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October 17th, 2017

Emergency Medicine: A Life of Interruption

Alexandra Godfrey, BSc PT, MS PA-C

Alexandra Godfrey, PA-C, practices emergency medicine in North Carolina.

Emergency medicine is a life of interruption. Physicians, nurses, PAs, radiology techs, registration clerks: we are all constantly interrupted or interrupting. Unfortunately, interruptions and distractions and the consequent attention shift may lead to error. Sometimes, we fail to return to the original task, make an error in that task, or waste time on less urgent needs, neglecting critical ones.

Learning when to focus and when to ignore a distraction is perhaps one of the most vital skills needed in emergency medicine. Working in the ER can lead to a culture of immediacy; everything is now, yesterday, too late already. But seriously — is it? Just because we want something STAT, does it need to be STAT?

Recently, as part of a course in narrative medicine, I have been studying attention, awareness and mindfulness. I realized as I studied this material that not only is interruption frequent in emergency medicine, it is also widely accepted. Yes, if the patient is moribund, exsanguinating, showing tombstones on his EKG or otherwise in extremis, then interruption is essential and valid. But what about all the other times — the telephone calls, the verbal interruptions, the pages, the side conversations?

Here are some interruptions I noticed during a recent ER shift:

  • A clerk is on the phone. A doctor asks her to page a specialist.
  • A PA is putting orders in on a patient. The triage nurse stops by and asks her to review an EKG.
  • A nurse is drawing up meds to give to a patient. A PA interrupts her, asking if she will get discharge vitals on another patient.
  • The physician is taking a history. The registration clerk enters the room and asks the patient for insurance information.
  • The NP is reviewing imaging. The radiology tech stops by and advises him to order a creatinine on another patient.
  • A physician is doing a critical procedure on a patient. A nurse walks in and asks him if she can give Zofran to another patient.
  • Two physicians are doing sign-out. The social worker interrupts to discuss a psychiatric admission.

Health care systems researchers have documented interruptions in health care environments, including the relatively high interruption rate in emergency departments compared with primary care. Other evidence supports the observation that, once interrupted, ER providers frequently fail to return to the task. Moreover, attention shifts can lead to procedural errors and incomplete patient orders and evaluations.

Given these risks, could we establish protocols or an etiquette that would reduce the number of distractions and interruptions?

I think we can.

Here are some ways we might start.

First, we could each consider the import of our interruptions – i.e., ask ourselves:

  • Do I need to ask this now?
  • Does this need immediate attention?

Another idea is for departments to identify critical tasks where interruption is most dangerous, such as:

  • Provider sign-out
  • Nurse medication preparation and administration
  • Patient evaluation by medical staff
  • Clinician review of labs and imaging
  • Putting in orders
  • Patient procedures

Such tasks could be designated as protected from non-emergent interruption. ERs might also consider developing protected work stations (areas), limiting phone calls, programming EMR cues, and setting monitor alarms to safe and appropriate levels.

At the individual level, developing awareness is also a tool to mitigate distraction. Awareness requires us to be reflective and notice what does and does not interest us — and to recognize when an attention shift occurs. I am aware that being interrupted or distracted while I am putting in orders can result in a dangerous attention shift. Consequently, I consider this protected time. Unless a critical need arises, I finish these tasks first. Awareness has helped me focus my attention and avoid errors.

Being able to bring back a wandering attention — and knowing it has wandered — is one way each of us can lessen the effects of a chaotic and noisy environment. Other tools that might help are:

  • List writing and post it notes
  • Limiting off-topic conversations
  • Limiting the number of visitors
  • Posting “do not disturb” signs during critical procedures
  • Limiting cell phone use by patients and their visitors

Interruption reduction is the responsibility of every member of the medical team. As both interrupters and the interrupted, I suggest we start by asking ourselves two simple questions at these moments:

Is this an appropriate time?

Should I delay this interruption?

 

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October 5th, 2017

An Old Procedure, A New Beginning

Emily F. Moore, RN, MSN, CPNP-PC, CCRN practices pediatric cardiovascular care across the Pacific Northwest.

“My heart hurts,” said Brooklyn, then three years old, as she grabbed her chest and sat down. Quickly checking the girl over, Brooklyn’s parents felt her heart indeed pounding in her chest, and took her to the emergency department. There, they were shocked to hear that their daughter was in cardiac arrest. Shortly afterward, Brooklyn was diagnosed with pulmonary hypertension. The following few years brought a multitude of procedures, medications, and doctor appointments.

After two years, the disease started to take its toll, and Brooklyn had increasing cyanosis. On the recommendation of their doctors, the family moved to Seattle to be at sea level. Initially, Brooklyn’s symptoms improved, but over the years, her health steadily declined. At eight years old, she was maxed out on medications, no longer growing, and unable to walk without shortness of breath — and her family was looking at transplantation as the only option. Unfortunately, due to her rapidly deteriorating disease combined with constant insurance obstacles, transplantation seemed out of reach.

