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.

Grand Rounds in the New Year

Grand Rounds took a break this week, for the first time in its history. We probably should have done it on earlier occasions, but in the past there was no shortage of willing hosts or participants.

Now is a different story. Recent hosts have remarked to me about sparse submissions and a decline in traffic -- it seems to vary week-to-week, and there are notable exeptions, but the trend is unmistakable. One new blogger (and recnt host) asked, "Does blogging even matter anymore?"

I don't have a great answer. It seems like most everyone still has a blog, if only to have something to link back to on tweets. Blog traffic and comments don't seem to motivate writers as much as followers, fans and retweets.

For years I've considered Twitter and Facebook as less flexible, and more lacking in meaningful content, compared to blogs. But it's clear that this is how the vast majority of online readers prefer to learn about quality health writing. And since the mission of Grand Rounds has always been to showcase excellent medical writing and creative writers, we're going to have to do more with these new platforms.

They might be giants

This year, I learned about the death of two physicians that were pretty important to me.

The first was my pathology teacher, Dr. Guido Majno. In addition to just being a tremendous person, kind and curious... He and his wife wrote the best textbook I've ever read.

The second death was that of my pediatrician growing up, Dr. Thomas Peebles.

Funny, although he followed me from birth to high school, my family never knew about his incredible research background. We learned it in the many obituaries.

It's worth reflecting on their accomplishments and the manner in which they conducted their lives and practice -- especially in this era, when doctors are encouraged to develop their social media presence and be proactive about online reviews.

Would they have used these new tools? Would they even have needed them? Would they have found the idea of trading links to medical stories on Twitter to be interesting? Stimulating? Or maybe distressing, or distasteful?

I never thought to ask them.

Time won't let me go

Before the App Store, way back in the spring of 2008, I jailbroke my refurbed first generation iPhone. I claimed it was for the cool native apps but also liked the customization that was possible (even now, animated backgrounds and control over device sounds is not allowed through official channels).

The innovation came at a price -- the phone became slower and more crash-prone.

When the App store was available, I quickly upgraded to the Apple-approved iPhone OS 2.0 and all my jailbreak hacks and apps disappeared.

Except, strangely, one hack.

There must be some kind of bad connection

A reader of my EMPractice LLSA review on paracentesis (still available, buy yours today!) wrote my editor with a question. Not, thankfully, on anything factual in my writeup, but rather on an issue of word usage.

This is picayune but a start. 2010 LLSA 4 paracentesis refers to a \"Z tract\" as a technique to avoid leakage. When I learned this years ago I thought it was Z track-as the pathway (track) left when the needle was removed. I thought using tract was just sloppy language. Checking Roberts for procedures I read Z tract-OK-solved. BUT then Roberts' Illustrative Guide calls it Z track. So, evidenced-based mavens which is it?!!!

Our editor referenced the original NEJM article on which my review was based. The NEJM uses the term “Z-tract.” But further Googling turned up varied usage, and "Z-track" was far more popular.

Is there a definitive answer?

When all is well and well is all

Slate's Juliet Lapidos recently reviewed a new book by Allan Metcalf on the story of OK ("America's Greatest Word").  Key graf:

The only etymology with hard evidence behind it, he says, is that OK began as a joke—a joke so bad, so boring, that I won't cover it in detail. Briefly: In the spring of 1839, the Boston Post ran an article tweaking the Providence Daily Journal, which included the phrase "OK—all correct." Get it? OK started as an intentionally misspelled abbreviation of all correct (oll korrect). It sprang, more generally, from an 1830s fad for abbreviations, like NG for no good and OW for oll wright or all right.

I've heard about this silliness before, and in fact referred to it whenever someone around me bemoaned the spelling of, say, "Gorillaz" or  "Flickr." The current trend in spelling hijinx doesn't portend the end of civilization or reflect a decline in education, but rather, continues a longstanding English tradition. 

But the part about the review that I really liked focused on the inscrutability of "OK" (more below):

You made me like it

Grand Rounds, the weekly rotating carnival of healthcare blogs, is in its seventh year.

