The most productive time of the year

For years I noticed a burst of productivity around the holidays. stuff that had been hanging over my head for months would suddenly get done. New ideas would suddenly pop into my head. 

I attributed it to things like the psychology of the calendar, or just having fewer emails to answer, or more unstructured time... But the recipe is simple:

Eat well. Sleep well. Stay connected to loved ones. Get some exercise.

That's it. That's all it really takes to complete projects, tackle nebulous fears, and poke the box.

Deck the halls (with questionable statistics)

Today's ACEP Member Communication email (entitled Emergency Medicine Today, in affiliation with BulletinHealthcare) had this as its top story: Injuries Linked to Holiday Decorating on the Rise, from a website called HealthDay News. The reported cites a US Consumer Product Safety Commission press release, crafted with help from Underwriter Laboratories (the wire engineers). They claim:

In November and December 2010, more than 13,000 people were treated in U.S. emergency departments for injuries involving holiday decorations, up from 10,000 in 2007, and 12,000 in 2008 and 2009, according to the U.S. Consumer Product Safety Commission (CPSC).
"A well-watered tree, carefully placed candles, and carefully checked holiday light sets will help prevent the joy of the holidays from turning into a trip to the emergency room or the loss of your home," said CPSC chairman Inez Tenenbaum in an agency news release.

Good advice. Though it's been said many times, many ways. So when it came time for CPSC and UL to raise the topic, did we need the very questionable statistics to justify it?

If you're having trouble wrapping your head around the number of decoration-related emergency department visits, consider this similarly bizarre statistic: 8000-10,000 kids are injured each year from falling televisions. So, for perspective: in the November to December period, Americans now endure more holiday-decoration-related trauma than an entire year's worth of falling TVs (though, now that I think about it, there may be some overlap, like if while putting up some Christmas lights, Dad knocks over the TV and it lands on Junior's foot -- that could be one ED visit logged in both categories.)

Without a trace

Heard about an old friend, sharing the stage with Billy Squier at our high school's send-off event (as another alum of some distinction noted, the building is being demolished).

Their performances got me thinking of a lot of the songs we practiced, growing up. And while I did say recently that music is "done" from the perspective that we can hear pretty much any song we'd ever want to hear, on demand, anywhere, the truth is there are some songs that seem lost to time.

If Google can't find a tune, does it really exist? There was some truly strange songs, burned into my head from repetition in middle school orchestra. From time to time, the tune or lyrics pop into my head -- but when I try to pin down that song -- Google's got nothing.

For instance, there was a whole awkward teen coming-of-age musical we put on. I think it was actually called Coming of Age. Songs included, "If I Had A Friend," "On the Outside, Looking In" and "Broken Home on the Range."

I want to know, were other middle schools forced to perform this, as well? Who wrote these songs? I'm not saying I'd be a fan, but I'm driven by a little nostalgia, plus the same kind of curiosity, I think, that drives people to hear Wesley Willis works.

Another example is a musical about singing troubadours -- this is the only reference I can find online. We praticed these songs on professional-looking sheet music, learning them by heart, just a few decades ago. Yet no trace of these songs seems to have made it into the digital era.

I suppose as every bit of trivia and ephemera from our lives makes its way onto the web, and we come to accept that no new experience will go undocumented, these last few holdouts will rankle, out of proportion to their significance.

Powered on

Sometimes, the blogosphere just decides they're going to discuss something in great detail. And now, with holiday travel upon us, we're talking about the inane rules that airlines inflict upon passengers -- especially the "turn off all electronic items that have off switches" rule at the beginning and end of flights. 

This past summer, when the IATA issued a largely anecdotal report on a few dozen incidents with no real bad outcome (spanning a period covering millions of flights), I thought the time for discussion was ripe, and compared some of the rituals of aviation to similar maddening rituals in healthcare

But now James Fallows is covering the topic, and has terrific input from a diverse and smart audience (it helps that he's a pilot, himself, and a terrific writer). Read it all -- just not during takeoff or landing. 

Built for speed

I had a couple of slow shifts in the emergency department recently, around Thanksgiving. And it made me think of Nomar Garciaparra, the old Red Sox shortstop.

Nomar always had to throw off-balance, while running and jumping. You can see his style on display when throwing the ceremonial first pitch at Fenway last year.

