play by play

Monday, January 1, 2018

Can you do play-by-play? Can you be Vin Scully or Mike Emrick, telling stories so that your audience can understand through your words, what your eyes are seeing? Every family has a great storyteller, but in the real world, it’s tough to explain complicated situations in just a few words. Imagine if your health depended upon that skill. Now, imagine 12 seconds.

You get 12 seconds to tell your story. If you’re lucky you get 18.  That’s the average time before your doctor will interrupt you as you tell the story of why you’re visiting. In that time, you have to describe your situation, frame what’s going on and explain your worries and fears. And while you’re doing your play-by-play, the doctor could be planning what happens for the rest of your life. Miscommunication may lead to confusion, inappropriate tests and errors in diagnosis and treatment. How good are you at play-by-play?

Imagine falling and being brought by ambulance to the ER. You would think that the nurses and doctors would know why you’re there, but they ask anyway. Everybody in the room, patient, family, nurse and doctor knows that you fell.

The story lines

  • The patient wants to tell you that they hurt their hip and can’t walk because of pain.
  • The family wants you to make the family member comfortable.
  • The nurse has numerous responsibilities including asking whether the patient feels safe at home.
  • The doctor may want to know why the fall happened.

Consider a couple of stories. It’s one consideration if the patient tripped on a loose mat in the bathroom and fell. It’s a totally different situation, if the patient passed out and then fell. Instead of an isolated hip injury, the focus switches to why a person would lose consciousness. Was it a stroke? How about a heart rhythm disturbance? If they were diabetic, was their blood sugar too low?

And perhaps the patient hit their head and can’t remember what happened. It’s all detective work. Then medication lists matter. If they are on a blood thinner, the big worry is bleeding within the skull brain, and a neurologic exam checking out the brain might be the priority.

“But I hurt my hip, not my brain!” It’s difficult when patient/family priorities and expectations are different than those of the doctor. And sometimes, the original reason for the visit can get lost. Ideally, the patient also gets to interrupt the doctor to make certain their both on the same page. There is somewhat of a power imbalance and patients may not like making that interruption.

Years ago, Dr. Jonathan Gilbert, a professor of medicine at the University of Alberta, would gently, and sometimes not so gently, remind his students that history was the key to diagnosis. His philosophy was that if the diagnosis couldn’t be made after talking to the patient, then the physical exam, lab tests and x-rays would be less than helpful. Dr. Gilbert was able to ask just the right questions and listened intently to the answers. The patient would lead him to the diagnosis, the physical exam would add to his suspicions and any tests would confirm the final answer.

That was a generation ago. His world was not ruled by 12 seconds and patient visits lasted more than the average of today’s 11 minutes. Allowing the patient to speak unfettered doesn’t fit into that time frame and interruptions are a technique used to direct the conversation to the specific questions that the doctor wants answered. Hopefully, those questions will be the same as the patient’s.

Planning

Play-by-play is hard. It takes hours of preparation and study to learn about the players on each team, their coaching philosophies and what to expect as the game starts. People need to plan for their doctor appointments as well as announcers plan for their game.

  • Why are you seeing the doctor?
  • What one or two problems do you specifically want addressed?
  • If the office has the capability, email ahead of time and let them know your needs.

Even a routine visit to recheck a chronic problem might be derailed if the patient brings up a concern that wasn’t expected. Unless an urgent intervention is needed, the doctor has two options. One is to deal with any and all concerns, knowing that the time spent will be taken from another patient, or the second is to ask the patient to schedule another appointment to deal with the unexpected concern.

Emergency visits are tougher because one usually doesn’t routinely plan for emergencies. Don’t expect your medical record to be always available. Even with electronic health records, systems can be down for maintenance, computers can crash and different electronic record systems don’t talk to each other. The medical world still depends on photocopying and faxing. But be prepared and carry these things, all the time.

Medical information list

  • Know your medical history.
  • Make a list of your diagnoses and previous operations
  • Have a list of your current medications
  • If you’ve had an EKG, keep a copy of the most recent tracing.Know the contact numbers for your doctor’s office and your hospital.

