Variation in Clinical Practice revisited - the video!

How long have you got for lunch today?  37 minutes and 48 seconds? Perfect!

The latest work we're doing in our office (to improve care for patients with bladder cancer) inspired a post in March about variation in clinical practice.  It was also the spark for a presentation I had the pleasure to give at the BCPSQC Quality Summit.  Thanks to Christina Krause and her team for putting on a terrific meeting and for producing this video (37m 48s).

If you're not sure about investing 37 minutes, try the first 7 - that should give you a good idea what to expect from the rest.

(Yes, the screen shot could have been marginally less goofy-looking. Or perhaps not.)

Customer voice changes my thinking on changing our office practice

Last week, several of my partners and I had been talking about whether we should change a long-standing office procedure.  Most medical practices use a nurse or receptionist to show patients into examination rooms, where the patient waits until the doctor arrives.  In our office, we don't employ a nurse.  Instead, the doctor greets the patient at the entrance to the waiting room and shows him back to the consultation/examination room.

I'm sure that Lean practitioners would cringe to hear this.

Think about the steps in this procedure:

Doctor walks down the hallway from his consultation room to the examining room. 

Doctor calls the patient's name. (Repeat as needed) 

Patient packs up reading material, closes cell phone, removes and hangs up coat, etc. 

Doctor greets patient. 

They walk back down the hallway to the consultation room.

That takes from 1-3 minutes to complete.  It doesn't sound like much, but it's a significant proportion of our "standard" 15 minute visit.  It's time that could be spent finishing dictation of the previous consultation report, reviewing the next patient's chart, checking in-coming reports, etc.

I had recently read about the practice of "self-rooming", where patients are given instructions by the receptionist and then make their own way down to the assigned consultation room.  This would let our receptionist remain at her desk, save us the need to hire additional staff, and give the docs a few minutes of extra time between each patient visit.

What a great idea!  I ran it by a few of my partners and started thinking about how we could do try out the concept in our office.

Then, late last week, I met a man who changed my thinking entirely.

I was attending Saskatchewan's Health Quality Summit, and introduced myself to the man (I'll call him Ken) sitting next to me at one of the workshop sessions.

"Oh, yes," Ken said.  "I've visited one of your partners.  You know what impressed me about your office?  That the doctor actually came out himself to the waiting room to call for me."

What a coincidence, I told him.  We were just thinking about changing that practice because it's inefficient.  I explained the amount of time it took for doctors to perform that task.

He agreed that it may take a few extra minutes to do, but that he found it to be an important part of building the doctor-patient relationship.  He felt it showed a degree of respect and caring.

"When I meet a doctor for the first time, I make a judgment as to whether I can trust that doctor.  I think the first impression your staff make is a very good way to build that relationship," Ken said.

That was a very powerful thing for me to hear.  I have often commented to medical students and residents that specialists need to be deliberate about building a trusting relationship with patients.  Unlike family physicians who have years in which to develop a bond with patients, specialists have only a short time to do so.  This is especially important for surgeons, who may meet someone for the first time and, within the course of that visit, inform the patient about a serious diagnosis - such as cancer - and discuss performing a life-changing procedure.

Ken was telling me that the simple habit of escorting my own patients to my consultation room was a valuable step in building a trusting relationship.

That doesn't change the fact that the procedure requires an investment of time, but it does mean that, if we're going to make a change, we can't measure the outcome solely on the basis of time saved.  We would also need to consider the impact on patient experience.  As Ken went on to say, "Spending a few minutes more up front is probably saving you time later on because patients feel you are considerate and caring."

What a valuable lesson! (Even if I do have to keep learning it over and over again...)

"Doing the Wife's Tummy Tuck" - An informal survey of surgeons' reactions

About 2 weeks ago, an American plastic surgeon told the story of how he performed his own wife's "tummy tuck" - a cosmetic surgical procedure to remove excess, sagging skin from the abdomen.  The blog post is on the popular medical blog aggregator site, KevinMD, and also on Dr. Di Saia's own website.  Rather than having me recount the story, I encourage you to follow one of the links and read the brief post for yourself.  Reading it on Dr. Di Saia's website may give you a better appreciation of his practice context and expertise.

