Doctors should write more medical notes

Let's face it - the dictaphone is OLD technology!Old habits are hard to brake. Many doctors are dependent on an old technology, the dictaphone, to create their notes despite many advantages of writing text themselves. Younger doctors, raised with laptops and smartphones in immediate reach, write as fast as they talk and wouldn't touch a dictaphone with a large pole.

I commonly hear from colleagues that they can’t imagine writing their own notes because “it’s stupid to have the most expensive workforce doing secretary work” Some argue that they write too slowly and have better things to do than learn typewriting.

So let's look into this, how come some doctors write almost all their notes, what is it that we "writers" have found out?

A medical note contains all relevant information for a patient case and is highly valuable to all caregivers, a little like the black box in airplanes. The note contains details which are easily left out in verbal reports, everyone who has played the whispering game knows this. The emergency department is unique in that a huge amount of valuable information is collected, history of present illness, clinical examination etc. Lots of health personal will be taking care of the patient not only in your ED but the hospital as the patient is admitted. It's obvious that this information must be ready for others to view immediately.

Quality not quantity

Handover is dangerous stuffExperienced physicians know that patient handover is the most dangerous point in patient care as information is easily lost or skewed. Remember - up to 10% of admitted patients are victims to medical errors, the sixth biggest killer in USA! A high quality medical note accessible to all caregivers decreases morbidity and mortality.

Thus, unless your secretary transcribes your dictations immediately you should consider writing your notes.

Patient security is an important issue but as we writers have found out there is lots to gain for the doctor. Seeing text in front of you on the screen gives you much better overview of the case you are describing and helps making the note structured and appropriately detailed. As you learn more about your patient you can modify or add that information directly rather than battling the dictaphone to edit your previous recording. Dictating is mostly an passive activity while writing makes your brain crunch the details, evaluating the pieces bit by bit to create the bigger picture and final conclusions. Thus I feel much more confident in my written notes than those I've dictated.

Having a note immediately ready allows me to use parts of it to copy & paste into associated notes e.g. radiology or clinical request forms. Medical letters can be created instantly and sent away only minutes after the patient has left the ED. This save you the time and hazzle of reading through your note days or weeks later and keeps your list of unsigned documents empty. The feeling of leaving work without unsigned work waiting is truly awesome.

With the rise of e-Patients, a final and ready medical report can be handed directly to the patient who is then better informed and can then easier follow the treatment plan or advice given and therefor less likely to come back unneccessarily to the ED.

But I'm a slow writer!

Learning to write faster is easily achieved and has been covered earlier on this blog. By learning touch typing and doing some training you can easily pimp your typing speed about 1-200%, it's as easy as learning to ride a bike. By writing faster you will also gain great productivity boost in daily life as described in the post above.

Since you do a structurized clinical examination and review of systems, templates are great to describe those parts that are normal. There are lots of ways to do this, I have a special document in Google Drive (Docs) with my template texts, with copy & paste I can finish the clinical examination part in less than a minute.

Abbrevations are also a great way to boost your typing speed and learning the most common ones is time well spent.

Voice to speech recognition allows you to create text by speaking to your computer or smartphone. Medical jargon may not be so easily transcribed but increasingly more common are software tools which understand these too.

Finally - you can use the best of both. Write the most important important information such as HPI, clinical examination, assessment and plan and then finish the rest with the dictaphone. Have a Coke AND a Snickers!

Patients are reading your notes

The times they are changing indeed. The public increasingly demands all kinds of information to be open and freely accessed. Sweden is currently adding law giving patients the right to see their medical journals even before the doctor has read them through and signed. This of course has caused a stir amongst doctors but trials have been in patients' favor.

My guess is that in 20 years time we will look back and laugh at that medical records once were the doctor's secret. Of course the patient should be totally involved right from the beginning.

This trend is yet another reason for us to start writing more notes with higher quality content, not only for the benefit of our patients but also ourselves.