This week we're trying something different.

Grand Rounds will be hosted on a blog, as usual, but this time it's a Facebook site (The fact that this is our first veterinarian host is noteworthy as well).

Earlier this year we launched an online presence for Grand Rounds on Facebook (and Twitter).  The justification? Facebook is now the #1 website in the US, accounting for one in four pageviews. This is simply where a lot of people spend a lot of time online. Facebook already drives more traffic to media sites than Google; it stands to reason that smaller sites like blogs would also benefit from FB's social referrer approach, alongside the Grand Rounds showcase or Google's PageRank valuation.

But what about blogs that make their home in Facebook's Pages? It was really just a matter of time. The original blog carnival model guaranteed a weekly spotlight and flood of traffic to the host. Some people would visit, maybe browse the archives, and add the host blog to their bookmarks or RSS readers. There's nothing about that scenario that's not possible with Facebook blogs, and their "Like" feature is arguably more intuitive and manageable than earlier ways of subscribing.

I had said before that Facebook, by virtue of its accounts being tied to real names, would encourage an era of more reasoned and responsible blog commenting. I expected that quantity of comments and posts might fall, the quality would rise -- an antidote for the trolling and choir-preaching that substitutes for real conversation at many sites today. This week's host, however high-quality her posts, is not a real person. The team behind "Amanda Brown, DVM" can write at will, and leave comments on other pages, with some level of professional protection.

What that means for the future of online healthcare discourse is not clear, but the I suspect this degree of anonymity, plus the ease of "Liking" and the fact that so many of people visit FB regularly already, will encourage more people to use Facebook as a platform for their healthcare musings. And they'll be welcome to host Grand Rounds.

1010 Wins

Calendar trivia has always interested me. And we've lived though some special dates, from the turn of the millennium to 9-02-10 day last month.

Today is no exception. And like 1/2/03 at 4:56, today we could experience a couple of memorable minutes.

But a few moments' thought on the matter leads me to believe that the high frequency of notable dates we've been enjoying is going to come to an end soon.

Another endangered calendric item: those plastic eyeglass-like frames that attain ubiquity every New Year's Eve, since the 1990 (or even earlier). In fact, for most of my life, each year has featured at least two bulbous numbers, ideal for making zany celebratory glasses (if I'm not explaining this well, see here).

I think this comes to an end for 2011. The impact on the economy is difficult to estimate.

Common disaster

I love this town. In the event of another disaster in NYC, I want to be able to help. So, years ago, I signed up for the NYC Medical Reserve Corps.

While I thought my services as an emergency physician might be of benefit someday, now I wonder if the most pressing need was for an interface & usability expert. Either that, or years of Google and Apple interfaces have spoiled me to the point where navigating forms online is pretty much unbearable.

The way I understood NYC Medical Reserve Corps (MRC) is this: you sign up. You give some details about yourself and your skill set. You give contact info. The city calls or emails you periodically to verify your info. We all stand ready to help.

Members recently got a flurry of emails about some kind of upgrade. New logins would be necessary, more features, etc.

Here's one small section of the process:

• Scroll down to “To become a volunteer, click on the Join Now button.”
• Enter NYC MRC ID and ServNY password, Click on ‘Log In’.
• When prompted, enter NYC MRC PIN, Click on ‘Continue’.
• To “Confirm your identity”; Enter last 4 digits of phone number or 5 digit zip code.
• Click on ‘Continue’. You have now ‘claimed’ NYC MRC records. Continue to Step 3.

But first you've got to get a ServNY userID:

• Change drop down box “NYC MRC ID” to ‘Yes’.
• Enter NYC MRC ID and NYC MRC PIN from Go Live/Welcome letter. Case-sensitive. NOTE: PIN is listed as “password” in Go Live/Welcome letter.

It goes on and on like this, forcing you to refer to info from multiple websites and emails. As you fill in the fields, there's often no indication when something worked or didn't. I thought I completed the process on several occasions, only to be unable to login later, or receive a reminder email asking me to repeat the same steps.