Looking as if they were out of options, their pulmonary hypertension specialist Dr. Delphine Yung introduced another option she had read about. It involved repurposing the once failed Potts shunt to redirect excess blood in the pulmonary artery to the aorta. (Created in 1940, the Potts shunt was meant to be used for the reverse purpose, to augment pulmonary blood flow. However, it quickly went out of favor because in many cases it had worked too well, causing pulmonary hypertension.)

Presenting her idea in a patient care conference with the cardiac surgical team, Dr. Yung explained that she had heard of the Potts shunt being used successfully in a few cases of pulmonary hypertension abroad and then later in the U.S., and she felt it held potential for Brooklyn. Our chief of cardiac surgery, Dr. Jonathan Chen, stated his concerns about the complexity of the surgery for patients with pulmonary hypertension. However, after researching the revised use of this shunt further, he was persuaded that it was worth going out on a limb to try to improve Brooklyn’s life.

Both Dr. Yung and Dr. Chen approached Brooklyn’s family with the idea of the repurposed shunt placement. Her parents were understandably nervous about the idea, as their daughter would be one of the few patients in the world to undergo this surgery. But knowing they were out of options, the family agreed to move forward with the surgery.

© 2004 The New England Journal of Medicine

The operation by Dr. Chen went smoothly, and Brooklyn’s vital signs indicated nearly instant relief for her heart.

Within a few weeks of surgery, Brooklyn’s medications were decreased and then stopped. She was weaned off oxygen, and a central line that had been in place for years was removed. She was finally able to go swimming and start living life to her full potential. Her parents were beyond grateful for the success of the procedure. To paraphrase Dr. Chen, it took an incredible amount of courage for these parents to try the shunt and trust the health care team with this decision. [He also reflected how, as a wedding is the mark of a new life, so was this procedure for Brooklyn and her family. And as with a well-known wedding tradition, her case even involved something old (the abandoned procedure), something new (its new use), something borrowed (the shunt and procedure techniques), and something blue (the cyanosis, now improved postprocedure).]

Brooklyn is now nearly three years post-surgery and doing remarkably well. Dr. Yung and Dr. Chen have one other patient who has since undergone the procedure with a similar outcome.

I am often in awe of the power of medical science to help us achieve advances in health care, and this particular story, and the remarkable level of success for the patient, are the best example of this I have witnessed.

 

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September 29th, 2017

I’ll Take “Nursing Ethics” for $200, Alex

Elizabeth Donahue, RN, MSN, NP-C, practices adult primary care medicine in Boston, MA.

First I noticed it all over my social media feed — the story of Alex Wubbels, a burn unit nurse at a university hospital in Utah who was arrested and manhandled by police for not allowing them to take a sample of blood from an unconscious patient without a warrant. Then came a slew of texts, emails and calls from people wanting to discuss the incident, asking me what I thought. Most recently, it came up while laying on the beach with family members, who wanted my reaction to the event.

My reaction is this: I could have been Alex Wubbels. I would have done the same thing she did. And the realization of that fact — after seeing how she was treated for following hospital policy and for protecting her patient — is kind of terrifying but also empowering. But I think most nurses would have done the same and here’s why.

Alex Wubbels knew the hospital policy and she followed it. By nature, I am detail-oriented and I adhere to guidelines. By education and training, my natural tendencies have been “encouraged.” I was taught how to make a perfect bed; I know how to calculate a drip rate by hand using stoichiometry and not a calculator; I have counted another human’s urinary output over a 12-hour period to the milliliter. If a patient is on precautions, you damn well better believe I have “gowned and gloved” to a tee for that level of need. When a parent calls my office about an adult child, the first thing I ask is if we have a signed release on file to share information with the caller — because otherwise, we are not legally allowed to disclose health information of the patient; it is protected under HIPAA.

“Hospital policy” has gotten a lot of flak in the dust-up that has followed this incident — but it exists for a reason, and it is my job and every hospital professional’s job to know it and to follow it, just like Alex did. While it may be impossible to know every policy, providers are trained on where policies are kept, how to read and interpret them, and also how to access supervisors as backup. According to the video footage of the incident, Alex did all of that, and most nurses I know would have done the same. We are cut from this same cloth and trained in the same way.

