Thursday, August 25, 2011

Doc why are you asking me all these questions? All that information is in the computer!

Disclaimer: This is a hypothetical case - any resemblance to anyone is purely coincidental.

Addendum 8/28/2011 Link to G+ discussion on this post 

Students learn about patient centered interviewing and focusing on patient problems and complaints.  That is the point of HPI (History of present illness).  When they come to work with a primary care provider, who has know his/her patients for a long time, some of these question can be irritating to the patient who expects the physician to remember everything about their health history.

The HPI helps when approaching a patient with a new problem. Students are often not familiar with the patient who has 5 serious chronic problems but no complaints.  They start by asking something like, "So what brings you in today?" and they get something like "Oh, this is just a follow up.  I am fine!" and then they don't know what to do next.

Part of the problem is that many medical students get only an acute exposure to chronic diseases.  They do an 8 week rotation in Internal Medicine where they almost never see the same patient again.

Recently I had a patient who came in to establish care.  She was the first patient of the day and she was 15 minutes late.  I had come in earlier than usual as I knew I had a third year student with me in clinic.  Because of these reasons, I got time to review her EHR data in some detail.  She had received all her care at our institution and this meant all her data was in one system.

The student was very bright and very comfortable with history taking but new to EHRs.  The previous day, she had faced the typical patient scenario, "Why are you asking me all these questions?  Its all there in the computer!"

After that last encounter, we had discussed how a lot of information can be gleaned from the EHR.  So we had decided to spend some time going over the strategy of using the EHR prior to seeing the patient.

We started off by looking at a Patient summary screen (a snapshot of her problem list, medications and health maintenance alerts). We saw that she had the following issues noted in the EHR by her previous physician:

1.  Hyperlipidemia

2.  Goiter

3.  Smoker

4.  Hypertension

Her medications included

1.  HCTZ 25

2.  Pravastatin 40

So in this patient we went over her chronic issues (problem list) and dug into each one to see what we could glean from the EHR.  This is how the conversation went:

1.  Lets look at the hyperlipidemia.  What would you want to know?

  • Last lipid level

  • Target LDL (how do we calculate this?) 

  • What medication, dose, is she compliant, tolerating?

  • Liver test results

  • Diet and exercise

So we click on Chart review >>; Lab results>> Select the last 2 lipid panels >> view in table form >> find that her LDL was about 150 1 year back.
We discuss ATP III >> go to the ATP calculator online >> put in her risk factors >> calculate that her LDL should be less than 130 mg/dL
We assume that whoever ordered that last lipid panel must have done something when the LDL came back above the target.  Go to Medication tab >> medication history >> sort by therapeutic class >> look for lipid lower meds >> find that she used to be on pravastatin 20 and had been increased to 40 mg after the date of the lab.  Did that work?  Lab results >> see that lipids and ALT had been ordered for 3 months after the change in dosage but not done.
So we create one agenda item: Find out if she is taking the 40 mg dose, and check lipids on that dose.

I recall reading about the new JAMA study on the dietary portfolio (oatmeal, soy and nuts) being better than just following a low saturated fat diet at lowering cholesterol.  Find it in Google Reader easily and share with student.
Create second agenda item: Discuss diet with patient and d/w her re' this study

2.  Goiter:  What questions do we have?
  • Has this been worked up? 

  • What was found?

  • What was done?

  • What is her thyroid status?

  • She is not on any meds so is she euthyroid?

So we click on the problem "Goiter" in the EHR and find that it was first noted in 2007.
Chart review >> Imaging>> USG thyroid >> has one large nodule and rest diffusely enlarged.
D/w student what she would do>> FNA >> Who does this? Endocrinology>> chart review >> Encounter tab >> sort by department >>Endocrinology >> saw them in 2008 >> had an FNA done>> Lab results tab>> Sort by test >> Surgical pathology >> Thyroid bx>> Benign. Also check last TSH >> low normal 2 years back.

Create agenda: Update problem list with this information so next physician does not have to do this again! Another agenda item: Ask also about symptoms and recheck TSH.

3.  Smoker: What would you want to know?
  • Is she still smoking?

  • If so is she interested in quitting?

Create agenda to ask these questions.

4.  Hypertension:  What would you want to know?
  • What is the BP today?

  • Is she taking her medication?  and side effect?

  • How has her control been?

