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Dropping The Ball In Patient Care: Provider Handoffs

August 11th, 2009 by Paul Auerbach, M.D. in Better Health Network, Health Tips

Tags: Change Of Shift, Emergency Medicine, Handoff, Handoffs, History, Internal Medicine, Medical Errors, Patient Safety, Provider Handoffs, Transitions

One of the most dangerous times for a patient is during the transition, or “handoff,” between providers. This is due to a number of reasons. First, the original provider(s) may not relay all the information he or she knows about the patient to the next provider(s). Second, the accepting team may take it for granted that everything is known about the patient, and therefore not take a complete history or perform an adequate physical examination. Third, if the patient initially looks good, the accepting providers may be lulled into a false sense of security, and not anticipate a deterioration in the patient’s condition.

We know this problem to exist in the hospital setting. Survey of doctors-in-training suggests that handoffs may commonly lead to patient harm. Last year (2008) in September, there was a blog written by Elizabeth Cooney in the Boston Globe that stated, “a 2006 survey of resident physicians at Massachusetts General Hospital found that handoffs commonly lead to patient harm, according to an article in The Joint Commission Journal on Quality and Patient Safety.” More than 50 percent “of the 161 medical or surgical residents who responded to the anonymous survey said they recalled at least one occasion in their last month-long rotation when a patient suffered from flawed handoffs.” Approximately “one in nine said the harm that resulted was significant.” The respondents said that “if the patient was coming from the emergency department or from another hospital, problematic handoffs were more likely.”

This holds true in the field. Unless the new treatment team makes the assumption that they need to begin their assessment of the patient’s condition from scratch, they are more likely to make a mistake. Obviously, such caution depends on the possible severity of the patient’s condition and the rescue/environmental situation. If I can get a decent handle on a patient’s condition, and there is little or no risk of me missing something, I will tailor my questioning and examination to suit the circumstances. However, I always start from the position that something has been hidden from me, of course not intentionally, and that the patient’s initial assessment has underestimated the problem(s).

I cannot begin to tell you how many times I have found something that was missed, or have accepted the care of a patient just as he or she began to “crash.” This is in no way a criticism of others, just a common fact of medical care. Previous rescuers may have been tired, the conditions may not have been conducive to a full examination, the patient may have been withholding information, or the situation may have just taken its natural course and worsened. Regardless, it’s my responsibility to learn what I can as quickly as I can about my patient, so that nothing slips through the cracks.

Here are some simple rules to follow:

1. If the situation permits, ask your new patient to repeat his or her history. If they are reticent to engage in a long conversation, at least try to get them to relate current relevant events.
2. Repeat as much of the physical examination as you can. Explain to the patient that you have assumed their care, and that in order to do the best that you can on their behalf, it’s important for you to understand their issues and to be able to monitor their progress based up the exam.
3. Assume that until you have talked to the patient or otherwise obtained a comprehensive history, and performed a physical examination with your own hands, eyes, and ears, that you do not know as much about your patient as you could.
4. If a patient is under your care for a prolonged time, or if you are managing a situation prone to rapid or undetected deterioration, interview and examine your patient as often as is necessary and practical. If you must be absent from a patient for a longer period than is prudent between examinations, delegate the responsibility to someone else.

image of leg splinting courtesy of www.princeton.edu

This post, Dropping The Ball In Patient Care: Provider Handoffs, was originally published on Healthine.com by Paul Auerbach, M.D..

Participatory Medicine: The New Face Of Personal Responsibility

August 10th, 2009 by eDocAmerica in Better Health Network, Opinion

Tags: ePatients, Journal of Participatory Medicine, Participatory Medicine, Personal Responsibility

Participatory Medicine is a cooperative model of health care that encourages and expects active involvement by all connected parties (health care professionals, patients, caregivers, etc.)

When patients are aware of such things as their weight, BMI, blood pressure, recent key laboratory results, and so on, and when they come to the office motivated and prepared, outcomes are likely to be much better. The patient who passively waits for advice and direction from the physician is more likely to forget instructions, make excuses for failures, lack the discipline to lose the needed weight or stay on the required diet, and so forth.

Patients themselves, not their doctors, must be the ones to make the essential decisions about their health. They must be able to obtain the necessary information to make key decisions, then act on them.

How does this process happen? A patient may agree with this statement and want to begin to operate in this mode, but not know how to do it. Here is a short list of the essential steps necessary to begin the practice of participatory medicine:

1. If possible, find a physician who understands, and supports, this concept, including one who is willing to communicate with you by e mail and directly answer your phone calls.

2. Consider the option of using a service like edocamerica, that is dedicated to providing you with the information necessary to make decisions about your own health care. They can supplement your physician and are available to you 24/7 and always welcome your questions. Moreover, they are dedicated the concept of PM and are oriented towards health and wellness, not just managing your diseases.

3. Start following blog and twitter posts by persons who are now actively discussing how Participatory Medicine is going to change the way health care is practiced.

4. Keep a current list of your medications, including the Brand name, generic name, dose and frequency of each one.

5. Look up the most common side effects of each of your medications.

6. Check your medications for any drug-drug interactions. You can use a web site such as drugstore.com for this.

7. Keep a list of all of your current medical conditions and review the basic information about each of them. A site such as Mayo Clinic or Medicine Net are good, trustworthy sources for this review.