While most people are familiar with the oath that physicians take to “do no harm” (who knew Hippocrates would still be quoted 2000+ years after his death?), reflecting on this incident made me wonder: Does anyone know where nurses get their call to provide care and avoid harm? The answer is that some graduating nurses still recite the Nightingale pledge made famous by another nurse in the late 19th century. But our working ethics go beyond this pledge. Nursing education is infused with the principles of caring, integrity, and excellence from start to finish. We are taught that our role centers around advocating for patients and families. We are called to integrate this into our daily practice. While in school, we buy and read copies of the 72-page ANA “Code of Ethics for Nurses with Interpretive Statements,” we study the concepts of Jean Watson’s theory of human caring, and we complete courses titled “Ethical Issues in Advanced Practice Nursing.” It is deeply ingrained within the collective nursing psyche to do what Alex Wubbels did — to put the patient first and advocate for patients, especially when they cannot advocate for themselves.

An annual national Gallup poll of Americans has ranked nursing the highest among 21 major professions in terms of honesty and ethics — for the 15th year in a row. Our patients place their trust in us to care for them and ensure no harm comes to them. So, thank you, Alex Wubbels, for this example of what it is to be a nurse, for reminding us of our calling.

 

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September 21st, 2017

The Opioid Epidemic: One Year Later

Harrison Reed, PA-C, practices critical care medicine in Baltimore, MD.

A year ago I wrote a blog for In Practice and an editorial in the Journal of the American Academy of Physician Assistants (JAAPA) that discussed the factors contributing to the opioid epidemic in America. If the passionate reaction to those articles is any indication, the topic stirred both intellect and emotion.

Since then, the issue of opioid abuse/overdose has not disappeared. Let’s take a look at some of the recent developments.

New Data Released

The Centers for Disease Control and Prevention (CDC) and other government agencies released new data last week that shed further light on the opioid crisis. These latest data show the number of drug overdose deaths from February 2016 through February 2017. This dataset is important as it is the first to include the period of time following the CDC’s updated 2016 opioid prescribing recommendations and the media frenzy that followed.

Here are the trends you should know. Deaths from the three most prevalent opioid types—natural/semi-synthetic (like oxycodone/hydrocodone), synthetic (like fentanyl), and heroin—all increased over the past year despite reported drops in prescribing rates. But the largest increase in deaths was from synthetics like fentanyl (more on that later). The geographic distribution of drug overdose deaths is also uneven, with some parts of the country reporting a decline (like an 8% drop in Nebraska) while others have seen an explosion in cases (like a 63% increase in Maryland).

The Rise of Fentanyl 

Another storyline has emerged from both data trends and media reports: the rise of illicit fentanyl. While the potent synthetic opioid has been a useful tool in certain medical settings for years, its illicit manufacture and abuse is one of the most significant developments in the opioid saga.

Stories of fentanyl’s immediate impact have filtered from some of the country’s hardest-hit areas. The drug is much more potent than typical heroin and is often combined with or laced into other drugs, sometimes unbeknownst to the user. That unpredictability has resulted in body counts that, for some communities, have been treated as mass-casualty events.

A wider view of the raw numbers is startling. The one-year CDC data mentioned above show that 14,465 people overdosed on natural and semi-synthetic opioids (like oxycodone and hydrocodone) while 15,549 people overdosed on heroin. But in the same period of time, 21,163 people died from synthetic opioids like fentanyl. Easily manufactured and highly lethal, synthetic opioids have become a frightening game-changer in the opioid epidemic.

Alternative Narratives

The arrival of fentanyl and other synthetic opioids as a major player in the overdose epidemic may have also opened the door for a troubling narrative. Some in the media and medical community—like the author of this editorial published in Emergency Medicine News—point to the rise of illicit fentanyl deaths as proof that the medical community is not responsible for the epidemic.

This flawed viewpoint implies a lack of obligation on the part of clinicians to find solutions to the nation’s opioid dependence. It also ignores the fact that the vast majority of illicit opioid users began with a prescription drug.

You can read more analysis of this false fentanyl narrative at my website The Contralateral.

President Trump Makes a Statement

The opioid epidemic received some high level attention last month when President Trump issued a verbal statement on the issue.

“The opioid crisis is an emergency, and I’m saying officially right now: it is an emergency,” he said on August 10th from the steps of his New Jersey golf club.

While the comment from the nation’s top official brings an added spotlight, it may lack the formality needed to spur additional action. Saying something is an emergency and signing a formal declaration of emergency are two different things. The latter would have several beneficial effects: it would make FEMA money available to states in need of assistance, allow the redeployment of Health and Human Services (HHS) personnel, and remove Medicare restrictions that act as barriers to substance abuse treatment.

A formal declaration may not happen, though, if HHS Secretary Tom Price’s comments are any indication.

“We believe that, at this point, that the resources that we need, or the focus that we need to bring to bear to the opioid crisis can be addressed without the declaration of an emergency,” he said shortly before the President’s statement.