  • Any evidence of end organ involvement?

In EHR to go graphs>> BP >> see that she is usually <140/80 over last 4 years
Chart review >> Cardiology>> Echo >> none, EKG >> normal (no evidence of LVH)
Chart review >> Lab results >> BMP>> Creatinine normal, K normal; UA >> no Hb or protein.

Create agenda: Ask about home BP measurements, does she have a machine, do cardiovascular exam for murmur, gallop, heave, bruit, pulses and look at fundus.

The student looks at me amazed!  She did not know the EHR could hold the answers to so many questions. I tell her how she can create her own agenda before going into the exam room.  Once she has elicited the patient's agenda and addressed it, she needs to cover the items on her own agenda.  Hopefully both the agendas are the same.  Hopefully there is time to cover both the agendas.  

We have spent 30 minutes discussing and reviewing all these issues.  We are lucky we got an early start and the patient was late!

So what is the point of this story?
1.  EHRs can hold an amazing amount of important information

2.  Getting this information out of the EHR takes a lot of time, clicks and knowledge of where to find this information.

3.  These benefits are visible when all the data is in one system.  If the consultants and labs and imaging were all done at different places, this would not be possible.  Even when external reports are scanned in, this data is not easily accessible.  As we develop electronic data interfaces this should not be a problem.

4.  Some patients expect that just because all the information is in the computer, it is also in the physician's brain!  Wish they could realize how much effort it takes to dig all this information out.

5.  As physicians use EHRs and spend time reviewing and summarizing the information, they should take time to encode it in a way that makes it easy for the next provider or the subsequent visit.

6.  Students learn how to get the history from the primary source but will also need to get comfortable getting the data from the EHR in a meaningful manner.  While looking up the information in the EHR prior to talking to a patient can create a huge bias and a kind of filter bubble, it is a great way to look up chronic problems.

7.  The time that it takes to review all the information occurs outside the exam room and it can become non-reimbursed care.  Doing this review is very important for patient care.  Will this become a non-issue once we move to ACO's?

Sunday, August 14, 2011

Health care and the Social (Media) Anxiety Syndrome - Do we need Baby Steps?

Let me state first off that there is no defined entity called "Social (Media) Anxiety Syndrome"*.  I am using it just as a metaphor. Social Media holds a lot of potential for the health care professionals.  Is fear of the medium inappropriately leading to professionals avoiding this "social situation"? Have we created a Social Media Anxiety syndrome?

We are aware of the social anxiety disorder or social phobia.  Among its many features are (this is a convenient list for the purpose of this post and not a strict definition):

  • Avoidance of interaction with others

  • Fear of being in a group, or being the center of attention

  • Fear that is made worse by a lack of social skills or experience in social situations

  • Possibly false beliefs about social situations

  • These factors lead to avoidance to of social situations.

Let us take a health care worker who has not used social media.  
  • It is possible that s/he would equate the term "Social Media" with Facebook and Twitter

  • Will likely be exposed to reports of unprofessional conduct on FB and Twitter and is afraid of getting in trouble

  • May be unaware of how one can have a closed Facebook account (so no patient can send you a friend request), how one can have protected tweets so only authorized people can see them.

  • Is quite unaware of useful applications of social media (e.g. RSS and feed readers to stay current with literature, use of Twitter to create a personal learning network, use of blogs to practice reflection etc.)

  • As a result avoids the entire medium. 

While there are clearly legitimate concerns about the use of Social Media by health care professionals, some of the potential problems can be averted by taking appropriate safeguards and some of the beliefs may be false.  It is possible that the voice of some experts is missing from the social media universe due to unfounded fears about this "social situation". 

Have we created a social media anxiety syndrome that prevents the voice of key people from being heard?  Do we need to develop some "baby steps" to help them?  Something like these:

Baby steps for Twitter:
  • Create a private account (Called protecting your tweets) and practice tweeting  - try adding a link to an online journal article and a short comment.  No one else can see this tweet unless you authorize it.  

  • Under “Whom to Follow” find someone whose ideas and writings you want to follow e.g.Atul Gawande.  His Twitter handle is Atul_Gawande.  You will now see their comments and links to articles and speeches.  

  • After you have added a few tweets, ask a friend or colleague who uses twitter to follow you.  You will need to authorize this.  They can give you feedback and show you some tips and tricks.

