Shadowing

Yesterday, I spent the morning shadowing my colleague while he saw patients in our clinic. The goal was for me to learn how one doctor manages the flow of a busy clinic while still providing good care to patients and addresses all their issues.

I love shadowing. In residency, we rarely shadowed our colleagues or faculty. Life was too busy, too scheduled, too chaotic. We de facto shadowed specialists in their clinics on some rotations, but I had no personal investment in their practices, I didn't have to do their jobs.

Shadowing colleagues in my own clinic is different. Watching doctors with strong medical and communication skills, working efficiently with complex cases, is inspiring. In my post yesterday, I hinted at how a visit can get bogged down in chart review, and that there appears to be a better way to use the electronic record, on a screen, to engage with patients.

What I observed in shadowing this week was a great demonstration about how to use the screen as a visual aid in addressing concerns. There seem to be a few guiding principles I should follow:

1. Turn the screen toward the patient! What I can see, my patient should see. It's their health record, no secrets.

2. Exhaust the patient's list of concerns ("What's on your mind today? What else? And what else?" Until the answer is "that's it.") This I learned in medical school and residency. But now I'm learning to make sure I note it in the chart when the patient brings it up. I put their list on the screen for us both to see: our agenda.

3. Ask permission to go through their problem list (these are the things the patient is currently dealing with, things we should check in about frequently) to make sure it looks right. Patients who use our online service can view their problem lists at home. I also ask if we can look at the medication list on the screen, make sure patients know exactly what they're taking and what the meds are for.

4. Update lists and important information in the room, with the patient. It would be easy to think that this is a waste of time, especially when visits a stacked every 20 minutes or so, but I think patients appreciate it, and as we tend this clinical data, we're talking about a lot of health issues. The list work just gets us started and help us cover a lot of important ground.

5. Get it done now. I had a patient ask if he should take an antibiotic before his upcoming surgery. I told him I didn't know, but we should ask his surgeon. So we did, right away. I sent an email to his surgeon and the task was done. Or started, at least (we'll need an answer).

6. Summarize! Doctors review plans with patients all the time. Then both doctors and patients forget. Our electronic record has a very nice after-visit summary function into which I can type patient instructions, which I do in the form of a brief letter, noting what we agreed to during our visit. Again, I write this while the patient watches (I type fast), then review it with the patient to make sure I got it right. I print it and give it to them as I walk with them down the hall.

I'm sure there are more principles I can generate, but I'll stop there. It's getting late.

But before I go, one more word about shadowing. I learn so much from watching others do what I do. This was true when I was an actor, and it's true in medicine (also a performance of sorts). I think healthy medical practices should all encourage regular shadowing of colleagues so docs can pick up (and demonstrate) good habits and not get stuck in their settled inclinations.

Like Chauncey Gardner, I like to watch. I think we all should.

Work: A New Job

This is tardy. Apologies.

I have this new job. I've had it since last December, actually, but I just started last week, after several wonderful weeks of summer. My job is with Group Health Cooperative, as a family doctor in the Burien clinic.

"Burien," most people say, "why on earth would you go to Burien to work?"

It's my dream job. That's what I thought when I took it, that's what I think now. What's happening there is what should be happening all over the nation. We're practicing a new model of primary care, the "Medical Home," with a goal to be the model clinic on which others build their own practices.

But I can't really help my colleagues spark a health care renaissance until I learn where the bathrooms are, so I'm taking it slow, and I'm grateful that others are dedicated to transitioning me to my job in a humane, rational way. It's a complicated system.

I started last week with several days of orientation: benefits for a day, the electronic medical record (EMR) for two days, and a day of finding the bathrooms and learning how things work in my clinic. On day five, last Friday, I saw my first post-residency patient. Practicing on my very own license.

Yikes.

The support is wonderful, though. The co-op has a great consultation process, using secure email, through which I can ask specialists to comment on the care I'm giving. A quick question with the chart "attached" (we all use the same medical record), and within a day I have recommendations to help guide the care I'm giving. It's great, and helps me to continue learning at a rapid pace.