The CDC Writes a Check

Despite not having a formal presidential declaration, the CDC recently awarded an additional $28.6 million to 44 states and D.C. to help combat the opioid epidemic. The funding was part of a congressional appropriations bill signed by President Trump earlier this year and will expand several HHS programs.

The money will help states bolster prescription drug monitoring programs, increase opioid risk awareness outreach, and improve surveillance and data-gathering programs.

There are many more opioid-related storylines that we don’t have time to cover in this blog. As new data emerge, we will need to continually reassess the impact of the epidemic and the efficacy of our interventions. If you have an important update to add, please post it in the comment section.

 

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September 15th, 2017

Curbside Consultations: Checks and Balances

Alexandra Godfrey, BSc PT, MS PA-C

Alexandra Godfrey, PA-C, practices emergency medicine in North Carolina.

A 34-year-old male presents to the emergency department with right arm weakness. He woke up 2 days ago unable to move his arm. The patient reports having hypertension but has no history of diabetes, stroke, cardiac disease or tobacco use. He drinks alcohol daily. The patient complains of numbness and tingling in his arm. He lacks wrist extension and has diminished grip power. His function in his biceps and triceps is normal. He has no other deficits or symptoms. You suspect the patient has a radial nerve palsy but feel a little uneasy because he appears to also have some involvement of the ulna and median nerves. 

The neurologist has just finished seeing another patient in the ED. You wander over to him as he settles down at the computer to chart. After some small talk, you mention you have a patient with what appears to be a radial nerve palsy but you are questioning why this patient has decreased grasp and pinch strength. You chat for a while about different nerve palsies and ways to isolate peripheral nerves; then you answer his questions about findings suggestive of more serious lesions. When you re-examine your patient based on your conversation, you feel comfortable that the patient has a radial injury. Later, you sit down to chart, and you wonder whether you should document your discussion with the neurologist. 

Photo by Rikki Chan on Unsplash

Informal, or “curbside,” consultations are a common and expected part of our medical practice. It’s checks and balances. We talk with each other when we encounter a presentation or condition that is outside of our usual area of expertise or just doesn’t fit the text. This can improve patient care and show thoughtfulness on the part of clinicians. Additionally, talking with colleagues — unlike reading textbooks and consulting web apps — allows for bidirectional learning.

However, such discussions are not risk free. For example, without knowing the specifics of a case or formally examining the patient, a consultant might offer well-intended advice that is inaccurate, incomplete or inappropriate. This can get us into deep water. Additionally, if the treating clinician shares insufficient information with the consultant, she might adversely affect patient care or have misplaced confidence in subsequent management of the patient. Sometimes there’s a disconnect between the consultant and the treating provider about what exactly is being asked. And humans being humans, recall later is likely to be different.

Risk Management

Generally speaking, risk is related to the degree of control the clinician has over patient care. The treating clinician — the individual who is directing care — carries the weight of responsibility for the patient and the medico-legal risk. Just because you discussed the case with the consultant doesn’t mean you are protected. If the consultant puts in orders or examines the patient, professional liability shifts.

Of course, medico-legal risk fluctuates according to setting, access to specialist services, and decisions made as a result of informal consultation discussions. Sometimes a face-to-face consultation is not possible and waiting for one would result in a delay in care. I work 72 miles from a tertiary center and frequently depend on telephone consultations. Some specialists are just not available at my primary site. In these circumstances, an informal consult may be better than no consult. Sometimes, I transfer the patient. This is usually a shared decision between myself, my attending, and the consultant. Such discussions help us identify the correct specialist, prioritize follow-up, and decide on need for transfer. (Here are a few citations I like on decision-making regarding informal consultation and care coordination.)

What topics are suitable for informal consultations? 

Academic questions, discussion of new research, requesting follow-up, and utility of tests are all topics that might be suitable for an informal consult. We learn through discussion and it is important that such learning isn’t lost. It’s good to bounce ideas off each other. In the hypothetical case presented, the treating clinician could ask simple questions like:

What is the best way to evaluate for a radial nerve palsy?

Do you think steroids have efficacy in the treatment of nerve palsies? 

As a matter of courtesy and professionalism, I avoid documenting the consultant’s name in the medical chart without their permission. I have met consultants upset to find their names in charts of patients whom they have never formally assessed. Asking if you can document the consultant’s name clues specialists in to the import of any advice given and prevents any surprises. I believe this is a mark of collegial respect, engendering the open and honest discussions much needed in medicine.

When is a formal consultation indicated? 

As a treating clinician, I consider seeking a formal consult if questions are complex or the consultant needs to examine the patient or review records to give good advice. Additionally, if the patient knows about the consult or if the treatment pathway is dependent on the consultant’s expertise, then a formal consult is warranted. If the consultant orders tests or treatments, this should precipitate a formal consult.

