Order Sets & the Art of Medicine

When I was part of Jeff Neilson's illustrious Informatics Research panel at SAEM in Dallas this past spring (we were recently invited back for San Diego next year) I spoke on the topic of simple clinical decision support projects, particularly evidence-based order sets. I also talked about incorporating clinical calculators into orders, so trainees could enter discrete patient data into the EHR and see if the test they were considering was appropriate.

These are feasible research projects that can have measurable impacts in utilization or even care, don't require big budgets, and can be done in a resident-friendly timeframe. 

There was a question from the audience. Someone wanted to know if order sets and clinical calculators were antithetical to the idea of resident education - that organizing tests and meds by complaint, and building calculators into the EHR, made it too easy to be a doctor. Might we consider abandoning order sets and focusing on memorizing doses and appropriate indications for tests? By focusing on these things, were we failing to train doctors in the Art of Medicine? 

I was surprised by the question. Perhaps it's because I'm in a bubble - surrounded by colleagues who know as much (or more) than me about patient safety, bedside teaching, EHR usability, and evidence-based guidelines for care. 

I don't remember exactly how I responded. I said something about how order sets and clinical calculators are here to stay, unquestionably reduce errors, improve efficiency and encourage appropriate resource utilization (when implemented well) and the only challenge remaining is making them as current and easy-to-use as possible. 

That was a start, but I should have also pointed the audience member to the Checklist Manifesto, which covers the evidence, obstacles and psychology behind getting doctors to put their ego aside, be humble and make sure everything worth doing is getting done. After all, there was probably a time where pilots complained about losing the artistry of flying, but the public cared about their planes not crashing. Similarly, in an era where we are trying to get 100% compliance on core measures, when we're asked to do more, and see more, with less time and less support, it's imperative we make the EHR work for us as best it can. 

The Art of Medicine may have once involved regaling patients and staff with feats of memory; now it seems more appropriately about forming a fast rapport with patients, and explaining Bayesian algorithms for risk stratification. Let computers do what they're good at - lists and calculators - and let doctors have meaningful conversations with patients. This seems like the new state of the Art. 

Modern convenience

I'm glad some people choose to share their health data - be it RunKeeper routes and times, or WiThings weights or blood pressures, or the latest Quantified Self device. There's certainly evidence that social pressure can promote real change in people's lives.

It's just not for me. At least, not at this time.

But I'm finding the problem with these modern fitness apps is, they're each in a deadly competition for VC funding, for market share, for app store rankings. So they're under huge pressure to grow their user base - and that means, increasingly, pestering users to access one's contacts and one's social feeds.

So now, if I want to use RunKeeper, I've got to tap through all these social popups, to decline to share my info, after each run.

Is there a way I can just spend a few dollars to not be annoyed by my own software? I loved the Moves app, which was elegant and minimalist, and with its one-time up-front fee, didn't pester me with sharing popups. But then it was bought by Facebook - so it's likely my data's available for sharing, despite my efforts.

Folks used to argue that Apple could charge a premium for Macs because you were paying to eliminate cruft - so that you didn't have a desktop full of AOL, MSN, or other unwanted services. 

Now, with Google and Facebook matching Apple in terms of sleek design, the premium is simply going to be privacy, and lack of social prompts. 

Coming down on The Night Shift

I've been reviewing episodes of NBC's The Night Shift for EPMonthly. Specifically, I took the pilot, then episodes 5-8, while Dr. Aaron Bright handled episodes 2, 3 and 4.

It's not a good show. The plot twists are predictable. The characters are mostly caricatures. Worst of all, to me, is that the medicine is awful - it's absolutely impossible for an emergency physician to say, "We manage patients like that," or "That's what my job is like."

But I understand there are fans of the show. A lot of them. And they may want a collection of our medical impressions. So, here you go:

Episode 1 - Pilot
Episode 2 - "Second Chances"
Episode 3 - "Hog Wild"
Episode 4 - "Grace Under Fire"
Episode 5 - "Storm Watch"
Episode 6 - "Coming Home"
Episode 7 - "Blood Brothers"
Episode 8 - "Save Me"

Greg Henry also chimed in, with his opinion.

If you're looking for one episode to hate-watch, make it Episode 5, where a storm causes a power outage, a main character delivers his twins in the rain (one is breech!), another main character confronts her father in ED after he gets stabbed, and another ED doc does everything for a patient, taking her from he wrecked home, via ambulance, all the way to the OR - without ever actually working in the ED. This is a typical episode, but is notable because it was directed by "ER" alum Eriq La Salle, and because it features the most 'progress' in the show's marquee romance (an ill-advised, childish affair).