In an interview (can't find the reference, sorry) he said he always had to throw this frenzied manner, even for an easy grounder where he'd normally have time to collect himself. If he paused too long to think about it, the throw would come off badly, he said.

I always thought this was a psychological issue -- dubbed "Steve Sax Syndrome" by some.

But on those slow holiday ED shifts, I think it's just a good habit. When you're used to functioning well at a fast pace, slowing it down doesn't necessarily make you any better. Our ED's workflows, our data collection, and our decision-making, all all calibrated to work at a certain speed. Slowing it down sometimes lets us unearth a valuable piece of information -- but more often, it just pushes the signal-to-noise ratio toward more noise.

And hey, it's not like Nomar's quirk kept him from having a stellar career.

FDA: Food & Drug (& App?) Administration

We've been considering FDA oversight of medical apps for a while, over at Now, the public comment period has concluded on the FDA's draft of how this oversight might look. The story:
The FDA will scrutinize medical apps that act as an accessory to a medical device and those that transform the mobile device into a medical device. A draft guidance issued by the FDA includes an extensive list of applications that will have to undergo review. Examples of apps that fall under the regulatory oversight are:
* Applications that allow the user to view medical images, such as digital mammography or digital images of potentially cancerous lesions on a mobile platform, and those that perform a health analysis or provide a diagnosis by trained health care professionals.
* Applications that allow the user to view patient-specific lab results.
* Applications that connect to a home use diagnostic medical device to collect historical data, or to receive, transmit, store, analyze, and display measurements from connected devices.
Great, right? The apps that do heavy lifting of patient information and connect to real medical devices get regulated, but the fun and educational apps I am working on remain free and open. Still, Harvey Castro, my favorite EM-doc-and-app-developer, was worried:
“Overall, I believe safety is the most important item when it comes to providing patient care,” said Harvey Castro, MD, an app developer ( and emergency physician. “Unfortunately, I believe this will hurt small businesses and entrepreneurs by making it cost-prohibitive to enter the market.”
“Applications will be dominated by a few companies capable of paying the high fees to get FDA approval. I will be saddened to see these changes in the future.”

Grand rounds 8.11 call for submissions

Next week, I host Grand Rounds... but not here! It'll be over at my new Tumblr blog
Want to be a part of it? Please mail me at nick -at- with the subject Grand Rounds, along with a URL link of your submission and a brief excerpt. Photos are also welcome! 
Submissions are due by 11:59PM, Sunday December 4 (Eastern US time). Then, head over to on the morning of December 6 for the first Tumbl’d Grand Rounds.

Thoughts on tumblr

Remember how people said there was no real need for a device category between smartphones and laptops? And then Apple sold 40 million iPads?

That's kind of how I felt about Tumblr.

Blogs are obviously great for musings, essays, and a web presence, and Twitter's fine for thoughts and links and pics. Why have something else, in between?

I don't really have a good answer, just like I can't fully articulate why the iPad experience is so much better than a laptop or smartphone. But I'm starting to see the appeal of Tumblr.

Beyond the usual accolades from early adopters / influencers, something that stayed with me was a quote from Tumblr's founder: "No one is proud of their identity on Facebook."

Medscape EM year in review

Medscape's EM editor asked Amal Mattu, Robert Glatter and me to discuss 2011's important papers in emergency medicine. I felt compelled to include an all-around terrible (but still important) paper, and a tidy nice decision-support paper for discharge prescriptions, among others. See what you think about my picks, as well as the great selections from Drs. Mattu and Glatter.

Thoughts on a reading, sharing & archiving solution

Music's pretty much done, right? It's fairly easy to hear any song you've ever liked, anywhere you happen to be. As a bonus, those songs can be stored, shared, tagged, rated, and linked to lyrics and album art.

Movies and TV... their delivery is not quite perfected, but the general outline seems apparent. Already I can watch the WKRP Turkey Drop episode in the kitchen on my iPad's Hulu app, and mirror it to my TV (via Apple's set top box) when I'm ready to sit on the couch. Other shows or films require more effort, though the combination of Netflix, iTunes, and for the remainder, torrents plus the Air Video server app, make it easy enough.