This leaves me with two questions:

How can we improve the safety and utility of curbside consults?

How do you manage curbside consults? 

 

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September 1st, 2017

Obesity Counseling: Getting Real

Emily F. Moore, RN, MSN, CPNP-PC, CCRN practices pediatric cardiovascular care across the Pacific Northwest.

“Your BMI puts you in the obese category. You need to limit weight gain to 10 pounds this pregnancy.”

As the obstetrician’s words sunk in, I was overcome with embarrassment. Sure, I knew I was overweight, but I was pregnant. And according to my BMI, I have been “obese” for years. But this was the first time a provider had actually called it to my attention, at least in such a blunt manner.

Sitting in the patient’s seat made me think about the best way to counsel families of pediatric patients about obesity. I have had plenty of practice discussing diets with people, but now I wondered — was I being sensitive to people’s feelings while also making the necessary lasting impression? The first time I had to educate a family regarding obesity, it wasn’t fun, but my preceptor broke the ice. Here’s what happened:

I had a patient in the 99th percentile for weight and BMI. He was only 7 and visibly obese. My preceptor counseled me before the appointment, educating me on why this was an important issue and how it would affect his life for years to come. He couldn’t stress enough how the family needed a provider to be “real” with them. I walked into the patient room and politely started asking about diet and exercise. After about 5 to 10 minutes of dancing around the subject, my preceptor barged into the room and said, “What she’s trying to say is, your son is overweight.” Though his approach was abrupt, it got the point across and got us all down to business. My preceptor asked me to show the family my patient’s growth charts and really explain, without beating around the bush, how serious the subject was. So, there I sat, showing charts and talking about the importance of exercise as well as avoiding juice, candy, soda, and the like. My patient left with a plan to change his diet and follow up in a few months.

My clinical training took place in an area where not every neighborhood is safe, and many of my patients were of low socioeconomic status. This complicated things when counseling them about diet and exercise. How does one encourage physical activity when there is no safe place to play? Similarly, with money scarcity, buying fresh fruits and vegetables in lieu of fast food was not always possible or a priority, especially in families where parents were working two jobs just to make ends meet. In these situations, a parent would often tell me that time and money were pretty influential in guiding meal choices. A box of macaroni and cheese is not only much cheaper but can feed a lot more people than a head of lettuce.

Hearing this story over and over again, I began to realize that although clinicians can do a lot to educate parents regarding childhood obesity and promote healthy eating, we must first understand the context of our patients’ lives — neighborhood safety, access to healthy foods, income level — to be most effective. By validating these hardships prior to suggesting solutions, I found that families were much more receptive to change.

After being on the receiving end of obesity counseling, I started to suggest rules for my patients’ families to follow. I picked up several of these from a physician I shadowed for a number of months, and now I use them all the time (in my home as well). Here they are:

  • First and foremost, diet and lifestyle changes need to happen now.
  • Always eat breakfast, and make sure this meal has protein in it, as some evidence shows that people who eat breakfast with protein eat fewer calories throughout the day. (I have personally found this to be true.)
  • No juice, soda, or other drinks high in sugar
  • And lastly, try not to eat in front of the television. If you are hungry, sit at the table or assigned family eating place and eat without distractions. This will hopefully keep you from consuming food mindlessly past the point of satiation.

In regard to my last pregnancy, I am proud to say that I only gained 12 pounds and gave birth to a 9+ pound baby! I made exercising a priority and followed a healthy eating plan. It was much easier to lose the weight after already having these practices in place. Was it fun? Not really; there were definitely days when I struggled. But I did it, and I am thankful for my provider’s transparency.

 

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August 24th, 2017

How to Land Your Dream PA or NP Job While You’re Still in School

Megan Tetlow, PA-C

Megan Tetlow, PA-C, is from Fort Myers, Florida, now working in Sheffield, England, as part of the National Physician Associate Expansion Program. She practices in gynecologic oncology and is a guest blogger for In Practice.

I have the pleasure of working with multiple PA students, both as a clinical preceptor and through teaching at the university. I’ve found myself fielding the “how do I find a job?” question a lot recently, so I thought I would address it here.

I think the best way to find a job as a PA or NP is while you are still a student. Finding a job through your rotations gives you the chance to get a real working sense of what being a PA or NP on a particular team might be like and lets you get familiar with your future team members. I was privileged to find my first job as a PA on my elective rotation, and it worked out well for me.

So, if you are a PA or NP student and are looking to secure a job while on your rotations, read on for my advice…

Treat every day like a job interview. 

