Mindfulness now!
Getting sleep versus staying engaged with the patient
Lisa Rosenbaum has posted a thoughtful piece over at The New Yorker entitled "Why Doesn't Medical Care Get Better When Doctors Rest More?" After introducing a story about a patient, she says,
A few days later, the resident caring for the patient neared the teaching hospital’s witching hour: whether or not his work was done, he had to leave at 6 P.M. That’s because, a decade ago, largely in response to widespread concerns that tired residents were making too many errors, the Accreditation Council for Graduate Medical Education enacted nationwide rules that limited the number of consecutive hours residents can work. Five years later, a review of the data suggested that, on average, the rules had failed to make our nation’s teaching hospitals any safer. Proponents of the reforms argued that the rules had neither gone far enough nor been properly enforced. Accordingly, in 2011, first-year residents were limited even more—to sixteen-hour shifts, rather than the thirty hours previously allowed. Training programs scrambled to comply.
Rosenbaum then leads to some of the intangible aspects of the work hours rules:
The data evaluating the impact of the 2003 reforms suggest that, when it comes to patient safety, little has changed in teaching hospitals. But when it comes to preparing young doctors to manage disease, the training environment has been completely transformed.
While these studies suggest the complex nature of patient safety—that manipulating one variable, like hours worked, inevitably affects another, like the number of handoffs—there is another tradeoff, more philosophical than quantifiable. It has less to do with the variables within the system and how we tinker with them, and more to do with what we overlook as we focus relentlessly on what we can count.
Near the end of the article, she starts a story:
As a third-generation physician, I did not think the cultural transformation of our educational environment would affect my fundamental sense of what it means to be a doctor. But the other night I had a phone conversation with my mother, who’s also a cardiologist.
I'll leave it to you to read the rest.
A few days later, the resident caring for the patient neared the teaching hospital’s witching hour: whether or not his work was done, he had to leave at 6 P.M. That’s because, a decade ago, largely in response to widespread concerns that tired residents were making too many errors, the Accreditation Council for Graduate Medical Education enacted nationwide rules that limited the number of consecutive hours residents can work. Five years later, a review of the data suggested that, on average, the rules had failed to make our nation’s teaching hospitals any safer. Proponents of the reforms argued that the rules had neither gone far enough nor been properly enforced. Accordingly, in 2011, first-year residents were limited even more—to sixteen-hour shifts, rather than the thirty hours previously allowed. Training programs scrambled to comply.
Rosenbaum then leads to some of the intangible aspects of the work hours rules:
The data evaluating the impact of the 2003 reforms suggest that, when it comes to patient safety, little has changed in teaching hospitals. But when it comes to preparing young doctors to manage disease, the training environment has been completely transformed.
While these studies suggest the complex nature of patient safety—that manipulating one variable, like hours worked, inevitably affects another, like the number of handoffs—there is another tradeoff, more philosophical than quantifiable. It has less to do with the variables within the system and how we tinker with them, and more to do with what we overlook as we focus relentlessly on what we can count.
Near the end of the article, she starts a story:
As a third-generation physician, I did not think the cultural transformation of our educational environment would affect my fundamental sense of what it means to be a doctor. But the other night I had a phone conversation with my mother, who’s also a cardiologist.
I'll leave it to you to read the rest.
Bending the Map
As I am reading the book The Lost Art of Finding Our Way by John Edward Huth, I am struck by a correspondence between the kind of confirmation bias experienced by a physician who has engaged in diagnostic anchoring and a phenomenon called "bending the map" that is experienced when people get lost in the wilderness. Here's the quote from the book:
The correspondence between a mental or physical map and our perceptions helps us stay oriented, but one of the first stages of getting lost involves a process called "bending the map." The phrase comes from the sport of orienteering, in which competitors find their way around a series of waypoints that are revealed to them on a map at the start of the race. Competitors can become lost and believe they are in one place indicated on the map and mentally try to force features they see to line up with ones indicated on the map even when the correspondence is poor.
Denial is an effective psychological defense mechanism, and map bending is one form that lost persons often engage in. A lost person might first believe he is located at a certain point on the map, but things around him do not seem quite right. He pays attention to details that confirm what he already believes to be true, ignoring all evidence to the contrary. A lost person may be looking for a creek that flows south on the map. In his mind he's sure that he has arrived at the creek. It flows east, yet he conveniently ignores this fact and follows it anyway. It can take some time, but there comes a moment when an eerie realization hits him that something is wrong and he doesn't know why.
