Thursday, January 27, 2011

A paper cut in a digital world

As I mentally gear up for another week on the inpatient team with our residents, I am vividly remembering a moment from my last week there.

First, a little background.  About five years ago, our hospital went live with an electronic medical record.  True, the documenting system is a bit clunky, but inputting daily progress notes, H&Ps, consults, and discharge summaries electronically became possible.

As a third-year resident here then, I practically leaped for joy.  Gone would be the days of squinting to read Dr. Scribbler's illegible H&P!  Gone would be the days of hunting down a paper chart to read a consult!  I imagined a beautiful new word of efficient legibility.

The majority of the attending staff, as you are probably already imaging, did not share my optimism.  They were unhappy with the clunkiness I alluded to above.  They didn't want to take the time to log in, pull up the right patient, open a new progress note, and type in their thoughts.  "Too many clicks" became their mantra.  The hospital decided to continue allowing paper documentation while the IT folks worked on ways to make physician documentation less cumbersome and more user-friendly.

Fast forward to my time on service last month.  After a lengthy search, I had finally grabbed hold of a patient's paper chart.  As I flipped through the pages to read the surgeon's recommendations for our patient, I felt a familiar sting in my index finger.  A drop of blood welled onto the page I was reading.

Paper cut.  I got a paper cut reading a patient's chart.  Carpal tunnel from clicking the mouse too much?  Ok.  Eye strain from staring at LCD screens for too long?  Understandable.  But a paper cut?!?

It is 2011, and my hospital is still using a hybrid electronic-paper system.  We are far from the only hospital still relying on paper this late into the 21st century.  In all fairness, electronic documentation for physicians does need to become more intuitive and less cumbersome.  But the time has come for us to demand better software, not bury our heads back into the sharp edges of an outmoded paper system.  Resisting better legibility and faster data retrieval denies patients the accurate and timely medical documentation - and care -that they deserve.

Anybody got a band-aid?

Tuesday, January 25, 2011

Goodbye, old books

My constantly expanding collection of books has been an increasing problem of late.  As an avid reader, I have always worked under the assumption that books are sacred.  Once brought into the home, a book cannot leave.  It is a record of a point in time, forever connected with what was happening when read.

I was an English major in college, and I still have every single one of the novels, anthologies, and poetry collections from that time.  I also ended up with a Chemistry degree, and every time I look at my Physical Chemistry textbook I remember my curve-busting test performance and fill with happy pride.

I am in a wonderful book club with some of my work colleagues, and just about every book we've read in the last seven years is there.

My medical school textbooks similarly still line the bookshelves.  They are all pretty much out-of-date by now, and it's ridiculous to think that I would leaf through the pages of a ten-year-old book to find guidance for my clinical decision making.  Yet I still cling to them; wouldn't it be great to share them with my future residents in thirty years?

("I know, can you imagine - treating type 2 diabetes with insulin and hepatotoxic pills when it turned out to be so obviously curable?  Ha ha ha!")

Lately, though, my husband has kindly confronted me with the reality that our house cannot continue to comfortably accommodate my ever-expanding book collection.  I came to see that, unless we plan to start replacing furniture with bookshelves (who needs a couch, anyway?), the book-to-living-space balance must tip the other direction.  Some of the books needed to go. 

I struggled to accept this fact for quite a while.  These books were like old friends, reminders of times and events, of feelings and ideas.   I slowly came to realize, however, that these reminders of the past were crowding out the here and now.  Worse, I was relying on those books to serve as visual personality props - a way to show off the wealth of my knowledge and experiences.  The final straw was realizing just how many of those books I would never, ever read again. 

So, over the course of a weekend, I sifted through every book on every shelf in the house.  I realized that I didn't need the books to keep the memories or to display the sum of my personality.   When done, I delivered two bags of long neglected tomes to Half-Price Books.  Handing them over was surprisingly easy in the end; I realized that they would all gain new life in the hands of new readers.

Goodbye, old books, and good luck to you all.