If I could impart one piece of wisdom to PA and NP students, it would be this: Treat every day you are on rotation like a job interview. Because it is one. Whether you treat it as such or not. Every rotation. Every interaction even. And it is your own actions, preparedness, and motivation that make getting a job either a very real possibility or a remote one. Would you turn up 15 minutes late for a job interview? Hopefully not. Would you prepare ahead of time and ask engaging questions? Hopefully yes. While on your rotations, ask yourself, “Would I do [such and such] if I were on a job interview?” The answer might just mean the difference in getting you a real job.

The best job may be the one you create yourself.

So the rotation you’re on doesn’t have an advertised listing for a PA job? Great. According to Forbes, half of all jobs are unadvertised. Perhaps the group you’re rotating with has never considered having a PA or NP on their team, but when they get a stellar student (ahem — like you), they start thinking that adding one might be just what the service needs. Perhaps they’ve seriously considered adding an additional provider to their group and are just waiting for the perfect candidate. Regardless of the reason, the lack of an advertisement online does not mean lack of a possible position. And don’t be afraid to gently field the question, “Has your group ever considered hiring an additional PA?” You might be surprised by the answer you get.

If you’re on a rotation you like, shout it from the rooftops.

If you’ve found an area while on rotation that you love, congratulations. Now, tell people about it. Both officially with your clinical preceptor and the practice/business manager, and also anytime it might come up in conversation with nurses, theatre staff, other providers, etc. We all talk. And word travels fast.

If you’re on a rotation you don’t like, keep it to yourself.

For the same reason as above. I’m an ob/gyn PA. Students tend to either love it or hate it. We get it. But you should assume that those of us in the field do like it and probably don’t want to hear you speak negatively about it. Consider it the professional version of “If you can’t say anything nice, don’t say anything at all.” Dislike often comes off as disinterest — and no one is going to go out of their way to help out a student who appears disengaged.

Practice gratitude.

If you’ve had a clinical preceptor who invested time and energy in teaching you how to be a good provider, thank them! Call me old-fashioned, but I’m a stickler for a handwritten thank-you note. Emails work too. Saying thank you leaves a good impression. It also helps you stand out in your preceptor’s mind should an opportunity present itself later, or if they are asked for their impressions of you for a role you’re considering later (like I said before, we all talk).

Good luck out there. Now go get ‘em!

 

 

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August 17th, 2017

Primary Care’s Got Talent

Elizabeth Donahue, RN, MSN, NP-C, practices adult primary care medicine in Boston, MA.

There is one hour each day in the office that I refer to as the “golden hour” – from 6:30 to 7:30, either AM or PM. For the sake of my personal life, most days I aim to be at my desk for one of those two slots but not both. During this time, I’m usually alone in the office and I find myself being uber productive; tackling notes and other tasks without distraction.

Last Thursday night, after all the patients and staff had gone, a colleague and I sat at our desks, listening to Dave Matthews Band and charting/chatting away. We got onto the topic of a certain tooth straightening system that rhymes with “shmin-vizza-line” and how we were both considering treatment. We wanted to know where we could see experienced providers for treatment in Boston, so we searched the brand’s website. To our surprise, the providers vetted by the company were ranked in a five-tier system from “preferred” all the way up to “top 1%.” And because I love to ask inane questions that make others go ‘hmmmm,’ I began a quest to pester my coworkers into answering this question: What do you do that would rank you in the top 1% among primary care providers?

For me, the answer came easily — if my office voted for “pap queen” instead of “prom queen,” I feel I could run uncontested. In fairness, I see a lot of young, female patients, I am a stickler for preventive care, and I’ve covered years of “pap only” visits for male physician colleagues. Therefore, some of this bravado is a direct result of quantity. But still, I maintain that I have a gift for finding a cervix — it can run, it can hide, but I will find it. On one occasion, I even found two instead of one! A septate uterus with bilateral cervices…  if that doesn’t qualify for top 1%, I’m not sure what does.

My pharmacy colleague suggested she might fall in the top percentile when it came to insulin management and diabetes control. She is a CDE and a self-proclaimed “type A personality,” so the numbers game of diabetes is where she excels. My NP teammate in the office shared her expertise and confidence in treating chronic pain; she had spent months shadowing specialists, studying guidelines (on cross titration, non-opioid management strategies, etc). In her words, she took something that primary care did not train her well for and “figured it out,” so now rather than being “scared of it,” she can do it well. When I asked my evening charting buddy what she excelled at, she sighed deeply and told me that her special talent was “making my patients cry.” (She has found, sometimes to her chagrin, that she has a way of letting patients open up.) A male physician colleague, always the jokester, responded immediately, “I inhibit that response, that’s my talent!” (An open-concept team room makes for frequent group conversations, but that’s a blog for another day.)