The parallels to doctors who have settled prematurely on a patient's diagnosis are compelling. Evidence that supports the conclusion is accepted. Contrary evidence is ignored.
Recall the story Jerome Groopman tells in his book How Doctors Think:
One of my patients was a middle-aged woman with seemingly endless complaints whose voice sounded to me like a nail scratching a blackboard. One day she had a new complaint, discomfort in her upper chest. I tried to pin down what caused the discomfort--eating, exercise, coughing--to no avail. Then I ordered routine tests, including a chest x-ray and a cardiogram. Both were normal. In desperation, I prescribed antacids. But her complaint persisted, and I became deaf to it. In essence, I couldn't think in a different way. Several weeks later, I was stat paged to the emergency room. My patient had a dissecting aortic aneurysm, a life-threatening tear of the large artery that carries blood from the heart to the rest of the body. She died. Although an aortic dissection is often fatal even when discovered, I have never forgiven myself for failing to diagnosis it. There was a chance she could have been saved.
I wish I had been taught, and had gained the self-awareness, to realize how emotion can blur a doctor's ability to listen and think. Physicians who dislike their patients regularly cut them off during the recitation of symptoms and fix on a convenient diagnosis and treatment. The doctor becomes increasingly convinced of the truth of his misjudgment, developing a psychological commitment to it. He becomes wedded to his distorted conclusion.
While Jerry focuses here on the situation where dislike of a patient leads to diagnostic anchoring, we now understand that it can apply in many situations, irrespective of the doctor's personal feelings about the patient.
Let's go further, though, and see if the following emotional reactions also apply to physicians. Huth says:
Suddenly, the lost hiker recognizes that his map and his perceptions don't line up. Panic sets in. The emotional centers of the brain send out warning signals, and perceptions get distorted with a fight-or-flight reaction. Massive amounts of adrenaline flood the mind and body. Breathing and heart rate increase. The person refuses to believe that he's lost and runs frantically in a direction that he's sure will lead back to the trail, only to get deeper into trouble. First one possibility, then another races through his overtaxed mind, and yet he cannot gain any certainty.
"Woods shock" is the term for this kind of anxiety attack brought on by the realization that the subject is lost.
I have seen woods shock occur to physicians. I have seen it in clinics and on the floors and ICUs. I have seen it during case reviews, when doctors are describing adverse events and trying to figure out what went wrong. When denial sets in, I have seen the figurative equivalent of "running frantically in a direction that he's sure will lead back to the trail." The flailing and emotion distress that occurs is painful to watch and, I'm sure, to experience for these people who have been trained not to be wrong. Rationalization comes into play. Blame of other parties--the nurses, the labs, the residents--is a common response.
In a post almost three years ago, I summarized a talk by Pat Croskerry from Dalhousie University, Halifax, Nova Scotia. Pat says we need to spend more time teaching clinicians to be more aware of the importance of decision-making as a discipline. He feels we should train people about the various forms of cognitive bias, and also affective bias. Given the extent to which intuitive decision-making will continue to be used, let's recognize that and improve our ability to carry out that approach by improving feedback, imposing circuit breakers, acknowledging the role of emotions, and the like. In summary, let's see if we can protect our clinicians from bending the map and experiencing woods shock.
The correspondence between a mental or physical map and our perceptions helps us stay oriented, but one of the first stages of getting lost involves a process called "bending the map." The phrase comes from the sport of orienteering, in which competitors find their way around a series of waypoints that are revealed to them on a map at the start of the race. Competitors can become lost and believe they are in one place indicated on the map and mentally try to force features they see to line up with ones indicated on the map even when the correspondence is poor.
Denial is an effective psychological defense mechanism, and map bending is one form that lost persons often engage in. A lost person might first believe he is located at a certain point on the map, but things around him do not seem quite right. He pays attention to details that confirm what he already believes to be true, ignoring all evidence to the contrary. A lost person may be looking for a creek that flows south on the map. In his mind he's sure that he has arrived at the creek. It flows east, yet he conveniently ignores this fact and follows it anyway. It can take some time, but there comes a moment when an eerie realization hits him that something is wrong and he doesn't know why.
The parallels to doctors who have settled prematurely on a patient's diagnosis are compelling. Evidence that supports the conclusion is accepted. Contrary evidence is ignored.
