Archive for December, 2008

OK. I had a sad, humbling experience on a trip to Wal-Mart last night. My wife asked me to return something and my daughter was/is sick, so I had to get a prescription filled. Not a big deal, right?

Well, three things… One. I am not a Wal-Mart guy. No offense to Wal-Mart Inc, but in my area the “customer service” there is quite pathetic. It is the type of place where those hilarious guys at Despair.com get inspiration. I have to consciously prepare myself to keep my mouth shut… suck it up… and move on.

Two. I am not a go-to-the-store-and-return something guy either. It’s just not me. I don’t like doing it. If I can get out of it, I will. (But if I’m wronged, I’m going full tilt - Better Business Bureau, letters to the home office, etc… just don’t make me return anything.)

Three. It’s the week after Christmas and the place is packed.

Anyway, I went.

There were no less than 40 people in line at the “customer service” desk (so naturally, I didn’t return anything :). I briskly bobbed and weaved to get to the pharmacy pick-up line. I was number 16 in line. Ahead of me stood 15 uncomfortable-looking, elderly patients. Since 11 of the 15 folks did not have a smooth pick-up, I had plenty of time to stand there… to just watch and listen.

Here is some of what I saw and heard:

• The patients in line were elderly and uncomfortable standing so long.
• Most of the patients had even sicker-looking (in a chronic sense) family members sitting aisles away on empty shelves or in wheelchairs.
• While in line, these patients were cordial and patient, but as time went on, frustration and fatigue began to show.
• While they were waiting and becoming increasingly tired, several employees were walking out from the back talking about their break and why they need to take it now, “even though it’s busy”.
• Several patients were discussing “coming back out of retirement” just to be able to afford things for daily living.
• Several quoted the $4 prescriptions as the reason they were willing to withstand the “customer service” and the lines.
• Despite their interest in the $4 bargain, most (8) of them were unable to actually get the $4 drug… mostly because the way it was written.
• 11 out of 15 had issues with their scripts being filled at all - and not one of the 11 was given a solution that they could control… The staff blamed each issue on the doctor or the government - 8 on the doctor, 2 on the government (specifically Medicare Part D), and one on both.
• The second person in line (appearing to be in her late 70s) ended up being shouted at by the pharmacist, “Didn’t you read Medicare Part D?! Your doctor has to put the indication on your prescription! It’s not my fault! Go ask your doctor. We called, but your doctor is not getting back to us.”
• There was one employee who was visibly working her tail off to get the patients their meds before they even reached the counter. She walked out and asked each person in line their names and began trying to get their stuff 3, 4, and 5 people deep in line. No one thanked her. No one said, “Job well done”, at least in the 45 minutes I stood in line.

Here are some tips and pearls for interns and residents to take away from this experience:

• Small things on your part can make a humongous difference for your patients.
• Write the indication on your elderly patients’ scripts.
• Advise your patients to bring their discharge instructions with them to the pharmacy when they leave the hospital for the first time.
• If you are writing a narcotic, put your DEA number and spell out the number of pills to dispense.
• Try to avoid writing “Use as directed”… that doesn’t fly with some co-pays, Medicare D, and some discount programs.
• Choose the medications wisely… with cost being a huge piece to factor in.
• Ask your patients if they’ve ever had problems filling scripts before and what the nature of the problem was… too many to dispense, not covered by insurance, etc.
• Consider titrating doses before adding new classes, if possible.
• Keep an updated list of the discount meds available. And familiarize yourself with other discount programs (Target, Wal-Mart, Giant, etc).
• Get in the habit of writing the generic name anyway.
• If you get paged from a pharmacy outside of your hospital, it is probably regarding a patient you just discharged… Answer it promptly. That person who was just hospitalized is probably standing in Wal-Mart, or sitting off to the side waiting for a family member to fill their scripts.
• Write legibly.
• If there’s a discrepancy when looking at their meds and the meds you thought they were taking at home, ask the patient. Reconcile your scripts with their current meds.
• Be careful what you talk about in front of others. Sure, there’s nothing wrong with discussing where everyone wants to order from for lunch. But if you do that while a patient or their family is in earshot, you might really rub them the wrong way.
• Social workers and case managers know about these patients’ frustrations and potential problems… learn from them. Ask them for feedback. And appreciate what they do. (The insurance industry is like Wal-Mart on steroids.)
• When someone does something well, or goes a little further than they have to, tell them about it… thank them… let them know that it was appreciated.

Now, it is important to realize that when you actually do these things, you will not be praised. No one will thank you. No one will really notice. And that’s okay. It’s not about you. It’s about them, the patients.

And if you don’t think it’s about your patients, then quit health care right now… and go work at Wal-Mart. You’ll fit right in… probably best-suited for “customer service”.