Surviving the terrible night-shifts

Too tired to eatNight shifts are dreadful. Even days before starting a week of night-shifts I feel my stomach beginning to turn upside and down. Hungering for sleep in the early morning hours, I'm almost in a dreamstate, careless as a sociopath, trying to stay alert while making important decisions that my patients’ life depends on. The last hours of the night-shift is one of my most terrible moments. There's only one way out of it - to stay awake and finish my work. And hope for the best.

Having done about 10 years of night-shifts in the ED I have tried many different tactics to make these a little easier. It seems there are indeed some things that work better than others and I wish someone had taught me these in my first years. Therefore I’d like to share my experiences with you.

The day before

Do lots of sports! Jog, bicycle, gym... 40-60 minutes of physical activity gives me the same amount of energy as a day-sleep. Also, being in good physical condition makes the difference of being a zombie in the ED or just a tired doc.

Avoid sleeping for longer time. I’ve tried all variants - long sleeps in the middle of the day and just before starting the shift. I’ve found out any nap longer than 30mins makes me tired already in the first hours of the shift. It’s like these utterly rare days when I manage to get ‘restoration sleep’ and sleep for 10 hours or longer... I feel energy-less and drowsy all day long when that happens. It is if my mind cannot wake up although my body has.

For this reason I’ve changed my tactics - more physical activity and less daytime sleeping. Crucial for this to work is to have had 8 hours of sleep after ending the last cycle.

Deep relaxation techniques. I’m habitually impatient and find it hard to do deep-relaxation as much as I’d like to do. But when it works I’ve found even as little as 20 minutes of deep relaxation to be equal to 1-2 hours of sleep and I feel much more energetic than if I’d slept. It is if some magical reset button is pressed and I’m not only physically more energetic but also mentally, especially when I manage to meditate also.

Enjoy a good podcast. Some podcasts from ED colleagues have made me so excited that I can’t wait to start my shift. A great example would be some the great ultrasound videos available which make me eager to try some amazing and new technique I've learned for new diagnostic approaches.
I'm not saying I start every night shift with goose-hairs... but a good podcast really helps me getting mentally prepared and reminds me I'm not the only one getting ready to stay awake a whole night. The worst night-shifts are those after being away from work for a longer time and suddenly thrown into the cage again. That’s when a good podcast while out jogging helps a whole lot.

In the lion-cage

Save the coffee for the last hours! Coffee is great but only when it’s timing is right. Too much coffee is as bad as no coffee. Thus I try to save it until the final hours, when I really need that energy boost to get it to the finish-line. But I also want to fall asleep when back home and even get a good, restoring sleep. That means no more coffee for the last 2-3 hours.
In an ideal night shift I would drink tea only. I’ve managed that maybe some 2-3 times and it felt good indeed. I hope you have more luck with that than I've had!

No heavy meals. Everyone feels tired after eating big and doing it in the middle of the night-shift is something I avoid - it’s like tying an anchor to my brain. I try to eat so that I feel just about full in the beginning of the shift, when my energy is at maximum, and then eat light meals in the night. I’d love to tell you I eat fruits and drink lots of water but the truth is I’m a candy junkie and I regularly break personal records in the early morning hours of a night shift. I try to stick to chocolate though - it makes my stomach less bloated and goes well with the coffee!

Move and stretch. This doesn’t have to be said, only reminded of! Taking 3 minutes to do a few arm bends, deep knee bends or just standing up on toes - these boost your circulation a little, enough to move the tired proteins away from your brain for a while. Even stretching helps.

Do power naps. When it’s as if I have zero energy left, I put all aside and do a power nap. I simply close my eyes and try to forget everything. Even as little as 5 minutes while sitting in front of the computer helps me to regain some energy to survive one more hour. Longer than that and my body enters sleep mode. A power nap is max 5-10 minutes.