But reading? The written word, for whatever reason, still lags behind. While strides have been made, a simple and universal, Apple-like solution to the problem of reading, sharing and archiving remains elusive.

Airborne toxic event

Longtime readers know my fondness of comparing the healthcare industry to the airline industry (based on similar goals of training, rituals of safety, and differing approaches to error, for starters).

Recently I've learned of a new intersection between medicine and aviation, when Delta chose to air ads to their captive cabin audience purchased by NVIC, the National Vaccine Information Center. The ads talk about staying healthy, maintaining good hygiene, and asking your doctor questions about the different flu shots available -- to stay informed and keep all the options open.

Sounds ... innocuous ... right?

The IOM Weighs In on Health IT Safety

Thanks to a tip from Brian Ahier, I've caught wind of excerpts from the IOM report on Health IT Safety a few days before its scheduled release.

iWatch has the scoop:
But the push [to adopt electronic health records] is occurring so far without any agency really ‘watch dogging’ the safety of health IT — the software, hardware and systems that record and manage patients’ health information. These expensive devices by and large have not gone through any regulatory checks for safety in the way that food, drugs and other medical technology must; most of that oversight is handled by the FDA. But at the moment, no one is required to report instances of harm caused by health information devices and no government agency currently monitors their safety. 
“With all of that money, marketing and public outreach, most simply affirm the value of health IT as an article of faith, rather than investigate it via careful evaluation,” said Ross Koppel, adjunct professor of sociology at the University of Pennsylvania and its School of Medicine, and investigator for RAND Corporation. He is listed as one of the reviewers of the report.
I've read Ross Koppel's work, and seen him speak, and firmly believe he's a brilliant guy. But I disagree that we're accepting health IT's value on faith, because of marketing. We've seen IT transform the way we do business in every other sphere of American life, and many of us have experienced the benefits of easily retrieved patient records and clear, electronic communication between providers. As I've said before -- aside from a few train-wreck implementations, who would go back to paper records, if given the chance? Who would build a new hospital based on anything but an electronic system?

The IOM isn't saying paper's better, but they do recommend caution with, and further study of, health IT:

EHR Cutting & Pasting, in Perspective

I've started to think the medical record is akin to DNA. Maybe 10% (or less) is useful information; the rest is junk. When folks want to find a sequence of significance, risk or reassurance, they've got to search for the good stuff and filter out all the garbage.

But junk DNA is believed to have a purpose. Some regions of junk DNA are highly conserved -- found in organism after organism -- suggesting an important function. In medical charts, conserved regions are also repeated. And they also serve an important function.

It's this repetition that Dr. Bryan Vartabedian called "Cut and Paste medicine" in his excellent recent post. He's concerned that all these computer-generated phrases of historical elements, exam findings and decision-making makes all patients look alike, and hurts continuity of care, as it becomes harder to discern what's actually going with the patient.

It's a reasonable concern. This problem, created by documentation regulations, compounded by declining reimbursements, and exacerbated by quick-fix features of some electronic records, can be solved through technology, too. Just as researchers and geneticists built tools to sift through DNA, to find the small section they're looking for, we need to easily search through records to show the details of patient care relevant to us.

Anywhere but here

While the output here has fallen from blogborygmi's heyday, this site's original purpose was to foster writing opportunities with, you know, real publishing platforms. By that standard, this past year has been a good one. If you're interested in reading more of my stuff, from health informatics to social networks, see below:
RIP Google Health. A look at the nearly-late, nearly-great Google Health, and the prospects for personal health records. 
Twitter, and emergency response. What if social media was available on 9/11?  
Redefining EMR Usability. When I got into electronic medical record usability, I thought it'd be about physician satisfaction, consistency, and counting clicks for key tasks. Recent developments suggest, however, it's going to be about estimating and reducing errors. 
Getting Social. How social media can change the public face of emergency medicine.  
When Charts Cry Wolf. The evidence surrounding the annoying, often irrelevant drug interaction warnings served up by electronic medical records. 
EPMonthly EMR Roundtable.  A freewheeling discussion on electronic medical records, conducted by Mark Plaster and featuring Rick Bukata, Bruce Janiak, and yours truly. 
Meaningful Use: A Really Good Kick in the Pants. My interview with Maimonides CMIO (and emergency physician) Steven Davidson 
MU and You. A primer on meaningful use of electronic health records, and what it will mean for emergency medicine. 