8. Start making a list of questions that you want your doctor to answer for you. If he doesn’t have time to answer all of them at the next visit, ask him if you can e mail them to him. If not, ask one or two at each visit until you get them all answered. If you can’t get him to address all of your questions in a satisfactory and timely fashion, consider getting another doctor who will.

Participatory medicine, working on an equal footing with your provider, in a partnership for your optimal health, is the only way you can get the most out of the health care system. So, get on the train before it leaves the station!

Your comments and dissenting opinions are always welcome.

*This blog post was originally published at eDocAmerica*

Social Media Ruins The Rorschach Test

August 10th, 2009 by Berci in Better Health Network, News

Tags: Ink Blots, Psychiatry, Psychology, Rorschach Test, Social Media, Wikipedia

*This blog post was originally published at ScienceRoll*

TMI: Lab Tests, Patients, And Wasted Analysis

August 10th, 2009 by DrRob in Better Health Network, Opinion

Tags: Blood Tests, Internal Medicine, Lab Tests, Reference Ranges, TMI, Too Much Information, What Do The Values Mean?, What's Normal?

Let me kick the hornets’ nest again.   I still have misgivings about sending information like this to my patients:

How does one not trained in what to overlook interpret the above?  To me, this lab result is entirely expected for this patient – given the other medical history that is there.  My concern is that this will either cause unneeded worry, or it would prompt a phone call to ask about labs that I would be quick to accept.  Yes, there are times when this may help the doctor who overlooked abnormal tests in error, but the majority of abnormal lab values are not significant.  The vast majority are insignificant.  I’d put the rate at nearly 10:1.

When we e-mail patients their lab results, we have two options: to send the actual report, or send an abbreviated form of it.   Here is what I sent this patient (for these actual labs):

I had a woman complain to me when I didn’t send her this “sanitized” version of her thyroid labs.  She didn’t understand the lab report and just wanted my explanation.  Which would you rather have?  Do patients really need to know their MCHC, RDW, RBC count, and absolute eosinophil count?  Do they want to?  I don’t care about those numbers 99.9% of the time I look at them.

Here’s another example:

“Doctor!  I am really worried about my Bun Level and Carbon dioxide levels.  I read that these can all mean I am dehydrated!  They also can mean I am going into kidney failure.  I don’t want to go on dialysis!  And what about the monocytes and MPV levels?  One website I saw said this could mean leukemia.”

Sound outlandish?  Sound like something that won’t happen much?  Wrong.  We spend a very large amount of time explaining these basically normal (MPV??  Absolute Monocytes??).  All lab tests need to be put in the perspective of the patient’s age, disease state, race, and medications they are taking.  They also need to be seen as a single point on the graph and so must be looked at in comparison with previous lab tests.  How would I interpret this?  Normal.

Do you, my readers, REALLY want to see the absolute monocyte counts and MPV?

Here’s another:

Look at all the extra information put at the bottom of the lab report.  What does it mean?

Most of this is fluff meant to keep the lawyers happy.  The average patient will not quite know where to look here and will either just be confused by it or become anxious and want to question this as being abnormal.  ”I thought you said my diabetes control was good, but the diabetes test was high according to this!” or “A hemoglobin of 6.5 is dangerous, isn’t it?”  I have had both of these comments from patients.

Here’s a typical echocardiogram report:

What percent of patients want all of this?  I don’t!  I really could care less about everything above the “Impression” section from the cardiologist.  I was not even aware that pressure had a halftime.  None of these findings are significant.

The cardiologist has to include all of these in his note for herself because of documentation requirements and because the fine details mean something to her.  But they mean nothing to me, and I would prefer just getting the “Impression” sent to me.  Why should patients be different from me?

Wouldn’t you rather get from me something that says: “Your echocardiogram looked good”?

I really think that giving full access to all information opens a hornet’s nest of its own.  We will spend a lot of time educating our patients to the nature of medical information and medical terminology.  Again, I am fine with having folks who feel they need this information; but I am a little skeptical that they really do need it.

I don’t need most of this stuff, and would be much happier if I got only what I asked for.

*This blog post was originally published at Musings of a Distractible Mind*

What We Have Here Is A Failure To Communicate

August 10th, 2009 by EvanFalchukJD in Better Health Network, Health Policy

Tags: Communication, Demonization, Fishy, Health Plans, Healthcare reform, Town Hall Meetings, Villains

If you were hoping for a thoughtful discussion on the reform of our health care system, I have bad, bad news.

It turns out that health insurers are “villians.”  Public anger over the massive, mostly unread, reform bills is “manufactured,” and anxiety created by the expectation of unknown changes to people’s most valued benefits is the result of disinformation and “fishy” stories.

It’s like an employee benefits roll-out gone horribly awry.

The protests and disastrous town halls look to me just like the kinds of angry protests that happen all the time when employers make important changes to a benefit plan and the employees either don’t understand them or don’t agree.

Blaming the people who don’t follow what you’re doing and why is a big mistake.  Sure, there is politics.  But health care is a serious, emotional issue, and it should be no surprise that people react badly when they think something to do with it may be taken away.

Dreaming up ideas of how health care ought to work is relatively easy.  But figuring out how to implement it is hard, and there are no short cuts.  The people who actually run benefits plans – employers, benefits consultants, HR professionals – can tell you:  there is no replacement for communication, engagement and respect for opposing views.

The strategy of demonizing those who aren’t on board is a mistake, and is as likely to set back the cause of reform as it is to further inflame an already volatile audience.

*This blog post was originally published at See First Blog*