If you're looking for their best episode, make it #6, the only time a major character had a real arc, making difficult decisions, facing consequences. All the other "drama" on this show is how characters respond to the unbelievable stuff that rolls into the ED (spoiler alert: they respond with grit and determination and occasionally, flashbacks to the war).

From my ep 1 review:
Sadly, however, it's been twenty years since "ER" debuted on NBC, and this show seems like a giant step backwards for medicine on television. It probably won't do much for public perception of emergency medicine either. Sure, "ER" had some unbelievable scenarios, particularly in the later years, but there was always a healthy volume of bread-and-butter cases, and it was clear the writers took pains to portray the medicine, procedures and specialities accurately. On "ER" you'd take it for granted that the doc would call out the right meds, do the right procedure, and hand-off to the right specialist if needed. On "The Night Shift," everyone seems trained to do everything (because, Afghanistan?) and very little feels right about the resuscitations. And the characters on "ER" had more depth and nuanced relationships than the broad brushstrokes we saw last night. 
From the season finale:

It’s genuinely discouraging to know millions of people are watching this show, and seeing the most outrageous caricatures of emergency care. A bunch of EPs joined me in live-tweeting the show and our impressions - mostly eye-rolling, snark and cringing - were in stark contrast to the praise coming in from most tweeters using the #NightShift hashtag. 
We used to fret that patients would develop unrealistic expectations, when in-hospital cardiac arrest survival rate on 90’s TV shows was higher than real life. Now we must contend with the expectation that any EP can perform any surgery in any setting, or the most serious and spectacular injuries are routinely encountered, and usually survivable with minimal complications after a few hours. And I’m still waiting for evidence that the job “Overnight Onsite Administrator” and “Chief of the Night Shift” are jobs that exist, anywhere. 
All this medical fiction may be worth it, if was in the service of telling good stories. But all the characters - despite their unbelievable medical abilities - are rarely driving the action. Stuff comes into the ED, and the cast responds. I can only think of one episode where a main character chose a course that was personally difficult, and grew as a result. Instead, the writers usually substitute medical feats for character development - somehow thinking that, if the doctor sweats a bit before performing a miracle, the audience will relate. 
So here’s hoping for season 2 to be more grounded in medical reality, which will give some breathing room for the characters to grow and develop - and not just react.

It occurs to me our profession, and viewers, would be better off if NBC just aired EPMonthly's own Mark Plaster reading his "Night Shift" columns.  That's as accurate a portrayal of our job as any, and the protagonist actually thinks and grows over time. But apparently that's too much to ask from a big budget network show.

No doubt

I've been a proponent of social media for over a decade. Broadly distributing the tools for sharing one's thoughts just seemed like it would lead to better communication, more understanding - and would improve the culture.

When apps like Secret and Whisper appeared, I dismissed them as a aberrations; deliberately incomplete tools that provided some brief novelty but were fundamentally unserious. These apps seemed to be built around gossip, and provided no actionable information to users. No links to useful resources. No identity. It's as if someone took Twitter's biggest problems - difficulties with authenticity, a preponderance of trivia - and branded them as features.

But it doesn't take more than a few minutes reading user comments on any news (or recipe) site to see that authenticity, and discussing serious issues, is not working out as well as hoped. Years ago I wondered if tying online comments to one's identity would improve discourse - it's clear now that's not the case.

Instead of enabling broader understanding, social media tools have led to polarization and closed-mindedness. Social networks serve as an echo-chamber, reinforcing existing beliefs and promoting orthodoxy. No amount of evidence convinces people of anything, anymore, because someone in the network will always offer comforting, alternative interpretations of new facts, and no one wants to show weakness amongst their peer group.

But apps - 'networks' - like Secret can counter the self-assuredness and conformity that exists now in social networks. Because when I spend a few minutes on Secret, I come away questioning some assumptions, and reflecting on the writers' perspectives. It's regrettable that this questioning, this doubt, is something that has gradually disappeared from my other feeds. I only wish there was a way to re-integrate this humility back into non-anonyous social networks; Secret and its ilk exist entirely apart from the web, without standard tools for archiving or research.

I think we can all agree, though, that the Yo app is dumb.

Everything in its right place

I once chided my med school roommate for entering dozens of numbers into his landline phone's high-capacity speed-dialer. After programming a few frequently-dialed numbers, I argued, you'll end up wasting more time entering digits than you could ever save through speed-dailing - the effort outweighed the benefit.