The ACEP Sessions

At ACEP last week, @drsamko tweeted a stat from the great Amal Mattu: the audience forgets 40% of new content from a presentation within 20 minutes, and 90% after a week.

I replied, "The Twitter audience never forgets!" 

If I had more room, I might have been a little more precise. Twitter makes forgetting less likely, as pearls from different lectures can be broadcasted, shared and debated. 

But Twitter is not Google or Pubmed. Once shared, Tweets, like good talking points from a lecture, have a way of disappearing into the ether. 

So I applaud GruntDoc for his reprinting 95 theses tweets from ACEP, on a more permanent form on his blog (look at what we've come to, when blog posts are considered durable). 

Here are a few of my own from ACEP #SA11 lectures and wanderings (largely stripped of hashtags, grouped by lecture, oldest first). If you make it all the way down, I have some (brief) thoughts on process of tweeting from conferences.

Going to California

I'll be speaking at BlogWorld Expo in LA on November 4 at 4pm, on how social networks can influence patient outcomes.

I'll be joined by two distinguished physicians and social media pioneers, Dr. Jen Dyer and Dr. Val Jones. We'll make a few brief presentations and then field questions. The session will be immediately followed by happy hour.

Also, be sure to check out all the other great topics in the social health track, spread throughout the conference. The speakers with Twitter accounts (approximately all of us) are listed here and tweets about the conference have the #BWELA hashtag.

If you're on the fence about attending the conference, consider: promo code BWEVIP20 to knock 20% off the registration fee.

Goin' Mobile

Long before my colleagues knew me as "that guy who sewed a pocket into his white coat so he could use his iPad in the ED" ... but sometime after they knew me as "the guy with the blog" ... I like to think they knew me as "that guy who helped edit many editions of EM Practice, the evidence-based, presentation-focused journal of emergency medicine."

With this post, I can be all three guys at once, and recommend the wonderful, iPad-optimized PDF of of many fine flowcharts featured in EMPractice in recent years, now available for free. 

Every issue of EMPractice has a flowchart to help guide emergency decision-making with the best available evidence. We've taken a bunch of recent flowcharts and bundled them into a useful, navigable document that will bring the best evidence to the point of care. 

Of course this PDF works well on paper, and the hyperlinks will work on other computers or devices, but it's sized and designed with the iPad in mind. It's really great for teaching or reviewing, on shift. 

NB: I'm on the editorial board for EMPractice and had a small role in developing this PDF. 

Falling farther from just what we are

I like asking patients about their jobs. Sometimes it may seem relevant to the complaint. Other times, it could potentially help the therapeutic bond. Mostly, it's just interesting.

Occasionally, I'll hear a patient is not working; that he or she is on disability.

This can surprise me, especially when the patient's interview responses and examination seem quite appropriate and unremarkable.

Now, I'm not in an ED where this happens too often (or maybe I don't ask enough). At any rate, I haven't been compelled to blog about this phenomenon, like, for example, Edwin Leap recently did. And I'm certainly not of the mind that disability payments are responsible for the debt crisis, or that the vast majority of folks on disability don't deserve it.

Comin' down on the nightshift

I was contacted by the folks at RN Central about running an infographic about the dangers and errors associated with hospital night shifts.

They thought I should publish it, "since you run a site about nursing."

Since that statement is an error, and since the email was sent at night, I assume the sender had to be overworked or undertrained. That off-the-cuff assumption, it turns out, may be more rigorous than anything in the infographic.

Since Canada came along

Over email, some far-flung EM colleagues and I were discussing a case, where an elderly but generally healthy man developed a fever, went to an emergency department, had blood cultures drawn (as well as other labs, films and urine). Ultimately the old man was discharged home.

A few days later, on a weekend, a positive blood culture report (gram negative rods) prompted another ED attending on duty to call the patient at home. Over the phone, the patient said he felt fine; back to normal, no worse for wear. The ED attending considered the matter closed.

On Monday, the primary care doc reviewed the case, and, with ID, admitted the patient (who still felt fine) to the hospital for monitoring and IV antibiotics. Apparently a nastygram was sent to the weekend ED attending, as well, citing some kind of policy that gram negative rods can't be ignored.

