiple perspectives, suspending judgement, and metacognition. It is more than just “visual skills,” and has little to do with perfect vision. In my opinion, many medical errors are a question of seeing or not seeing.
“Seeing patients” is a central to medical practice, but it’s an out secret that medical training lacks a consistent model for learning to look. In fact, systemic pressures often justify skipping adequate patient inspection. Too often, treatments and tests take precedent overseeing the problem in the first place—and this is where medicine risks failing on its first promise, to “do no harm.”
Seeing to learn about art, patients, and cognition
ArtsPractica is based on the concept that careful study of art can support the development of skills in diagnostic acumen and in communication. This work stems from a decade of collaboration with Harvard physician-educators on the “Training the Eye” program, an arts-based course that produced published outcomes.
Our research found that learning to view detail in art translates to better skills in observation. Students who participated in seven or more arts-based sessions, for example, made 38% more observations in response to both clinical and art imagery than their peers. They further provided evidence for their interpretations significantly more frequently.
Our qualitative study further showed changes in language. Arts concepts like “contour” or “shading” appeared in students’ clinical descriptions after taking ”Training the Eye,” producing more robust and precise clinical communication. Other studies in medical humanities and arts learning indicate arts interventions link with increases in clinically-relevant abilities, such as critical thinking and tolerance of ambiguity.
Learning to look in art helps practitioners notice their biases, see what others see, discover that what we see is sometimes different from what we want or hope to see, and experience how discussing the vast differences in individual processing are an asset to seeing the whole picture.
Cultivating an environment where it’s “safe to ask”
Let’s face it: medicine is vulnerable to certain pressures—an ethos of certainty, hierarchical inhibitors to communication—which present safety issues. Students and practitioners alike often feel pressure to know everything. Arts experiences are one place where authentic uncertainty is a positive thing, and where effective habits for contending with it can be cultivated.
In art-viewing, colleagues work together to get at truth in ambiguity, as they might in teams on the wards, although the conditions are quite different from those of the clinic. Stakes are low. No one is the expert. Everyone’s perspective is uniquely helpful. It is far easier in this context to cross the boundaries to seeking second opinions. It’s easier to cultivate curiosity about what others have to say, easier to stay a place of not-knowing, easier to inquire, and easier to turn inquiry into action. It is in this way that ArtsPractica aims to help contribute to larger discussions about seeking second opinions.
People look differently at the things that we understand and the things we do not yet understand. In art, we can play with this difference, develop skills, and learn a lot about how we see. It is only in looking together that we can cultivate fresh eyes and see anew.
Leana Wen, MD
Harvard/Brigham & Women’s/Mass. General Hospital
As an emergency physician and patient advocate, I meet more and more patients who are confused and frustrated because they don’t feel involved in their own care. Many patients feel doctors aren’t listening, and the disconnect between what patients want and what their doctors provide is growing.
Here are 5 steps to establishing a partnership with your patients as you work together to come to their diagnoses:
1. Assure your patients that you are a physician who agrees with shared decision-making for diagnosis. Your patients want to know that you will listen to them, care about them, and feel comfortable—even seek out—involving them as a partner in the decision-making process. As a physician who really believes in this process, you need to assure patients that you will welcome and actively solicit their suggestions. Avoid impatience and defensiveness when discussing diagnoses with your patients. Encourage patients to ask questions, and let them know you welcome the input rather than feel challenged by it.
2. Express your intentions. Doctors aren’t mind readers, and are used to patients being passive participants in their healthcare. No matter if this is a new patient, or one that you’ve had a relationship with for a while, state clearly at the beginning of the visit that you’d like the patient to be involved as a partner in the decision-making process. Invite them to share in your diagnostic thought process and possible diagnoses.
3. Tell patient how they can help you help them. Most diagnoses can be made by the story—the history of illness—alone. Yet, one of the most frequent complaints patients have is that their doctors don’t listen to them. No doubt, there are limitations and pressures on doctor’s time, but neglecting to listen can result in misdiagnoses. Patients can help by telling a good story; and you can help them do it. Encourage them to begin at the beginning and proceed chronologically. Gently prompt them to provide context, such as how their illness affected their life. Instruct them to use their own voice instead of what they believe is medical jargon. Allow for pauses in their narratives, and propose that they write down key details before they tell their story. Promoting effective communication is a key part in helping your patients learn to advocate for themselves.