And here are some tips for Wal-Mart and pharmacies, in general:

• Put some seats or benches for your elderly patrons. Be generous and be strategic. Put them in such a way that people can remain in line and remain seated if need be.
• Consider having a health professional (MD, DO, NP, PA, Pharm D, etc) that can write scripts for the edits and tweaks that someone else simply forgot… things like indication, quantity, etc.
• Consider having a looping video that explains procedures, policies, what’s needed, etc. so that people don’t have to wait in line to find out that they’re missing something.
• Keep track of all of the issues that prevent people from getting their scripts on the first trip up to the counter… use that list to get to the root causes… or at least publish it. If it is truly the doctors, then send the list to me, I’ll get it out there.
• Try to hire people that “own” problems, not the Me-Myself-and-I types that consistently shunt blame.
• Remind your workers that it might be viewed as a little inconsiderate to discuss their breaks while frustrated customers look on. Remind them to consider how they would feel.
• Tell your pharmacists that it is a very, very rare patient that ever “reads Medicare Part D”… In fact, I’ve never met one.

There’s my rant, but there are lessons in there, though. I learned a lot standing in line at Wal-Mart.

Information and data are increasing at alarming rates. On the one hand, this is great because we are witnessing some amazing advances in health care (and computer science, and communication, etc). However, it is becoming increasingly difficult to navigate through this body of data to arrive at the most relevant, most up-to-date, most easy-to-apply information that is suited to your specific need and specific situation. This is true if you are a doctor, a computer programmer, a world leader, or a secretary.

Many have stopped calling this the Age of Information, and started calling it the Age of Distraction, or the Attention Age. It is not enough to know a lot. Instead, it becomes increasingly important to be able to:

• Find the most up-to-date, relevant information,
• Find it quickly,
• Synthesize or process that information, and then
• Apply that information.

The one who manages information well is the successful one.

For that reason, I thought you might find the following very short video to be a useful one. In it, Rich Schefren discusses the difference between “just enough” information and “just in time” information. This is a very important distinction to make. And once you grasp it, you may find your internship and residency less stressful. Check it out…

I made a short 7 minute video as a quick introduction to Twitter and how you can use it to get tips and strategies for your med school rotations, internship, and residency. Just click on the video image below to get started. You will need the most up-to-date QuickTime player (free version).

Developing good documentation skills can be a tremendous part of your training - with profound implications for your patients, the effectiveness of consults you request, your evaluations from attendings, and developing efficiency for your future work. I have been called several times, thanking me for my documentation - by malpractice lawyers, by risk management personnel, and once by the Chief of Medicine at another hospital - you would be surprised at the information that others find useful in your old notes.

Anyway, here are a few tips I extracted from the Documentation Module of the RookieDoc Members area… Let me know what you think in the comments below or through email.

1. Know who reads your notes - you may be shocked at how many people rely on your documentation. If you know who these people are and what they are looking for, you will be light years ahead of others in your program.

2. Write legibly - If you work in a hospital or office that does not yet use electronic records, you better write legibly. It can have a huge impact on patient care, lawsuits, and your evaluations from attendings.

3. Use bulleted lists - Most people scan notes to the parts they think are important. If you list things like Past Medical History, recent tests and studies, Past Surgical History, recent hospitalizations, etc as bullets in a list, it will make it much easier for people that read the chart after you. You will stand out and your patients will be better for it.

4. Indent consistently - when making paragraphs or headings, do it in a consistent fashion. Avoid writing everything in one big blob of a paragraph.

5. Consistent order of things - from note-to-note, stay consistent.

6. Refer to other parts of the documentation - It’s okay to write, “See Dr. Smith’s review of the CT results in his note dated 12/13″ or “Exam is unchanged from 12/12″ or “See #2 above”. A good example of “see #2 above” may be if you have to refer to a problem more than once… like renal insufficiency in it’s own section, and then also again under diabetes.

7. Ask for specific feedback - ask attendings, risk management nurses, and upper level residents to look at your notes and give you feedback. And don’t accept answers like, “They’re good. Keep it up.” No. Ask specifically, “Well, what could I do better? What should I work on?”

I’ve mentioned before that you should not wear shirts with logos on them at work. Your hospital probably has a policy against it, plus you could offend someone or just appear unprofessional. Anyway, in light of the holidays and the fact that GiggleMed.com hooked me up with the RookieDoc logo, I thought I’d share with you a shirt that might be a pretty funny gift for your medical student, intern, and resident friends and colleagues.

You can get other medical humor gifts like hats, mugs, shirts, bags, etc at GiggleMed’s Store.

Even though a blog is often the writer’s soap box… that’s not what I’m going to do with this particular subject. I’m just pointing it out for med students, interns, and residents… just to be aware that there are even more changes being discussed in resident work-hour reform. I want to suggest that you reserve judgment. Here’s why…

It’s easy to think about yourself in the short-term and think, “Heck yeah! I want to limit my work hours!” But be careful, there are definite pros and cons. And we are talking about a dynamic system here.

Part of being remarkable in your profession is your ability to “see systems”. You should know that one tweak in one part of the system may have profound implications in other parts of the system. And in this “me world” you might miss the effects on other parts. And in this “right now world” you might miss, even, the longer-term implications for yourself.

But I’m not going to go there right now. (RookieDoc members - I’ll teach you how to overcome the cons with a whole separate bonus module…) Just keeping you informed here by linking to an interesting article and an interesting blog post. Check them out.

• Does More Sleep Make for Better Doctors?
• Consequences of Limiting Resident Work Hours

By the way, if you’re on Twitter, you may want to follow “kevinmd” too… he’s got a lot of great insights.