To be fair, NYC MRC has offered to help, and set up phone numbers and better step-by-step guides. But I'm also not sure why we're even being forced to re-register. Don't they already have my contact info? Isn't that pretty much all that's needed?

I think, like with many systems and institutions, something got lost along the line, and a simple volunteer network became a massive bureaucracy. The simple act of offering to help, and providing contact information, is now insufficient. There's too many hoops to jump through, for the privilege of helping New Yorkers.

Brothers in arms

It's happened again.

Almost every day, I get a brochure or three about courses, credentialing, or some educational opportunities for doctors. I thought it would let up when I passed the boards, but no.

On many of them, there's stock photography like this:

http://www.fotosearch.com/UPC005/tre01014/

http://www.fotosearch.com/RBL008/a01394/

http://www.fotosearch.com/BLD131/cb0408awh_0528/

http://www.123rf.com/photo_3193578.html

http://www.istockphoto.com/stock-photo-8149905-lady-doctor-standing-with-her-arms-crossed.php

http://www.fotosearch.com/OJO105/pe0007596/

http://www.istockphoto.com/stock-photo-11943832-female-doctor-smiling-with-arms-crossed.php

http://www.istockphoto.com/stock-photo-10361626-happy-mature-doctor-with-his-arms-crossed.php

http://www.istockphoto.com/file_closeup.php?id=12217867

If you're too lazy to click the link, that's ok, I'm too lazy to import the pics. I'll save you some time:

Everyone one of these pictures, and most of these brochures, feature a doctor with his or her arms crossed. Often, they're looking at the camera, with an air of seriousness and, I daresay, a trace of disapproval.

I can understand maybe patients seeing us this way -- we have some experience and education, and a lot our workload comes from theoretically preventable disease. So a doctor with arms folded might work if you're trying to sell treadmills or grape nuts.

But is this an image that works on other doctors? Are we more likely to sign up for a board review course if it's offered to us by a stern, standoffish colleague?

Then I think back to medical school, and realize: of course.

Get it together

Bill Simmons sometimes pokes fun at the journalism cliche of collocated words that rarely appear apart from each other -- you don't often see the word 'ruffled', and when you do, you  know the word 'feathers' is likely to be close by.

There's a similar phenomenon in medicine, though I stubbornly have refused to acknowledge it.

Consider the followed dialog that transpired during a recent overnight ED shift:

Resident: "I have a 32 year old woman with hyperemesis. I'd like to start antiemetics and IV fluids."

Me: "Is she pregnant?"

Resident, befuddled: "Um, yeah? I said she has hyperemesis."

Of course, the resident was using hyperemesis to denote hyperemesis gravidarum. But really, hyperemesis just means lots of vomiting. Just because it's rarely used outside the context of pregnancy, it doesn't mean it's not a useful term (indeed, cannabinoid hyperemesis is another entity we sometimes see in the ED.)

What other terms get truncated like this? Anorexia nervosa comes to mind -- saying "the patient has anorexia" literally just means there's a lack of appetite, not a lethal eating disorder.

I'm sure there are countless others, but I'm wondering: could any of these medical terminology shortcuts lead to particularly dangerous misunderstandings?

I don't think anyone would mistake a triad for a joint if a colleague said, "they've got Charcot..." On the other hand, abbreviating the confusing term "superficial venous thrombosis" could lead to a mixup in therapies...

Program Note

Bora's back hosting Grand Rounds this coming Tuesday at his site, Blog Around the Clock -- but I'm going to help him collect submissions over the weekend. Please email me a link to your best recent material at nick /at/ blogborygmi.com (a little blurb is helpful, too)! Deadline is Monday night.

How'd you get to be happiness

Somebody at Apple likes Goldfrapp.

They've used her latest album for this tutorial (scroll down) and the sublime Seventh Tree was pictured on the first Apple descriptions of the Remote app.

It's nice when a monolithic institution shows a little personality.

Of course, my interest in Goldfrapp is mostly professional -- who else has sung as well about ending up in an emergency department?