Recall the story Jerome Groopman tells in his book How Doctors Think:
One of my patients was a middle-aged woman with seemingly endless complaints whose voice sounded to me like a nail scratching a blackboard. One day she had a new complaint, discomfort in her upper chest. I tried to pin down what caused the discomfort--eating, exercise, coughing--to no avail. Then I ordered routine tests, including a chest x-ray and a cardiogram. Both were normal. In desperation, I prescribed antacids. But her complaint persisted, and I became deaf to it. In essence, I couldn't think in a different way. Several weeks later, I was stat paged to the emergency room. My patient had a dissecting aortic aneurysm, a life-threatening tear of the large artery that carries blood from the heart to the rest of the body. She died. Although an aortic dissection is often fatal even when discovered, I have never forgiven myself for failing to diagnosis it. There was a chance she could have been saved.
I wish I had been taught, and had gained the self-awareness, to realize how emotion can blur a doctor's ability to listen and think. Physicians who dislike their patients regularly cut them off during the recitation of symptoms and fix on a convenient diagnosis and treatment. The doctor becomes increasingly convinced of the truth of his misjudgment, developing a psychological commitment to it. He becomes wedded to his distorted conclusion.
While Jerry focuses here on the situation where dislike of a patient leads to diagnostic anchoring, we now understand that it can apply in many situations, irrespective of the doctor's personal feelings about the patient.
Let's go further, though, and see if the following emotional reactions also apply to physicians. Huth says:
Suddenly, the lost hiker recognizes that his map and his perceptions don't line up. Panic sets in. The emotional centers of the brain send out warning signals, and perceptions get distorted with a fight-or-flight reaction. Massive amounts of adrenaline flood the mind and body. Breathing and heart rate increase. The person refuses to believe that he's lost and runs frantically in a direction that he's sure will lead back to the trail, only to get deeper into trouble. First one possibility, then another races through his overtaxed mind, and yet he cannot gain any certainty.
"Woods shock" is the term for this kind of anxiety attack brought on by the realization that the subject is lost.
I have seen woods shock occur to physicians. I have seen it in clinics and on the floors and ICUs. I have seen it during case reviews, when doctors are describing adverse events and trying to figure out what went wrong. When denial sets in, I have seen the figurative equivalent of "running frantically in a direction that he's sure will lead back to the trail." The flailing and emotion distress that occurs is painful to watch and, I'm sure, to experience for these people who have been trained not to be wrong. Rationalization comes into play. Blame of other parties--the nurses, the labs, the residents--is a common response.
In a post almost three years ago, I summarized a talk by Pat Croskerry from Dalhousie University, Halifax, Nova Scotia. Pat says we need to spend more time teaching clinicians to be more aware of the importance of decision-making as a discipline. He feels we should train people about the various forms of cognitive bias, and also affective bias. Given the extent to which intuitive decision-making will continue to be used, let's recognize that and improve our ability to carry out that approach by improving feedback, imposing circuit breakers, acknowledging the role of emotions, and the like. In summary, let's see if we can protect our clinicians from bending the map and experiencing woods shock.
Most wired?
Now that I am a "civilian," I get to experience the health care system like most of you. I marvel at the degree to which customer service mechanisms used by service providers in other sectors do not exist in health care. Please understand that I am not talking about the quality of care, or empathy, or attentiveness offered by doctors, nurses, rad techs, lab techs and the like. On that front, I remain tremendously impressed. Indeed, I am even more impressed that they can offer such fine care now that I get to witness the logistical "systems" in place to do the humdrum things that are required to provide service, work flows whose design not only makes things harder for patients but also for providers. Examples:
I contact my PCP who recommends that I see a specialist. The PCP is on the patient information portal, but the specialist is not. This means that I cannot use the portal to set up an appointment. Can I do it by email? No, I am told. I must call the specialist's office. This results in several back and forth telephone calls, using up the precious time of both the patient and the desk clerk. An opportunity to benefit from the asynchronous nature of email or other electronic scheduling is lost.
I need to have an image made before seeing the specialist. His office tries to enter the order for the image, but the system kicks it out because my insurance company does not have the name of my PCP in its records. The person entering the order does not have the authority or ability to inform the insurance company of this piece of data, although it is known to her. Instead, the specialist's office has to contact me, and then I have to contact the insurance company, and then I have to call the office back and tell them that I have done so, and then the order can be entered.
Then, because electronic scheduling does not exist, I have to call the radiology department to get an appointment for the scan. Here's the first bit of good news. The scan and the radiologist's reading is inserted into my electronic medical record so the specialist has access to it before my appointment. Indeed, I have access to the report, too, through the patient portal (oddly, in that the specialist does not participate in the patient portal.)