If my caffeine level is too high a power nap is not an option. In that case sitting down and listening to one or two favorite songs with ear-buds can help a little. Music helps my mind draft away to other dimensions. It's all about coming up to the surface and inhale just a little fresh air. To get away from the night-shift just a little bit!
When the world is sleeping...Talk with the patients. I have a few extraordinary memories of conversations with patients in the middle of the night. After all, the night does have it's charm - the little things happening while the world is sleeping somehow have magic in them. There is something in the air that makes talking intimately easier. Patients smiling through their tears or telling about an amazing life-changing event gives me more energy than any power nap. I just have to remember to relax and listen. And so often these extra few minutes have revealed essential clues for the diagnosis and patients are much more tolerant to the tired ED doctor.

Finally

All in all - the more physical activity I can do the day or days before, the better my physical condition and the less sleeping-the-hours-before I do, the better I survive the terrors of a night-shift.

I’d love to have your night-shift tips - please share below!

Irvine ultrasound videos

Maybe this is how Youtube got a concussion?If you have in some way been involved in ultrasound you surely haven't missed hearing Chris Fox mentioned and his awesome ultrasound lectures. The Ultrasound podcast has made him appear as a god-like figure and judging from the work he's been putting into ultrasound teachings, I think they're absolutely right. You will not find any better ultrasound video tutorials in the Milky way!
Not only is his work great but he has shared them all for free. They have been available on Youtube and iTunes. Youtube got a concussion recently and thinks they're infringing copyrights and iTunes is not for all. That leaves one final option for downloading the lectures directly to your computer - the torrent system.


First of all, using torrents to share content is 100% legal, it is sharing copyright content which is not. Using torrents you will download from multiple sources instead of a single one, giving you much faster download speeds. A whoppy 10 gigabyte collection like Chris' ultrasound videos thus can easily be downloaded in 30-60mins.

First you'll need a torrent software client. uTorrent has a good reputation and has all the features needed, it's free so go and install it.

Then you need the torrent file which has the description of the contents and where to look for it. You could google something like "irvine ultrasound torrent" but there are some other similiar torrent files out there which do not include the whole 10gb package. Also, there are many bad torrent websites forcing ads and even bloatware on your computer, thus I recommend www.isohunt.com which I find better than the others and have used for a while. You can also download the file directly from my Dropbox here
 http://dl.dropbox.com/u/484919/Ultrasound%20Video%20Lectures%202011-2012-Uni%20of%20cal.torrent

That's all there is to it. Open the torrent file in uTorrent and it takes care of the rest. Remember, torrents live only as long as those who have already downloaded continue sharing them. Please keep your connection open, you can set a max upload rate in the torrent program so that your Internet connection isn't clogged.

A few shoutouts for productivity

These are some very interesting discoveries I've stumbled upon the recent weeks which I think may be useful to you.

Stereomood

http://www.stereomood.com
Stereomood is one of many Internet radio stations, providing free, streamed music. What makes Stereomood different is that you can choose the music channel appropriate for your mood. Thus you can listen to ambient background music for paper-work, inspiring drummy tunes for an energetic hour or just dreamy instrumental music while taking a nap. If you suddenly feel like jumping to the "opposite mood" there is a button for that, for example when returning to work after napping!

The mood tags are collaboratively done by the listeners so they are pretty natural and music rightly tagged most of the time.

Everytime you hear a tune that impresses you more than others you can "favorite it" for playing later. For all music there's a link to buy the tune or whole CD if you like the artist.

Finally, there's a smartphone app for both iPhone and Android.

TalkTyper

http://talktyper.com
Image from http://paulhami.edublogs.orgHere is a little gem that caught me by surprise as I didn't realise how easy it has become to translate speech to text now a days. Well, TalkTyper, does that exactly and it does it amazingly well. As you talk to the microphone sentences are converted to text almost instantly and collected in a mini-notepad.

You can select input language and all major languages are provided for and I expect the list to grow quickly as the web is in the background using a Google based speech to speech server. On a technical level, it is a built in Chrome feature (version 11 and above) being decorated with additional tools.

An excellent productivity tool worth knowing about!

Online XPS to PDF converter

http://xps2pdf.co.uk
Internet Explorer is notoriously stubborn, refusing to implement features users need. Printing a document to PDF file is one such feature, whereas Chrome allows you to just select "Save as PDF" as target printer. Explorer has a similiar feature but uses a Microsoft only technology called XPS instead of PDF. And most institutions force us to use Explorer. Thus, an online XPS to PDF converting tool was very much welcomed in my productivity link/tool collection.