Thursday, January 20, 2011

White Coats

After the (greatly appreciated!) multiple responses to my last entry on the "Doctor" title, I thought I'd expand the conversation to include another of those doctor identifiers: the white coat.

In my time in the medical world, I have seen a wide variety of attitudes from my medical colleagues regarding the white coat.  Some appreciate the pockets.  Some worry that it may be off-putting to patients, especially disadvantaged ones.  Some feel that it's an important symbol of the doctor-patient boundary.  Some don't like having their style cramped by white polyester. 

We physicians might make assumptions about what patients want us to look like, but what does the evidence say?

A cross-sectional survey in Tennessee a few years ago found that patients prefer family physicians who wear white coats (1).  Another study in a South Carolina internal medicine office found that patients "overwhelmingly" preferred physicians in white coats (2).  A Northeast Ohio OB residency found similarly; patients preferred a white coat and professional dress to scrubs (3).  A quick PubMed search pulls up the same theme over and over: the patients studied have more trust in, and comfort with, physicians who wear white coats. 

We can misuse boundaries and labels, and they can chafe at times.  But the chaos of a totally boundary-less world is equally unappealing.  Patients already struggle at times to identify what role each of the people they interact with play.  In our hospital, the nursing students wear long white coats while physicians often favor fuzzy half-zip sweatshirts over their scrubs. 

Some may argue that the above studies are not generalizable to the populations they care for.  Others may describe their excellent patient relationships despite abolishing the white coat long ago.  I'm certainly not discounting any of those thoughts; actually, I was quite surprised that my literature findings were so one-sided.  I have to wonder if these studies are demonstrating our patients' desire to clearly identify who we are and, by extension, what we have pledged regarding our duty to them.

Fuzzy half-zip, I'll see you after work.

(1) Keenum AJ, Wallace LS, Stevens AR. Patients' attitudes regarding physical characteristics of family practice physicians. Southern Med J 2003; 96:1190-94.
(2) Rehman SU et al.  What to wear today? Effect of doctor's attire on the trust and confidence of patients.  Am J Med.  2005 Nov;118(11):1279-86.
(3) Cha A et al.  Resident physician attire: does it make a difference to our patients? Am J Obstet Gynecol.  2004 May;190(5):1484-8.

Thursday, January 13, 2011

What ever happened to "Doctor"?

I was sitting next to a resident in the preceptor room yesterday.  He was calling a patient to discuss lab results, and introduced himself on the phone by his first name and last name...but not with "Doctor."  (e.g., "Hi, this is John Smith from the Family Health Center.")

I occasionally see the residents' patients for urgent visits.  When I ask them who their regular PCP is at the office, I get a first name response about half of the time. (e.g., "Jane" or "Dr. Jane")  I have seen this same phenomenon in the hospital when I'm on the inpatient service; I'll reference the family medicine resident caring for a particular patient by title and last name, and the patient will say "who?"  I have since learned to then provide the resident's first name, to which the patient will invariably sigh with relief and say "oh yes.  He/she has been so nice."

You have probably guessed by now how I feel about this use of first names.  I may be only in my mid-thirties, but perhaps I belong to an earlier era.  I address my patients (over the age of 18) by their titles and last names unless they have given me permission to do otherwise.  When I meet new patients, I address them by their first and last names and then ask them how they would like for me to address them.  My expectation is that they will address me as I prefer to be professionally addressed: "Dr. Middleton."

I suspect the blurring of casual and corporate that has occurred in the rest of the business world is happening in medicine.  I am addressed by my first name in the vast majority of transactions I undertake as a customer, almost always by people who don't know me.  Perhaps the "Doctor" title is yet another casualty of that blurring.  I would, however, argue against allowing the traditional cues of our professional identity to erode.

Unlike most other businesses and professions, we physicians have a sacred contract with our patients.  They allow us into the most private and intimate details of their lives.  In return, we pledge to maintain stringent professional boundaries related to our behavior and give them the best of our intellect and compassion.  Being addressed as "Doctor" is a constant reminder to me - and to everyone I interact with - of the oath I took to fulfill that pledge.

