Show me that you care. With sticky notes!

I knew I was in good hands when I saw this on the table:

"Yay! Sticky notes! Today is going to be a good day."

I was only half-joking to my table mates as I sat down to start a day-long meeting.  In the centre of the table was a plastic bin full of coloured sticky notes and marking pens.  And the sight really did give me a warm feeling.

Sticky notes and marking pens mean that audience participation is planned. Usually, participants are invited to write comments and contributions on the notes, then post them on a flipchart where they form the basis of, well, just about any kind of planning work. They also usually indicate that there will be discussion and debate.  That's fun.  (Also, occasionally, productive.)

But most importantly, their presence means that someone prepared for this meeting.  Somebody thought about what needed to be accomplished and how the attendees could be active participants.  Somebody wanted to hear our opinions.

Somebody cared about the day's outcome.

That's the real reason I was excited; the sticky notes were just an indicator.  An epiphenomenon.


The meeting's closing speaker related a story that linked my sticky note experience to my daily clinical work.  She told us about a man who had gone through 2 joint replacement surgeries.  At the first surgery, he remembered that the OR staff had been laughing and joking when he entered the room and he felt that they weren't paying attention to him.

Several years later, at the time of his second operation,  the surgical safety checklist had been used.  Staff all stopped what they were doing and focussed on hearing the plan for his surgery.  The man related that he felt everyone really cared about what happened to him that day.

Completion of the surgical safety checklist didn't guarantee a better outcome for him.  But he (rightly) interpreted its use as an indicator that someone had put effort into planning for his safe care.


What other indicators - positive or negative - are patients reading as they traverse the healthcare system?

Making it easier to do the right thing - Is there an app for that?

I was out running this morning and came across this:

A beer can on the road.

I'll pick up the occasional piece of garbage while I'm out and about, but I don't want to lug it all the way home with me.  I definitely didn't want to run very far carrying a beer can because, you know, people would talk.

I happened to be on a familiar path and knew that there was a garbage can right around the next corner, so:

That made me think that there must be plenty of like-minded people walking around Saskatoon, that is, people who will pick up a piece of garbage, but only if they know a garbage can is handy.  They may be motivated to do the right thing (clean up their neighbourhood) but need a little help to follow through.

Here's a suggestion for some entrepreneurial programmer:

Smartphone app that people activate when they are in an outdoor public space.  The GPS-enabled phone signals when a garbage can is within X metres (X varies according to individual preference).  Maybe there would be a recorded voice encouraging the user to "Pick it up" or "Let's clean up".

Each city would need to enter the locations of garbage cans.  This could be done by municipal employees who geo-locate garbage cans, once again with GPS-enabled phones.  Or, public users could contribute the locations.  This might be a revenue source for the app developer, as each city would need a unique database of garbage cans, licensed on the developer's server.

Individual users could record their contribution by logging the number of pieces of garbage they pick up.  Nothing like a little competition to encourage participation!  Users could submit pictures of the trash they pick up, with prizes for the most unusual object.

I'm not sure if there are researchers studying trash, but if there are, they could ask users to log the type of litter they find (e.g. fast food packaging including the restaurant name) to better understand the source of the garbage, and lobby the responsible businesses to reduce packaging.

Anyone up for this?

Wasting time and money on a long weekend

I often hear stories about physicians repeating lab tests or x-rays because it's inconvenient to get results from other hospitals or physician offices. I flatter myself that I'll make a concerted effort to track down test results before subjecting patients to repeat testing. Sometimes however, "the system" will not yield.


Here is a little story:

Earlier in the week, I saw a lady who was passing a kidney stone. We agreed that she would give it a few days but if the pain continued, we would do emergency surgery over the holiday long weekend. The complicating factor was that she lives in a community that is more than a 5 hour drive away from Saskatoon and she didn't want to come to Saskatoon if she didn't have to (that is, if she passed the stone in the meantime). For that reason, she had an x-ray done in her home community late in the week. The written x-ray report came down to me by fax and there was no mention of a kidney stone. (This can either mean that the stone is gone or that the radiologist has not noticed the stone on the x-ray.) Also, she was still having some discomfort, making us both suspicious that the stone might still be present. I needed to compare the x-ray to the one she had done earlier in the week to see if the stone truly had passed.


The challenge was that her home community is not connected with our electronic access system for x-rays (PACS). PACS allows online access to x-rays done in many places around the province as soon as they are completed. This innovation has markedly improved the speed with which we can make appropriate diagnosis. In her case, however, she would need to have the hospital make a CD with her x-ray on it and then send the CD to me. With this being a holiday long weekend, it would be well into next week before I could make a diagnosis.

She called me back to let me know that her plans had changed and she was planning to come to Saskatoon for the long weekend. She would drop a CD off at one of the hospitals when she arrived and I would pick it up in the morning.

The next morning turned out to be a vignette of frustration.

I searched around the department where my patient said she had left the CD but no one knew where was. I called her to check that she had actually dropped off and she assured me she had. I returned to the department and someone remembered where it was. I tried to open the x-ray files on a computer but was unable to do so. (Usually, loading the CD on a computer automatically opens the x-ray pictures.) I hunted down the on-call radiologist to see if he could open the pictures. He spent 10 minutes trying but was also unsuccessful.