But my PCP and the specialist recommend that I see yet another specialist. I search for his information and find that he uses the patient portal. I go to my page in the patient portal and attempt to add him as one of my doctors so I can make an appointment electronically, but the following message appears saying that I must have an initial appointment with him before I can do so:
Ah, Catch-22!
There is no email available for him, so I am left to call his clinic and make an appointment.
By the way, this occurs in a physician practice organization that regularly receives awards for being part of one of the "most wired" health care institutions in the country. And, truly, it deserves that honor compared to many others, but the kind of lacunae I describe above are indicative that the standard against which such awards are granted is low compared to what you would expect in many other industries.
Oh, also, the Press Ganey survey I received after the appointment with the first specialist had no questions related to any of these problems.
I contact my PCP who recommends that I see a specialist. The PCP is on the patient information portal, but the specialist is not. This means that I cannot use the portal to set up an appointment. Can I do it by email? No, I am told. I must call the specialist's office. This results in several back and forth telephone calls, using up the precious time of both the patient and the desk clerk. An opportunity to benefit from the asynchronous nature of email or other electronic scheduling is lost.
I need to have an image made before seeing the specialist. His office tries to enter the order for the image, but the system kicks it out because my insurance company does not have the name of my PCP in its records. The person entering the order does not have the authority or ability to inform the insurance company of this piece of data, although it is known to her. Instead, the specialist's office has to contact me, and then I have to contact the insurance company, and then I have to call the office back and tell them that I have done so, and then the order can be entered.
Then, because electronic scheduling does not exist, I have to call the radiology department to get an appointment for the scan. Here's the first bit of good news. The scan and the radiologist's reading is inserted into my electronic medical record so the specialist has access to it before my appointment. Indeed, I have access to the report, too, through the patient portal (oddly, in that the specialist does not participate in the patient portal.)
But my PCP and the specialist recommend that I see yet another specialist. I search for his information and find that he uses the patient portal. I go to my page in the patient portal and attempt to add him as one of my doctors so I can make an appointment electronically, but the following message appears saying that I must have an initial appointment with him before I can do so:
There is no email available for him, so I am left to call his clinic and make an appointment.
By the way, this occurs in a physician practice organization that regularly receives awards for being part of one of the "most wired" health care institutions in the country. And, truly, it deserves that honor compared to many others, but the kind of lacunae I describe above are indicative that the standard against which such awards are granted is low compared to what you would expect in many other industries.
Oh, also, the Press Ganey survey I received after the appointment with the first specialist had no questions related to any of these problems.
See them for who they are and not for the illnesses they have
Jane Carmody is Chief Nursing Officer at Alegent Creighton Health in Omaha, Nebraska. She publishes a regular note from the CNO for the hospital staff. This personal account moved me, and I reprint it with her permission.
Courage. My sister is about nine years older than me. For about ten years she has battled carcinoid tumors, and it is starting to take its toll. I visit her about every weekend I can; she lives in Des Moines. I have to say how I admire her courage. She is a nurse and worked for years at her small town clinic with the physician and the nurse practitioner. They “huddled” every day (although they did not call it that) and discussed the patients for the day and who would need follow up, who would be called and who would come in for a “RN check.” She was well known in the town.
She retired a couple of years ago and tells me now, “Never retire…stay working as long as you can…it is hard for a nurse to retire…the work is too exciting and interesting…”. I know she looks at me and wishes she were in good health, and I so I am careful not to complain about work schedules or work pressures because she would love to have them.
On a recent visit we took her shopping. My sister loves shoes, purses and hair and skin products…and certainly not the inexpensive ones. We thought about taking her to the mall so she could shop at Von Maur (her favorite) and yet the mall only provides wheel chairs…she hates that. So, we took her to Target: They have motorized carts and she had so much fun. Gave her freedom to shop and to knock down displays…she said she was so “embarrassed” to have to use the riding carts, but she had so much fun. She has lost most of her hair and so she wears lots of hats and so we bought matching ones.
I tell this story because she is courageously and gracefully managing. It reminds me of how you all experience the courage of your own patients and families and how we have to remind ourselves to see them for who they are and not for the illnesses they have. Please pray with me for my sister and all those suffering. She starts another round of radiation this week because the tumors grow more on her spine. This further weakens her status and yet not her hope, humor and courage.
Subscribe to:
Comments (Atom)