He had a lengthy response, that appealed to a sense of order and touted the less-tangible benefits of reducing cognitive load. The phone is for calling people. By having people's numbers in the phone, instead of in a half-dozen notepads and desk drawers scattered about the apartment, he could make calls without much fuss. He didn't have to remember whose numbers resided where. He could unburden his mind to focus on other (presumably more involved) tasks.

I was still a little skeptical (why not keep a list of numbers by the phone?) but saw his point. And it's colored my organizational decisions ever since - especially since Allen's Getting Things Done places such high priority on reducing the mental stress associated with reminders - to improve clarity, creativity and fulfillment.

So for years I've used organizational schemes, mostly centered around smartphone apps like Remember the Milk and Evernote, and email management tools like Mailbox. When I heard about other folks spending substantial amounts of cash for things like OmniFocus, which had a huge instruction manual, I shook my head. It was my roommate's old problem - investing too much in organization, for little actual measurable benefit. These people were shelling out money and spending hours on discussion forums and blogs ... to talk about reminder lists? Optimize their organizational software? Why not use that time to, you know, get stuff done?

Well, things change, and work got hectic, and my system was growing unwieldy. I had switched to Apple's iOS Reminders, because I could quickly ask Siri to remind me about things that occurred to me, and her transcription was usually good enough to give me the gist, later. And it would sync with other Reminders, in the cloud. As far as systems go, Reminders was pretty basic - but I didn't think that any other system could tap into Siri.

Things had come to a head - then I heard OmniFocus had a workaround for Siri. I was ready to take the plunge.

It's been as engrossing as I've feared - but kind of exhilarating, too. The software is slick and well designed, especially the mobile apps and the new OS X OmniFocus 2. And as I've learned the experts' opinions on Contexts vs Perspectives, Deferring vs Due Dates, well, I've rationalized that complex problems often require sophisticated solutions.

I do feel more on top of things, or at least, unstressed enough to indulge in some blogging for the first time in ages. And while I haven't commented on any discussion forums - yet - I do find myself browsing them for tips and insights.

When Extensions for iOS 8 was announced, I found myself hoping there'd be a quick way to generate OmniFocus tasks from Mail or Mailbox on my phone (and no, Dispatch doesn't count, and the existing mail-to-OmniFocus feature isn't ideal). And I'm waiting for the Mailbox desktop version (wouldn't that be so serene? where's my beta invite?)

Alas. Like many things, it's easy to go overboard. Better to remind myself that these tools exist to serve a purpose, and are not an end unto themselves.

You can go FOAM again

Last month I got on stage at SAEM's Annual Meeting, and said (among other things) that excelling at medical education through social networks was a calling - one that I didn't hear. Despite being an early adopter of social media for EM education, it's clear when you look at the best exemplars of #FOAMed that there's a passion behind what they do. Just look at the prodigious output and quality at sites like ALiEM or Emcrit, for instance.

And while I've lodged some criticisms of #FOAMed (in the pages of EPMonthly and in a Skeptic's Guide to Emergency Medicine podcast), it's mostly because they've been so successful in teaching their areas of expertise that they risk crowding out EM core content. You can't blame the listeners, though - who wouldn't rather spend a few hours listening to experts discussing the finer points of critical care, instead of reading vanilla core content written in a scholarly, passive voice?

But I'm not trying to continue this debate - just point out that I think #FOAMed is evolving.

I say this because I noticed my name come up in #FOAMed circles - in ways that weren't tied to criticism.

First, the excellent EMLyceum just hosted a discussion about monarticular arthritis, and referenced our review of the topic (coauthored by Makini Chisolm-Straker) in EMPractice a few years back. And last week Sinai EM resident Jeremy Faust dropped me a line, letting me know his FOAMcast with Lauren Westafer was covering liver emergencies, and would touch on some points from my recent CDM presentation. It was posted online today.

Of course, most social med-ed content was well-referenced before now, and many sources feature guest experts in their blogs or podcasts. But I consider it a good sign that these smart, talented, passionate teachers are reaching out and including content from folks like me - who write the occasional review article, or present some core content material at a CME conference.

I'd call it a sign of a maturing community. The professional level of writing and speaking that has characterized much of EM FOAMed will certainly continue, but the content seems to be broadening beyond the interests of its practitioners. That's good for the listeners still in training, and I think it's also good for the #FOAMed movement itself, as it develops beyond a hobby to a true academic pursuit.