I've been seeing patients at a slower rate than my much more experienced colleagues, and for this I am grateful. I use the extra time I have to get used to the logistics of delivering care in a new place that is part of a big, complicated, but effective network of resources. It's not always intuitive how to get something done. I use every minute I've got learning how to be more thorough and more efficient.

One of my big challenges--one I'm thrilled to take on--is to integrate technology (our EMR) into visits in a way that engages patients and doesn't shut them out. Often, even with paper charts, the visit can become a kind of one-on-one between doctor and chart, with patients pushed aside while doctors dig for old notes, labs, and results to try to make sense of the patient sitting in front of them. In residency, I had many moments like this, me looking for a mammogram result while the patient looked at me looking down into a mess of paper.

I could easily make the same mistake, though at least it would be a paperless offense. What I've learned though shadowing one of my partners is to use the EMR with the patient to be more thorough, cover every concern the patient brings, and finish the work of coordinating and documenting care before seeing the next patient.

For those readers who don't have to chart for a living, I'll just say that's a huge accomplishment. The norm in primary care is "batch and cue," meaning a doctor finishes seeing a patient and puts the work generated by that visit into a cue--or a pile--to complete at the end of the morning, the day, or even later.

Trouble is, how do we remember everything that happened in the visit? We don't. We start forgetting things the moment the visit ends, and if we don't get to the work (making notes, writing orders, reviewing results) quickly, important things fall out of our heads, and things get left undone. Not good for patient care. Not good for clinic employees. Not good for families of clinic employees.

"Today's work today" is the buzz I've heard among the new model folks. What I'm learning at Group Health is even more immediate: something like "this moment's work this moment." Whatever our patients bring to discuss, we can work on it now.

We have powerful tools available to help us accomplish this, and I hope to write more about these tools and my experience as I learn (I'll bundle these under the label "work").

For now I'll say this. I am happy.

News flash. Naked bicyclists...in Seward Park!

Gun salesman?

I've been getting a lot of wrong number calls on my cell phone these days. One voice mail last week was from the billing office of a local clinic, responding to a call about overdue medical bills (I'm current, wasn't for me). No biggie.

This morning I found my phone, lost for the last couple of days, and retrieved a message from someone wanting to pick up the "military 38" he had bid on over the weekend.

That's a gun, right?

I don't make a habit of calling back wrong numbers (as some have done to me: "Who's this? Why did you call me? What do you want? Don't call again."), and I think I'm going to hang on to that policy.

Cancer in the South End?

I posted this to my neighborhood blog this morning, and thought I'd put it here, too, mostly so my mom can see how I'm spending my vacation.

There has been some buzz in the press and local blogs this week about the recently-released Agency for Toxic Substances and Disease Registry study, which finds, according to the P-I article published in this morning's print edition, that:

Residents of a broad swath of South Seattle from Seward Park to West Seattle face elevated cancer risks because of air pollution, according to a soon-to-be released government study.

The risks are significantly elevated in pockets of industrial pollution – and skyrocket within about 200 yards of highways, says the long-awaited study by state and federal scientists.

The affected areas are shown in the map I've grabbed from the P-I article, and risks appear highest, theoretically, in the industrial areas around Georgetown, which get pollution from factories, roads, and airplanes.

I decided to bring the study to the Colman Triangle blog because of the red, high-risk areas on the map at the north end of the Triangle (at I-90). I read the P-I article, and was curious, so I dove into the ATSDR report for more information, which I think is worth sharing.

Non-Cancer Risks

The press has focused on cancer, which I'll get to below, but the freeway at the north end of our neighborhood offers more hazards to our health. The bulk of non-cancer risks come from a chemical called acrolein, with exposure coming from car exhaust and cigarette smoke (note, are you still shopping for reasons to quit smoking?). From the report (bold type by me):

Similar to cancer risk, non-cancer hazards are highest near major roadways. Hazard indices decrease with distance from the center of highways, but exceed one (meaning risk is greater than baseline) up to a few hundred meters on either side of major highways. Acrolein is the primary contaminant associated with non-cancer hazards from road sources. The following four pollutants are the main contributors to non-cancer hazards from mobile sources in descending order.