Finally, one very seasoned colleague, who I’ll call Bob, new to primary care but with years of experience in emergency and hospital medicine, patently refused to answer the question. “I’m so new (to primary care),” he said. “I don’t think anything I do is in the top 1%,” he said. “I’m never answering that question. Forget about it.” Finally, under protest, he gave his answer — that maybe (just maybe) his talent across his years of practice was connecting with the patient quickly and “making them feel like I give a damn.” In response, I told him I might award him the “top 1% in humility.” He laughed sheepishly. I just love that Bob.

This initially lighthearted question led to a deeper conversation among my colleagues that uncovers for me a few of the beautiful things about primary care. First, you can find a different problem to manage each day behind each exam room door. Also, as a provider, you can choose to hone specific skills — those that interest you, or which demand or trends might dictate — or you can bring a gift that comes naturally to you to each patient you see. And in a team-based care environment, we have the ability to rely on one another’s gifts and talents. To adapt the old adage, “jack of all trades, master of none” to suit my point, I’d suggest that my talented colleagues in primary care are jacks of many trades, masters of some (they just need to be asked which ones … unless you ask Bob, because he’s still not fessing up!)

P.S. Names have been changed or withheld to protect the innocent subjects of my extracurricular pursuits.

 

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August 9th, 2017

Curing the Culture — A Gentle Nudge

Harrison Reed, PA-C, practices critical care medicine in Baltimore, MD.

You and I have covered a lot of ground this year.

We exposed the fallout of a toxic workplace culture and discussed some of the first steps we can take to fix it. We reestablished respect for our patients. We adjusted some of the biggest problems with our sign-out process. We reminded ourselves of the power of the letter of condolence. And, just for fun, we resolved to lose some of our wordy weight.

All the while, however, we have danced around a more central truth: much of the emotional and psychological damage we accrue in the workplace is inflicted by other healthcare workers. In a field that already struggles against the laws of physics and biology, we complicate our mission with the additional burden of interpersonal conflict. Like the illnesses of so many of our patients, that affliction is preventable.

It’s easy to ignore the problem; denial becomes a refuge. But once we take full responsibility for the toxic behavior in our environment, we can work toward a solution. It will take hundreds of small acts—performed by hundreds of thousands of people—to help nudge our culture in the right direction. Here are a few to get us started:

Mind your manners

I hate to say it, but our parents were right. Manners matter.

Polite society can vanish within the walls of a hospital. We place phone calls without introducing ourselves. We abolish “please” and “thank you” (or mutter it like a curse). We would rather attack than apologize. We act like jerks.

If you want to test just how alien even basic pleasantries are in healthcare, do this: the next time someone from another team or service calls you, ask them how their day is going. That tiny gesture surprises the people I talk to so much that they often stumble over their responses.

A friendly comment can declare a cease-fire when tensions run high or can pick someone up when they are pummeled by stress. It reminds everyone in the room of a simple truth: we are all human.

Roll out the welcome mat

There is nothing worse than the combination of disorientation and isolation that comes from plunging into an unfamiliar environment. And to make matters worse, workplace culture often punishes new employees with additional social penalties or outright hazing.

Even after new employees pay their dues and are welcomed into the fold, it is hard to forget a rocky path to acceptance. Resentment can linger and undermine team cohesion for years. Unfortunately, many of those who experience hazing later replicate the same behavior when the next generation of colleagues joins the workforce.

Someone has to break the cycle. When new employees show up, ensure they feel welcome and included. Establish a clear, positive culture with new recruits from day one—a culture that has no tolerance for abuse.

End tribalism

It feels great to be part of a cohesive team. And one of the surest ways to bring a group together is to focus on a common goal—or a common enemy. Unfortunately, that shortcut to team unity breeds an unpleasant byproduct: rivalry. In healthcare, it’s all too easy to draw lines between “us” and “them.” We form packs based on a variety of criteria: our professions (“doctors vs. nurses”), our specialties (“medicine vs. surgery”), and our institutions (“Everyone vs. Us”).

But, with rare exceptions, we don’t practice medicine in silos. Healthcare is far too complex, far too diverse, and far too interdependent to avoid working with people from other “tribes.” Casting aside these arbitrary differences erases a major barrier to teamwork.

Call it when you see it

Most who work in healthcare, at their core, are great people. But we all need an occasional reminder to clean up our acts when our behavior falls below the standards of our principles. A healthy organization should create mechanisms to call out toxic behavior. Some teams—those with a deep sense of trust and respect—can do this in situ and head off an incident before it escalates. But there should also be a formal pathway to highlight and discuss incidents confidentially after the heat of the moment has passed.

There will always be outliers, individuals who spew toxicity on a regular basis despite warnings. Administrations should lay out clear consequences for repeat offenders—and enforce them as needed. But for most, a gentle reminder is all it takes to keep us all focused on the same goal: helping patients and supporting each other.