My friend, the Canadian Doctor, commented:
This is ridiculous.  Because of the "unique" medico-legal climate in the US, there will never be an incentive for any physician to endorse conservative, less aggressive management.  Without the support of colleagues from other specialties for anything but aggressive knee-jerk responses, patients suffer the consequences of a peer-pressured physician environment where we must all cave to the most conservative (brainless) approach.  While I am comfortably protected in Canada (and its different set of imperfections, of course), I hope that this American death spiral of false logic and spineless non-decision making is arrested soon by some tort reform and financial accountability.
In the past I've really tried to shy away from policy discussions on this blog. There are already great sites for that sort of thing, and I don't want my words taken out of context or brought back to haunt me.

But I did tell my Canadian friend that his emailed paragraph was delicious enough to deserve a wider audience. With a few minor alterations, he's ok'd its appearance, here.

Signal in the sky

Notable figures such as Atul Gawande and Captain Sullenburger have, when discussing safety in medicine, drawn comparisons from the world of airline operations. Lots of people, actually, have made comparisons to these disparate fields.

If healthcare were more like aviation, the thinking goes, there would be fewer errors, greater transparency, and more uniform ways of doing things (and thus, presumably, lower costs). Gawande and Sully both talk about the egos of doctors, who view checklists as beneath them, who view their patients and practice as worthy of exceptions to guideline-based practice, who view their gestalt as superior to cookbooks and calculators.

No doubt, that's part of the problem. But consider: New York magazine publishes a list of top doctors, but not top pilots. Lots of people brag about the acclaimed specialist they see, but no one brags about the pilot that they've booked for their trip to Paris. I think society's expectations of physicians have never been in line with their expectations of air travel. The relationship between passenger and pilot is nothing like the relationship between patient and doctor, except that we rely on pilots and doctors to get us from point A to point B safely and smoothly.

US healthcare has maddening inefficiencies and rituals. But so, too, do airlines. I'm not even talking about TSA security theater (at least, not this time). Just consider the flight attendant preamble about using your seat as a flotation device in the event of a water landing, or the rules about electronics below 10,000 feet. These always seemed to me to be put in place by cautious administrators, years or decades ago, with a "better safe than sorry" rationale that's hard to study or rescind, once put in place.

These speeches and restrictions always reminded me of the over-the-top, out-of-date rules about cell phones in hospitals. Sure, there's one confirmed case that I'm aware of, years ago, where a mobile phone caused an IV infusion pump to malfunction. But it never seemed reasonable to extrapolate from that event, to banning personal communications at a time when patients and families are most inclined to get in touch.

Recently, the IATA issued a report on passenger-generated electronic interference with flight systems. Via TechCrunch:
The reported incidents were based on 125 airlines’ responses submitted between 2003 and 2009, noting that flight controls, autopilot, auto-thrust equipment, landing gear, and the communications kit were all allegedly affected by electronics use. Of course, not one of the seventy-five incidents were verified to be caused by electronic devices. Instead, the IATA reports that crew-members and pilots believed that electronics were the culprits in those cases.
In one instance, with two laptops being used nearby, the plane’s clock spun backwards and GPS readings began going off. In another example, altitude details were jumbled until the pilot asked passengers to turn off their gizmos. A Boeing advisor, Dave Carson, believes that the signals radiating from portable electronics can mess with sensors hidden in the passenger areas of a plane, and that those signals are far stronger than what Boeing considers acceptable during a flight.

I didn't know some sensors were in the passenger area, where nearby device signals could interfere. Still, the article goes on to say a true cause/effect relationship between portable electronic devices and malfunctioning sensors has not been demonstrated by any of these IATA incidents.

What I found particularly interesting were the outraged comments, in response to the "scofflow" writer who admitted to keeping his phone on during landing. He was attacked for jeopardizing the lives of everyone on every plane he's flown on. With 4000 flights a day in the US alone, and a lot of forgetful or sleeping passengers on each flight, I have a hard time believing that electronic interference poses any measurable risk. Even if all 125 citations over 6 years were really due to electronic interference, there were still no "bad outcomes" (to borrow from medical QA parlance) and the event rate, as commenters point out, was approaches zero and is far less than the odds of being struck by lightning.