It’s the new year. Learn a new skill. The best play-by-play announcers have lots of notes and refer to them routinely. They can paint pictures with their words so that their audiences understand what’s going on. Become the next Vin Scully or Mike Emrick.

 

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diagnostic errors

Monday, May 18, 2015

It’s the spectacular play that makes the highlight package on Sportscenter. Fans can be amazed at the amazing catch or incredible shot. But at the end of the day, it’s mistakes that lose games and cost championships. Sometimes, it’s the referee or umpire who misses a call and is blamed for adversity. The solution often offered is technology with instant replay, slow motion and multiple camera angles to oversee what had been judged in the blink of an eye. Victors are those who avoid the most mistakes and take advantage of the errors of their opponents.

It is not widely publicized, but mistakes happen in medicine and at an alarming rate. There is a presumption, by patient and family, that technology decreases the risk of errors and makes for better care. That line of thinking opens a Pandora’s box of wrong. Some doctors feel obligated to order tests to confirm their clinical suspicions. Some suffer from a lack of confidence to stand by their bedside decisions. Others believe that ordering a test will decrease their perceived risk of being sued, the concept of “covering their butt”. And sometimes, tests are ordered because families want the reassurance of technology, since blood tests and x-rays can be tangible proof that all is well…except those tests are only as good as their interpretation, done by a radiologist or pathologist who is an anonymous, faceless provider. All the doctor or patient sees are the results on a computer screen. After all, if it’s in the computer, it must be true.

But mistakes happen and at a relatively high rate. X-ray results aren’t always perfect and different radiologists can interpret the same picture in different ways. When reviewing a radiologist’s reports, the error rate can range between 3 and 3.5%. More complicated studies like CT, MRI and ultrasound can have error rates as high as 7%. Interestingly, if one asks more than one radiologist to read a film, the resulting discrepancy rate can run higher than 30%, meaning they don’t agree with each other a third of the time. But that does not necessarily lead to patient harm, because any test result needs to be interpreted in the context of the bedside assessment of the patient.

The key begins with ordering the test in the first place. There needs to be an expectation that the extra information will be a decision maker for the doctor when it comes to diagnosis and treatment. There needs to be a plan of action for each positive or negative result. Blood tests can be very reassuring when they are normal, except when there are false positives and false negatives. The doctor needs to understand the limitations of each blood test and not be falsely reassured when a test comes back normal, only because it was drawn too early in the disease process…or too late. Imagine taking a pregnancy test immediately after intercourse, knowing that it is too early to turn positive, and yet relying on that result for the next none months.

No matter how much or how little technology is used, getting the right diagnosis is tough. Studies from Johns Hopkins estimate 80,000-180,000 patients in the US are harmed each year because of diagnostic errors. Most happen in the doctor’s office as opposed to the hospital and most are due to a missed diagnosis, rather than a delayed or wrong one. Which brings the discussion back to using technology as a crutch instead of a tool.

Diagnosis is based on history. The patient will tell the doctor what’s wrong if the doctor has time to listen, ask the right questions and interpret the answers. Patients and families are often frustrated when the same questions are repeatedly asked by the person who escorts them to the exam room, the nurse who takes their vital signs and the doctor who seems to be in too much of a hurry to really listen. Each listener can interpret an answer in a different way, and nuance can be helpful in pointing the doctor in the right direction to make a diagnosis. Physical exam is helpful but the guiding light tends to be the history, the old fashioned sitting down and talking to the patient. Diagnosis may be self evident but most often it takes time.

Errors will happen in sports and in the doctor’s office. Minimizing the number of errors should increase the chances of winning; the stakes are just a little higher for the patient. There is an art to diagnosis and technology offers few short cuts. For those who prefer computer algorithms in making a diagnosis, try asking a computer to assess the wife’s face that frowns when her husband minimizes a complaint with that recognition leading to a new line of questioning and perhaps the right answer. Nobody said anything about talking needing words.

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