• Acrolein
• Formaldehyde
• Diesel Engine Exhaust, Particulate Matter
• Nitrogen Dioxide

I've linked three of the agents above to the ATSDR info sheets about them. There aren't any well-defined cancer risks to these pollutants, but they do make breathing unpleasant and can affect folks with lung disease (asthma, COPD...) and children more than the rest of us.

Cancer Risks

There are a few things floating around the Colman Triangle that bring an increased cancer risk. From the report:

Diesel particulate matter, benzene, and 1,3-butadiene are the chemicals that contribute to the bulk of risk.

What kinds of cancer, you ask? Benzene is associated with leukemia (and anemia; benzene suppresses bone marrow production of red blood cells), while 1,3 butadiene appears to be associated with a "variety of tumor types."

Keep in mind that cancer results from long-term exposure, and that there are many other, non-cancer but unpleasant effects from shorter-term exposures (follow the links to read about these).

What to make of this?

I'm not a toxicologist or epidemiologist, so my ability to interpret the ATSDR study is limited to my training as a regular old physician (family doctor) and concerned citizen with two kids whose well-being I cherish more than my own. From what I've read, here's what I take away:

1. Our little neighborhood sits just south of a major interstate with tons of diesel traffic passing through, leaving us with a variety of pollutants in our air, water, and soil. The risk of toxic exposure drops with distance from the freeway (it's about 200 meters from the center of I-90 to Massachusetts), but risks still exist beyond the "red zone." We're also bounded to our west and east by Rainier and MLK, which carry plenty of pollutant-spewing trucks and cars.
2. Most of I-90 is covered in our neighborhood, which is nice. But...what happens to the pollution in the tunnel? Where does it go? The risk map is red even in the lidded areas.
   
3. Kids and the chronically ill, as usual, have it worse than the rest of us.
4. Cancer is bad, for sure, but anemia, birth defects, and lung disease are also significant effects of the pollutants found in the ATSDR study, and are likely to ruin your good time before cancer creeps in.
   
5. Smoking is still stupid. This study reminds me that smoking tobacco is similar to wrapping your mouth around the exhaust pipe of a running diesel engine.
6. The "fixes" to the problem are mostly to be found in rational public policy. Pollution standards for automobiles and factories should be designed to prevent disease and should be vigorously enforced. In our neighborhood, we can advocate for safe practices from our industrial neighbors (most of the Triangle is zoned for commercial and residential, creating a potential mini-Georgetown effect).

Those are my reflections. I look forward to comments and face-to-face discussions around the neighborhood.

Crossposted

Zero across the board

Here's a screen shot of the King County West Nile Virus surveillance report that landed in my mailbox this morning. It's like a no-hitter going into the seventh inning.

Washington state has been pretty lucky with West Nile thus far. We've presumed the virus would arrive here, in humans, sooner or later. Look at the 2007 CDC reporting map:


We totally lucked out (unless you're among the bird or animal cases noted), an island of gray in a sea of orange. Gray is my favorite color. So far this year we're free even of animal, bird, or mosquito cases (in King County, the state has animal/bird/insect cases).

But check out Oregon. Nothing across the state. Good year to be a bird there.

So I guess the next fever I see in clinic (once this luxurious six weeks of vacation is over--next week) is just a fever, or at least not West Nile.

Not a Blue Angels fan

But he tolerated today's show pretty well. Yagi's biggest concern was the curious chihuahua and some Cheerios some kid dropped while watching the planes.

Blue Angels fans

Here's a portion of the crowd that gathered atop the ridge over I-90 to watch the Blue Angels practice show. They got to see several direct flyovers from this viewpoint.