  • Create a private group twitter account - you can use GroupTweet for this.  This can be used to share informal learning objectives between residents on hospital service or longitudinal clinic)

  • Once you feel comfortable, you can unprotect your account and move towards creating a global learning network for yourself.

Do you believe that Social Media has some value for a health professional? If so would it be more valuable if more professionals were to participate in this medium? If so what is stopping them? Can we help remove some barriers? Should we even bother?

* [Since writing this I found that the term "Social Media Anxiety Disorder" has been used in 2010 by Phil Baumann for describing Pharma's Social Media Anxiety Disorder. The term "Social Network Anxiety Disorder was used in 2008 by Nicole Ferraro]

Friday, August 12, 2011

Getting comfortable with Uncertainty

Medical students are usually taught a rather comprehensive approach to history and physical exam.  They appear to go through a mental check list of all the things that need to be asked and examined.  They start off by following this check list regardless of presentation.  They may also think that a test is needed to rule in or rule out each condition on the differential.  It takes them a while to realize that a good history and physical can diagnose almost 70-80% of unknown cases presenting in the out-patient clinic and that even when one is not sure of the diagnosis, one does not always have to order tests.

When they first show up in clinics students tend to be quite confused that the clinical world is very different from the one they were training for.  The experienced doctor seems to ask questions in a very different order than what they expected and seems to be quite comfortable with uncertainty, tending to order far fewer tests than they would have thought.

What can we do to ease the transition to the clinical years?
Some techniques I have tried are:
  1. I teach a mantra that "Time is a diagnostic tool".  This is particularly true in outpatient medicine.  Some conditions can best diagnosed by waiting and watching.  Either they will go away or they will show new features which will help diagnose them.  

  2. Empiric treatment is also a diagnostic tool.  Sometimes a short course of medication can help - if the condition gets better (or it does not) it can point to the diagnosis.

  3. I give them a framework and ask them to try and place the patients possible diagnoses (from the differential) into one of 3 buckets (categories):

    1. Potentially serious (e.g. life threatening) and urgent (needs to be diagnosed or ruled out quickly)

    2. Potentially serious but not (very) urgent  - this is on a scale 

    3. Likely not serious and not urgent

I then ask them to see if they can eliminate any condition on their differential that falls into category 1.  If that cannot be done, they need to absolutely do some thing right away including ordering a test.  If they can, then they have time and then they can try still order a test or try empiric treatment or wait and watch.

Forcing a student to try and place the likely possible conditions in these categories helps them ask the questions that matter rather than go down a checklist of HPI and ROS and PMH that are often irrelevant.

They students are often confused that they spend a long time with the patient asking questions and doing a head to toe exam and then when the preceptors talk to the patient, they ask one or two pointed questions or check a couple of physical exam findings that change the management completely (see table).  Discussing this with the student early in their clinical rotation can help smooth their transition and reduce their frustration.


Category 1

Category 2

Category 3

Low back pain

Epidural metastases (history of cancer), abscess (Systemic features of infection), (Spine tenderness), (Nocturnal pain)

Sciatica (Straight leg raise test)

Muscle strain (paraspinal tenderness, history of unusual exertion)

Chest pain

Acute coronary syndrome (previous stress test/cath,), aortic dissection  features of affected arteries or nerves e.g horner/recc laryngeal etc)

GERD, viral pericarditis (systemic features, rub, EKG findings)

Rib/muscle strain (reproducible tenderness)


Aneurysm (neuro findings check the pupils disc), Temporal arteritis (age, jaw claudication, eye symptoms, scalp tenderness)

Migraine (photophonophobia, triggers, caffeine)

Scalp hematoma from minor injury

The items in parentheses are just examples of types of questions or exam findings that may not be part of the standard check list that a student my use. These not meant to be inclusive of all such questions. Also there are several guidelines that students can be directed to e.g. the guidelines regarding which head injuries should get a CT scan.

[This is not to say that there is no role for the comprehensive H and P.  Often the students will discover something important about a patient that their primary care provider was unaware of.  This is especially important in someone who has an unresolved symptom/s even after being seen by multiple providers/consultants.  A fresh look at the case with a systematic approach can reveal clues to the answer.

Clinicians will sometimes miss a diagnosis but if the patient is appropriately instructed regarding any red flags and followed closely, the prognosis will usually not be any different.]