Please hold me accountable, and keep calling me "Doctor."

Sunday, January 9, 2011

Showers of expectations

I think that I am missing a gene from one of my X chromosomes.

I attended my sister-in-law's baby shower yesterday.  I love my sister-in-law dearly and was happy to be there to support her.  If only I could have supported her in another way.

I detest showers.  Once I was engaged, I stated clearly to everyone I knew that I did not, under any circumstances, want a bridal shower.  Naturally, everyone assumed I was just being humble or something, and I ended up with three of them.

Apparently, women enjoy playing games like "watch the bride stuff marshmallows into her mouth for every question she gets wrong about her fiance" or "guess the candy bar smushed up in the diaper to represent baby poo."  Not to mention that the sitting-in-front-of people-unwrapping-presents felt just as awkward as I had imagined when it was my turn to do it (three times).   I continually reminded myself that the people who threw me these showers sincerely cared for me and were just following societal norms; the abnormality was me.

Don't get me wrong; I am happily married and hoping to be a mother someday.  But, I don't feel compelled to rush over to every baby I see and "goo" and "coo."  I think patting and rubbing other women's pregnant abdomens is a reprehensible lack of respect for the pregnant lady's personal space.  I am exponentially more interested in health behavior theory, our hypertension METRIC project, and the data behind that new Pradaxa than I am in cooking and baking.

Please note, also, that I have the utmost respect for cooks and bakers!  Secretly, I wish that I was more interested in cooking and baking; I'd probably be better at both tasks if I was, for one thing.  And, if I shared these interests the way I'm "supposed to," maybe I would fit in with the other guests at the bridal and baby showers I attend, at family gatherings, in church ladies' groups.  Instead, I am made keenly aware of my different-ness, which, when viewed with the consistency of countless events over countless years, starts to feel like deficiency.

Did my medical career seduce me away from these interests?  Or, did my inherent lack of interest in them make it easier to choose a demanding career?

I would like to feel that it's 2011, and gender roles are much more fluid than even twenty years ago.  I would like to feel that I am not less of a woman for not enjoying all things domestic, that a woman can be anything and anybody that she chooses. I would like to feel that it's okay to just be myself.

Today, though, I'm feeling that I'd better give another go at that Betty Crocker cookbook instead.

Thursday, January 6, 2011

Why is relaxing so hard?

Well, the Singing Pen is back after a much-needed holiday hiatus. 

The end of 2010 found me tired and "toxic" (an adjective from my med school days for burn-out).  I love my job and feel so fortunate to be an academic family physician, but the juggling act of my responsibilities was wearing me down.  I was overdue for a vacation and eagerly looked forward to this one.

I have come to expect that it takes me a minimum of 48 hours into a vacation to truly begin to relax, but I wish it didn't take so long.  I want to be able to turn my work mindset off and on like a switch.  That magic switch would allow me to maximally enjoy my vacations, as I'd be in the right frame of mind from the outset! 

But, no, instead I spend the first couple of days consumed with the restless feeling that I should be doing "something."  Knowing that I need to relax, I force myself to sit with a book or get in the jet-spray bathtub, but somehow I always find myself distracted by something else to do.  The "something else" is always some trivial domestic chore or errand (or, to my wonderfully patient husband's dismay, occasional furniture rearranging).  Gradually, the intervals between distractions lengthen, and I catch myself happily unwilling to "work" on anything at all by day 2 or 3 of the vacation.

I also completely unplug from e-mail, Facebook, Twitter, the blogosphere, etc. for the entire duration of my times away.  It's not that I regard all things electronic as negative and intrusive (quite the opposite, actually!), but they do cost mental energy to interact with.  I don't mind returning to an overflowing e-mail bin, and the benefits of a few days' introspection and rest are completely worth it to me.

I would welcome your thoughts on relaxation and physician wellness.  And, if anyone knows of a "magic switch," please let me know!  :)

My sincerest wishes to you for a healthy and balanced 2011.