I shopped this story around the surgeons' lounge last week and the response was vigorous and unanimous: Bad idea.  The surgeons expressed several concerns:

First, while the outcome for the patient/wife was good in this case, any surgeon knows that this will not always be so.  In the rare case when things go wrong in the operating room, it becomes an extremely stressful and dangerous situation very rapidly.  In those cases, the patient's best asset is a calm, dispassionate surgical team that can think clearly and act decisively.  Every surgeon I spoke with admitted that their judgement would suffer if they were called upon to lead the team managing their loved one's surgical crisis.

Next, many of the surgeons wondered about the possible effects on a marriage if the results of the surgery were not exemplary.  Would the wife be comfortable in raising a concern to her husband?  If her own lifestyle depended on her husband's professional reputation, would she admit that she was dissatisfied with the outcome?  How would the surgeon/husband balance his professional appraisal of the cosmetic result against his personal satisfaction with his partner's appearance?

One surgeon commented that there is a ethical prohibition against physicians establishing intimate relationships with their patients, and wondered how that principle should be applied in this case.  The intertwining of professional and personal relationships can be messy.

During the discussions, almost everyone commented that they had, at one time or another, rendered some medical care to their family members: antibiotics for strep throat, sutures for a cut suffered while at the cabin, or various and sundry slings, splints and bandages.  And, most agreed that, in case of an emergency with absolutely no other suitable care available, they would operate on a loved one to save their life.  But this doesn't apply to a tummy tuck - the ultimate in elective, cosmetic surgery.

Some other comments:

How would Dr. Di Saia obtain full, informed and free consent to blog/tell the world about his wife's surgery?  

Was there any commercial incentive to perform this surgery, and then tell the story (i.e. "I'm so confident of my skills that I operated on my own wife!")?

Did the facility where the surgery was performed have any rules about this situation?  How did the rest of the surgical team feel about this? 

What do you think?  Are we over-reacting to this story?

Getting feedback on drug shortage - Do we need additional measures?

More on SHR's efforts to cope with the national drug shortage.

Last week, we received some positive feedback from our pharmacy about our efforts to conserve injectable medications:

The most recent review revealed an average 37% reduction in usage for the most affected injectable drugs.

That represents the combined efforts of both those prescribing/ordering the medication, and those administering them.  In our department, we've been conscious of the need to order both injectable and oral medications for postoperative patients, so that nurses can make the switch to oral medications as soon as it's appropriate, rather than needing to wait for new orders to be written.

It's encouraging to see this desired change, and I hope that pharmacy will continue to track the drug usage and report back to clinicians.  We're interested in a sustained change in practice, and will need to chart usage over time to see if clinicians need reinforcement, or perhaps some other intervention.

But, is measuring reduction in usage sufficient?  Let's go back to that pesky Model for Improvement.

The Model's first question is answered in an aim statement.  I suggested that our aim statement might be something like:

We will ensure that patients receive appropriate care and access to necessary medication.  We will do this through careful management of the injectable drug supply and by use of alternative medications and administration routes.

The second question relates to how we measure progress.  We currently have one measure - an outcome measure - namely the usage of injectable drugs.  But, any time we change one part of a system, unintended changes may happen in other parts.   Perhaps we should also look at  these possible consequences of our conservation efforts with a balancing measure.  For example, could we be overzealous in our attempts to conserve injectable medication? What if patients had inadequate control of symptoms, like pain or nausea, because oral medication was being used when an injectable form may be more effective?

If you were the pharmacist in charge of this effort, you'd be gnashing your teeth right about now.  "We don't have the time and resources to do comparisons of patients' symptom control with and without injectable drugs," you might say.  That would be a lot of work, so perhaps we could start with a surrogate measure.  How about a survey of physician and nursing staff from various wards to see what their impressions are.  Do they notice a difference in patient comfort?  Are the oral medications giving prompt relief of symptoms?

If staff are noticing that oral medications are less effective, we owe it to our patients to investigate further. (Note: in my own practice, I have not seen any sign that patient care has suffered.  There you go, pharmacist, your first data point is collected!)



P.S. To the Anonymous commenter asking if SHR's medication substitution table is available for wider consumption, I haven't been able to find an external link for you.