Would these same outraged commenters angrily force a patient's family member to hang up their mobile phone, if they saw them talking in the ED near a stretcher? Would they yell at a car driver who's not wearing a seatbelt? Or do these commenters feel people who keep their devices on during plane takeoffs and landings are not just jeopardizing themselves, but perhaps the commenters as well?

This seems like yet another example of our attitudes and behaviors toward risks being poorly aligned to the actual danger. It's more David Ropiek's territory -- though I'm sure Sullenbuger and Gawande would agree, getting the public's perceptions to match the true hazards in aviation would make air travel a good deal more smooth and productive.

As for healthcare, it seems almost impossible to calculate how much money, time, and stress would be saved if patients' risk perceptions were brought into better agreement with true health risks. Yet I'm more optimistic that the culture of aviation -- with its transparency, uniformity, and lack of ego -- is more likely to lead to progressive policy changes and successful public education, when compared to the culture of medicine.

Paranoia strikes deep

You know, I already thought that someone at Apple shared my taste in music, as they've highlighted Goldfrapp albums on their site, on several occasions.

But sometimes, while surfing the web, some examples hit a little too close to home. For instance, here's an article on iPhone tracking, that happens to show my neighborhood in the Maps app.

Sure, you say, lots of iOS screenshots feature Central Park. Lest you think this is just Manhattanite navel-gazing, here's a new Medgadget post with a screenshot of the iPhone app called FindER that just happens to show the town I grew up in, and the hospital where my scalp lac was stapled (twenty years ago).

Maybe I'm reading too much into this. Or maybe I'm reading too much about iOS apps.

Best practices

Grand Rounds needs you.

Val Jones and I have recognized that GR works better when we invest in a higher profile  --

  • e-mail blasts about the next host's deadline and address. 
  • daily tweets through the @grandrounds account, highlighting links from that week's edition
  • identifying and guiding new bloggers through the hosting process
  • coordinating with other online health networks

Trouble is, neither Val or I are in a position right now to do this ourselves.

If you've got the time and inclination to tackle at least a couple of these items, contact us.

Through their vocations

According to this reputable source, (and backed up a little by this source) the concept of the modern grocery store was once laughable. Customers used to walk up to clerks with their shopping lists, and the clerks would fetch the items for them.

No one thought people would want to do the work of picking their own fruits and vegetables.

I think the same is true for CPOE -- computerized physician order entry.

I try to remember this when I encounter opposition to CPOE and electronic medical records (EMR). Sure, I learned for the oral board exam how to rattle off a long list of lab tests to order, medications to give, based on a clinical scenario. But I trained, and practice, with order sets on EMRs. It's just more natural for me to pick among preselected agents and doses, and prompts me to consider alternatives I might not have. I like perusing the items listed in front of me, or a few clicks away, just as I like to feel a few avocados before picking one to purchase.

CPOE is a hot topic, right now. I spent months with my colleagues creating and refining order sets for our new ED information system. I'm watching ACEP's informatics section settle on a policy statement on scribes, who many ED physicians rely on to interface with computerized systems. Here's my own recent piece for EPMonthly about drug-drug interaction warnings and coming era (hopefully) of smarter, more context-aware clinical decision support.

I suppose the analogy to decision support would be expiration dates, or nutrition labels, to help consumers shop. I'd also allow the comparison that modern EMRs are like a confusingly organized grocery store that requires hours of training, and federal incentive plans, before people shopped there.

Maybe the news that NIST is convening an EMR usability workshop should be interpreted in this light -- we've acknowledged that we're heading away from clerks and toward picking out our own items, but the store aisles are going to have to be laid out more intuitively.

Nothing Much to Lose

Reading the ER Stories blog is often a guilty pleasure for me. Today's post, however, struck a nerve: 