I called my patient and told her we would need to repeat the x-ray. She came to the emergency department and registered herself. She had the x-ray repeated and I checked the results. After comparing to the previous x-ray, I could see that the stone had actually passed. I met her in the emergency department and gave her the good news.

I estimate the time I spent with phone calls, searching for the disc, and trying to open it with the radiologist was about 30 minutes. That's 30 minutes of completely non-value added time.

Also, there is the real cost of registering my patient in the emergency department, doing another x-ray, paying the radiologist fee for interpreting the x-ray, and paying my bill for seeing the patient in the emergency department.  (I've ignored any patient costs...)  If I would have had access to the x-ray electronically, I would have phoned her and the additional cost to "the system" would be zero. There is also a non-tangible cost of frustration both on my and my patient's part. When a similar situation comes up in the future, I'll be tempted to make things easier for myself by insisting that the patient come to Saskatoon to have another x-ray done.

Multiply these costs by the number of times similar scenarios play out across our health care system and you begin to see the money and resources we are squandering by not having a fully integrated electronic medical record. What a waste!

Asking family physicians how we can help them provide care

We've been working on improving patient care and access for over 5 years.  While we continue to improve processes in our practice, it's been frustrating to see that, after our initial success in improving access, patients have been waiting longer over the last 2 years.  This is partly because of reduced manpower in our group (retirements and semi-retirements) and a shift in focus of urologists' time (provincial emphasis on reducing surgical wait times takes urologists away from office consultations and puts them in the operating room).

Wait times have crept up enough that patients and referring physicians are feeling a strain.  We recently received several calls from family physicians commenting on our wait time and the problems it's causing.  Not only do patients have to put up with the anxiety and suffering from their medical condition, but family physicians have to spend more time reassessing patients and then sending "re-referral" letters to us.  Sometimes these letters are indicating a change in the patient's condition and asking for a more urgent appointment.  Sometimes these letters are just checking that our office has actually received the initial referral.  Either way, it's more work for the GP, the urologist (who has to reveiw the second letter) and our respective staffs.

Last week, I visited one of Saskatoon's large family physician group practices.  I attended their regular practice management meetings to acknowledge the difficulty they were having in getting access to urology services and to ask for their advice.  They had some useful suggestions:

While they would prefer to have rapid access for their patients, if there is going to be a wait, they would like to be able to give their patients an accurate idea of how long the wait would be.  They felt that this would reduce anxiety and the number of repeat phone calls from patients wondering when their appointment would be.  One doctor commented that, when our urology clinic had initally improved wait times, family physicians had become used to the rapid access and were still telling patients that "it shouldn't be too long to get in".  Unfortunately, this isn't consistent with our current access, so patients become concerned when they don't get a prompt appointment.

The family physicians were interested in a more collaborative approach to the consultation process.  They asked if we could provide guidelines to help them carry out appropriate investigations prior to their patient seeing the urologist.  I mentioned our hematuria evaluation guidelines (requesting that the GP arrange an ultrasound and certain lab testing, so that we can arrange a "one-stop" consultation for the patient to undergo cystoscopy/bladder examination) and they agreed that more of the same would be useful.  They suggested a urology referral template that would list common conditions and symptoms along with suggested pre-consultation testing and management.  They could load the template onto their EMR for easy access.

One of the senior group members made a frank observation.  He said that, over the years, he's come to rely on our practice to manage his patients' urologic conditions, so much so that he may have become a little "lazy" in managing some of the conditions himself.  He wondered if he could have a "refresher" about common urologic conditions, such as erectile dysfunction and enlarged prostate.   Several of the clinic members agreed that they would like to have guidelines on how to manage these common problems in primary care.  

They also made an interesting observation about the utility of clinical guidelines.  Many guidelines and protocols are available from various sources, including family physician and specialty organizations at both the local and national levels.  The GPs indicated that the multitude of available guidelines becomes confusing for them and their patients.  They were particularly conscious of the fact that if they chose to follow a legitimate national guideline in managing say, bladder infections, and later refer their patient to the local urologist who follows a different guideline, their patient may be distressed and question the GP's aptitude.  For this reason, they preferred that any guidelines bear the "stamp of approval" of local specialists so as to take into consideration local practices and resources.  This doesn't mean that we would have to generate recommendations independent of national standards, but rather that we would review available practice guidelines, and adjust appropriately for local practice before disseminating them.

They also suggested that a variety of continuing professional development tools would be helpful.  In addition to having specialists make presentations at local family practice conferences, opportunistic instruction ("teachable moment") could also be used.  For example, if our urology clinic received a referral regarding a patient with a common condition that can be managed by the primary care practitioner (recurrent bladder infection, for example), rather than making the patient wait to hear the treatment advice from the urologist, we would fax back to the referring practitioner a treatment algorithm, along with an educational module and patient information. 

None of these ideas is earth-shattering, but they demonstrate family physicians' genuine appetite to break out of the current consultation model in which we are stuck, and is not serving our patients well.