 

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August 3rd, 2017

“As I Lay Dying” — Patient Readmission and Non-Compliance

Alexandra Godfrey, BSc PT, MS PA-C

Alexandra Godfrey, PA-C, practices emergency medicine in North Carolina.

As I tie the last knot in a neat row of nine sutures, the night nurse calls me to room two. I  drop my hemostats, peel off my gloves, and tell my patient I will be back. Across the hall, I find a girl thrashing around the gurney, chest heaving up and down, hands clasped around her abdomen. She stops moving only to retch into a bag. Her gasping breaths smell of pear drops, nail polish, and sugar candy. The ER attending is soon by my side. We know this girl. She presents this way every one to two months. I give her a nod of recognition, then start looking for IV access. Later, the labs confirm our clinical suspicion; she is in severe diabetic ketoacidosis (DKA).

When I review this patient’s records, I count seventeen admissions (to various facilities) for DKA in the past two years. Her HbA1c averages 14. Each time, the patient is admitted to ICU, treated and stabilized, then discharged with a plan for follow-up. Prior to discharge, the patient receives education regarding the management of diabetes, a consultation with a dietitian, a referral to a specialist clinic, and resources to aid her with her healthcare. Both psychiatry and social work have evaluated this patient. In spite of this, the patient continues to miss appointments, fails to refill her meds, and pays little attention to important factors, such as diet, exercise, and glucose control. Reasons for non-compliance, include: I am tired of being sick, insulin makes me fat, my boyfriend stole my meds, and I don’t like doctors.

The patient’s recurrent admissions have resulted in job loss, relationship breakdown and economic stress. The patient is stabilized during every admission, but she never appears to retain any of the education or advice given to her. Or if she does, she pays little attention to it. Control of her diabetes worsens. She lives crisis to crisis.

Truth is, she is not alone. Most emergency medicine providers have encountered patients like this, as have most of the broader medical community.

Let’s face it — the thoughts, actions, and motives of our patients frequently don’t make sense to us. And every human has a thought process that tumbles with varying levels of rationality, sometimes intentional and other times unintentional. Delusions and rationalizations along with a layer of narcissism and a sad tendency for self-destruction are part of the human narrative. But for the most part we don’t dance with death. Certainly, our patient’s narrative may sometimes seem irrational, but as clinicians we need to find ways — must find ways — to work around it.

Way back, Flexner et al in their article, “Repeated Hospitalizations for Diabetic Ketoacidosis: The Game of Sartoris” compared such patients to Faulkner’s Sartoris family. The Sartoris family appears hell bent on self-destruction. After the loss of a beloved son and brother in World War I, the family lives life on the edge and suffers for it. Their lives spiral out of control and the only resolution seems to be death, which inevitably comes. The authors liken the behaviors of this family to those of patients with recurrent admissions for DKA. They suggest that these patients – with theoretically manageable diseases – are, like Faulkner’s family, hellbent on a not-so-glamorous death. I am unsure whether these patients are truly hell-bent on death but I found the idea thought-provoking.

Recurrent admission for the same diagnosis is a serious problem for patients, providers, and healthcare systems. Non-compliance with medications and failure to follow up is associated with greater mortality and morbidity. The long-term complications of poorly controlled diabetes are devastating. We don’t want this for our patients. It contradicts the basic tenets of medicine, what we are about. Additionally, patients who are repeatedly readmitted consume a disproportionate amount of health care resources. Readmissions create problems with reimbursement. Furthermore, physicians and other healthcare providers struggle to manage these patients: they consume more time and resources, appear to not care about their health, and can trigger both frustration and compassion fatigue. The hard part, it seems, is not the management of the crisis but the prevention of future crises.

If we look at this problem logically, we can identify some manageable factors associated with patient non-compliance and readmission:

• Poor patient understanding of the disease or treatment
• Inadequate follow-up or confusion about follow-up
• Comorbidities such as substance abuse and psychiatric diagnoses
• Financial difficulties
• Lack of insurance
• Premature discharge
• Lack of discussion about care goals
• Low health literacy

I like to believe that there are ways we can improve the health of these patients. I do not think we have to resign ourselves to the fictional games of Faulkner. Undoubtedly, I have my own thoughts on how we do this. But I would prefer to hear the perspectives of my esteemed colleagues in the wider medical community rather than focus on my own narrative. So —

1) What can we do to prevent these readmissions?

2) How do you establish an effective care partnership with these patients?

 

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NP/PA Bloggers

NP/PA Bloggers

Elizabeth Donahue, RN, MSN, NP‑C
Alexandra Godfrey, BSc PT, MS PA‑C
Emily F. Moore, RN, MSN, CPNP‑PC, CCRN
Harrison Reed, PA‑C

Advanced practice clinicians treating patients in a variety of settings and specialties

Learn more about In Practice: Reflections from NPs and PAs.