Very often I ask patients about their recent visits to other doctors.  While I am taking a history, it’s important for me to know if you’ve recently been seen by another provider for the same or similar complaints and what they did, what they diagnosed you with, what they prescribed, etc.  
I often get a kind of irritated response such as “Oh, he didn’t do anything” or “he said it was nothing” or “he didn’t say anything to me”.  Although I know my share of layzee doctors, I bet the vast majority of times, the doctor DID do something and DID say something.
Just not what the patient either wanted to hear or that their perception or comprehension was wrong.  ...
... Now, maybe he is not a good communicator. Maybe he doesn’t have the time to sit there and explain the pathophysiology of viruses or something like benign peripheral vertigo  – and thus you feel short changed. After all he “just asked me a few questions, listened to my lungs and told me to go home and rest”.
Early on in my training I was fortunate to be taught that proper communication is the responsibility of both doctor and patient. So when a patient shows up in my ED and says their last doctor "did nothing"  -- when I can see with a few clicks that they got labs, a CT, and two prescriptions -- well, there's a failure to communicate. And the other doctor carries at least some of the blame for this.
Certainly, the patient is dissatisfied (because they're still seeking care, in an ED). You could argue that they're consciously downplaying what was done elsewhere in the hopes we enthusiastic ED docs can take a fresh look at the case. Maybe that's it -- but I bet from the patients' perspective, since they've still got a complaint, they've figured that nothing successful was done. 
From the ED physician's perspective, however, ruling out a bunch of life threatening conditions is a success. Or at the very least, not nothing. Same with providing symptomatic relief until clinic followup.
Communicating this to patients takes time, and constant effort. So many things in the department are working against a meaningful conversation about the visit -- the interruptions, the stress, the duty to document. Even discharge, which should be a chance to clarify and communicate, is often a rush job. A colleague of mine has a first-author paper in Annals this month, on what gets said when discharge instructions are provided. The sobering stat: 
"Only 22% of providers confirmed patients' understanding of instructions."
I would have thought that the emergency medicine, which is gifted with so many talented bloggers and podcasters, would do better at communicating with patients. If comprehension of discharge instructions is so infrequently done (and there's supporting evidence), it's not hard to imagine how hours of complex diagnostic workup gets interpreted by the patient as "the doctor did nothing."

What can help reverse this situation? I don't want to be Johnny-One-Note with my espousal of technology, but the iPad is proving helpful in reviewing a visit with a patient, at the bedside. You can go over lab reports, show x-rays, and clarify prescriptions before they're printed. I think it seems more tangible to the patient than just saying "everything came back normal."

Even the iPad, efficient as it is, requires time. And there are certainly some shifts where time isn't readily available. So another thing some of my friends in EM have done is share their email addresses in discharge summaries, and invite followup questions on their care.

This used to give me pause, for a lot of reasons. But when I think about the fair chunk of my non-clinical time I spend on quasi-medical communication -- to colleagues, in print, and on blogs and social media, I've got to ask: what kind of communication is most important? Wouldn't some of that time be better spent going clarifying care, with my patients?

After all, while composing this blog post, plenty of people could say "this doctor did nothing."

Present Tense

I made my first PowerPoint presentation in 1997, and actually used Microsoft's application to prepare 35mm Kodachrome slides for a carousel projector. Since then, I've seen thousands of PowerPoint presentations (and a few dozen Keynotes), and had a hand in creating many, myself.

Not since a conference a decade ago have I needed to make Kodachrome slides. Yet almost everyone still uses software built around printing slides, making a linear progression of topics. The impact of this format on human thought is substantial -- PowerPoint was fingered as contributing to the Columbia disaster and has spawned a lot of discussion and linkage, even here, regarding effective communication (probably all conceived of during dull PowerPoint presentations).

While compelling presentations are possible with Powerpoint (using the Lessig Method, for example) those kinds of talks require planning, and a mastery of the material. And some great stock photos. My experience in school and training is that the PowerPoint is often made as the presenter is learning the content and so is bound to lack the organization and expertise necessary for a Lessig-style presentation. People procrastinate about public speaking, and when crunch time comes it's just too easy to flip through a a textbook, call up a Pubmed abstract, and churn out another verbose PowerPoint slide. With practice, it's possible to whittle down the number of words and bullets per slide -- but who has time for that? Much easier to read the talk from the slide itself.

While I strive for Lessig-like clarity and impact in my talks, it's rare that I can eliminate all the slides with three or more bullet-points on them. PowerPoint, even though it's based on making Kodachromes for obsolete carousel projectors, is just too much of a crutch.

Which is why I was relieved to see Prezi come along. If you could imagine what presentations should look like with modern computers and digital projectors, Prezi is pretty much that -- more like a mind map than a slide deck.