4. Make sure patients understand every test that is ordered. Every test should be performed for a specific reason. Study after study shows have called into question the role of the “screening” test and every test, even the basic blood draw, has potential harms (a CT has many more potential harms, including increasing lifetime risk of cancer). When you recommend lab work for a patient, identify the reason and share it with your patient. Tell them how the test will affect the disease diagnosis and management, informing them of risks, and present the alternatives. Helping your patients learn to ask questions during the diagnostic process not only lays the foundations for a solid partnership, but arms them with vital knowledge of their own diagnosis and treatment.
5. Make decisions together, always with the diagnosis in mind. A test or procedure should be done only if it helps make the diagnosis; otherwise, what’s the purpose? The treatment should be targeted to the diagnosis; otherwise, what is it being done for? Perhaps there are two or three possible diagnoses; what is going to be done to try to narrow this down? What’s the natural course of the illness; what should the patient expect and what can they do to start feeling better? Encourage the patient to be proactive in thinking through their health concerns and goals and asking questions, and be prepared to see that all their questions are answered.
A critical component of shared decision-making is working with your patient to find a diagnosis. Focusing on this first, key part of care will have transformative effects on patient outcomes and health.
Patients facing chronic or challenging diseases may be dissatisfied and frustrated with their medical care, but there is a way to make it better. Remind patients that they hold the key to transforming their health. I discuss more tips in my book, When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests.
Dr. Leana S. Wen, M.D., is an emergency physician at Brigham & Women’s Hospital and Massachusetts General Hospital and a clinical fellow at Harvard Medical School. She is the author When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests. For more information, visit her blog The Doctor is Listening or her website. You can also follow her on Twitter at @DrLeanaWen.
Nickolas Dawlabani, MD, FAAP
Assistant Professor of Clinical Pediatrics
Attending Physician, Hospital Medicine
Drexel University College of Medicine
St. Christopher’s Hospital for Children
It’s good to talk about clinical reasoning and its link to diagnostic error. It’s good that this conversation has begun, and it’s good that physicians are forming societies and attending conferences which can amplify the conversation.
But wouldn’t it be great if we could take the next step in making medicine safer for patients by formally teaching and evaluating clinical reasoning skills early on during resident’s training? We’re endeavoring to do just that at St. Christopher’s Hospital for Children in Philadelphia.
I recently enlisted four residents to test a pilot course in clinical reasoning. This course is intended to teach the pediatric residents to self -identify clinical reasoning missteps and where and why they occurred. Also, it is imperative to examine any inherent underlying cognitive biases which could have contributed to misdiagnosis.
Doctors, and the progressive #epatient community, know that misdiagnosis is a leading malpractice claim. To improve patient care and outcomes, as well as to equip our young doctors to avoid misdiagnosis, it is increasingly important to develop creative ways to help reduce these errors. Taking cues from Croskerry’s theories on cognitive forcing strategies in the clinical decision-making process, we structured this pilot to teach one of the most effective strategies for formal cognitive de-biasing: thinking about your own thinking.
In our course, pediatric residents were given a simulated case representing a patient with respiratory distress. The study tested cognitive forcing as the residents’ thought processes were put to test when dealing with uncertainty and new information being presented.
The residents’ performances were evaluated, based on three criteria:
Before the simulated cases, residents were given a pre-test questionnaire on their awareness of cognitive forcing strategy and related concepts. They were then asked to read the Croskerry article cited above and to participate in the simulated exercises. Self-reported awareness of the concepts of cognitive decision-making changed drastically over the course of the study:
The results are encouraging, and hopefully will begin to open a new facet of the diagnostic accuracy conversation. A facet which addresses that cognitive forcing strategies can and should be taught to doctors, so that cognitive traps can be avoided.
But the most encouraging results, perhaps, are the reactions of the residents themselves. Those who participated in this study were enthusiastic about the effect they reported on their decision-making skills. All have expressed interest in continuing and expanding the study with new simulated case scenarios to enhance their clinical reasoning skills.
Most doctors will make intelligent medical decisions instinctively. Thus, understanding why they’ve made that diagnosis, and the cognitive path which lead them to it, is paramount in identifying situations which trigger diagnostic missteps. This in turn will more likely lead to better doctors and excellent patient care in the long run.