Prezis can still be a linear progression of images, text, bullets, etc. But even linearly, it's easy to make big concepts stand out, and parenthetical points diminutive and aside from the main progression. Tangents can literally be tangential. Related ideas can be visually grouped, and you can easily give your audience the bird's eye view, for perspective. Most significantly, though -- Prezis needn't be linear. A presentation can go in various directions, based on audience input or presenter's whim. I think this will ultimately lead to much more interactive, engaging presentations.

Furthermore, Prezis just look great. I was always trained to avoid flashy animations and effects -- my grad school advisor wisely counseled, "Let your data do the dazzling." And I agreed with him, especially whit PowerPoint's cheap, tacked-on effects. But Prezi's more fluid animations have purpose -- they are literally moving the audience's focus along, from one concept to another, or to multiple ideas.

I gave my first Prezi presentation last week (here's the public version, stripped of many incriminating screenshots and some diversions). It was a challenge, and I still have a lot to learn, but I think it was more compelling than I could've made the material, in PowerPoint. And coming at the end of a long conference, I think people were ready for something different.

It wasn't easy, though. It took a while to get the hang of the zebra circle controller. There are still some things about frames that baffle me (no resize option? really?) But the greatest hurdle was old habits: Prezi forced me to think much more about the outline of my talk, up front. I couldn't just churn out some slides to get the ball rolling, but really had to plan where I'd take the audience.

Other thoughts:

  • A poorly planned PowerPoint will bore the audience. A poorly planned Prezi could make the audience violently ill. 
  • PowerPoint encourages and even rewards procrastination. With Prezi, it's hard to make (as many) last-second rearrangements without disrupting the carefully-laid path.
  • Getting videos to reliably display in Prezis is easier than in PowerPoint. Images should be as easy, but there are quirks -- .png files look pixelated, and pdf's don't yet display on the iPad app. 
  • We are pretty close to the point where a presenter can walk around with an iPad and control (or let an audience member control) a Prezi projected on the big screen (this may already be possible with extra hardware, but the Prezi iPad app doesn't faithfully reproduce the Flash-based web Prezis, and doesn't yet allow Prezis over AirPlay).
Even though my talk was (mostly) linear, I'm looking forward to trying some choose-your-own-adventure style presentations, which could be especially useful for talks on medical decision-making. When you think about how many hours people spend looking at PowerPoints, it's easy to get excited about the potential for Prezi. Other Academic EM types are experimenting with Prezi  -- and someone has gone and made a Prezi touting its advantages. Finally, inevitably, there's now a blog about Prezi tips.  

Land of a Thousand Words

I've spent some time recently working with our new ED information system vendors on verbiage.

That's what the industry calls the result of all the boxes we check when filling out an electronic chart. Those checked boxes develop into a narrative, with the help of software:
The patient's chief complaint is abdominal pain. The onset was described as gradual. This episode began 6 hours ago. The problem is localized to the RLQ. The complaint is associated with fever and nausea and vomit. This is no association with diarrhea or constipation. The problem is persistent. 
Chekhov, it ain't. But there's a lot of pertinent positives and negatives that need to make it into the record, from a galaxy of possible complaints, modifying factors, and associated symptoms. I'm not aiming for art; just trying to maintain subject-verb agreement (though some phrases have had a certain poetry -- my favorite so far is, "The presence of foreign bodies is uncertain.")

Some thoughts on this process:

  • I will generate more chart verbiage than I could ever match with research publications, columns, blog posts and tweets. By this metric, I am finally a prolific writer (though my compensation per word is probably below industry standards). 
  • The (considerable) amount of time we're spending on the verbiage is still not nearly commensurate with the amount of times we'll see it (even understanding that any single chart is unlikely to ever be read again once the encounter is over, the phrases will come up over and over, in multiple encounters).
  • While it's regrettable that circumstances force me to decrease the signal-to-noise ratio in our charts, I consider it worthwhile to try to make the noise a little less jarring.
  • While there are a lot of ED metrics worth streaming to the web or twitter (wait time, chief complaints for biosurveillance stats) I would really enjoy seeing (deidentified) brief excerpts -- sort of like @GiggleMed but artful.  
Does your EMR have any noteworthy stock phrases? Good or bad? I think we'd be happy to cite your system as an influence.