Pixlr

http://pixlr.com
Image from http://www.thegeeksclub.comThis is the web-application of the century and should be topmost in this list but I've mentioned it already a few times. It's the one web-app I use almost everyday and is indespinsible while working with images or photos. It has all of Photoshop's most used features, it's free, it can sync your images with Google Drive or Picasa... its' totally amazing. If you haven't used it, you should now!

Finally,  a few IT tips

I love keyboard shortcuts as they make computer life so much easier - these are the latest I've discovered and definitely worth sharing!

Middle-mouse-clicking a link in your web-browser (Chrome and Firefox at least) will open it in a new tab. Also, middle-clicking an open tab closes it. So lovely!

While doing a Google search, you can anytime start writing again if you want to change your search - just start typing. No need to move mouse pointer to input field!

Impatient while scanning a Youtube video? There's a button for changing playback speed, you can play up to 2x times faster, great for example to quickly browse through a ultrasound tutorial you've seen before. Notice this works only in the HTML5 player, switch here if you're still using Flash.

A shocking blood gas!

A healthy young man comes to the ED after having being chased by the police, they say he'd ran for his life at least 1km after which they found him lying down, presumably unconscious. With all systems intact and stable vitals he's presumed to be faking (pseudocoma).

A quick glance in the ED reveals nothing new to refuse this theory - the patient has closed eyes and is extremily resistant to pain stimulation but has all reflexes intact (eg. gag, cornea-) and with eyes forced open he's looking straight forwards (to contrast with eg. roving eye movements if true coma). ECG comes in normal.

The police officers are informed that patient can return to police station as soon as blood results have been seen. And here they come...


With a hefty metabolic acidosis and lactate of 12,9 there's a minute of silence and doctors start thinking if there's a red herring in the room...

Could the patient be intoxicated after all?

Alcohols maybe?

He doesn't smell - but do all alcohols smell?

That's an anion gap of 18 - is it all explained by lactate?




With a presumed intoxicated patient fluids are ordered and patient is prepared for admission. Just that 45mins later the policemen come to let know that the patient is now awake and feeling well and ready to leave the ED with the officers. So a new blood gas (venous of course, who's sticking arteries these days anyways!) is drawn and voila;


All results normal... So the lactate acidosis turns out to be caused by strenous physical excercise. Now howzaaat!



Learning points
  • Lactate can be very high after exercise! I remember a study where alpine ski-ers had 6-7 after coming down a slope and I've heard experienced clinicians state it may temporarily reach 20 after seizure). But you can even get disturbing pH levels from it!
  • Ethylene-glycol and methanol are odorless!

And my question to the audience: can I somehow calculate presumed anion gap from lactate levels, so that I can exclude other agents?

Five IT skills every doctor should learn and master

IT is not a very sexy term for doctors' ears despite having potential to boost productivity and clinical skills. I find it hard to convince my colleagues that IT could be one the hopes for battling rising costs and burden of modern healthcare. Productivity and effective work is the one most important factor today - a doctor who is highly educated and trained is a much too valuable resource to be seen wasting time fighting a computer or software. Computers are everywhere today and can't be dodged - we are practising desktop medicine instead of bedside medicine. Same goes for the information tsunami, you have to ride it instead of being drowned in it. So I would like to share with you what IT skills I think every doctor should learn and master.

1. Touch type writing

Doc wrote a coffe and drank some emailDoctors write text all day long and no single skill is as underestimated as writing fast, many doctors picking the keyboard with one finger for same typing speed as Stephen Hawking.
Words per minute:
Stephen Hawking 15
Slow writer 20
2-3 days training 60
Professional writer 90
Reading aloud 150
World record 216
Training for 2-3 days will give you 300% gain in writing speed - such a number in the NNT world would normally be a breakthrough article in the medical journals!

2. Google Docs (Drive)

A doctor's office does not need to be like this today!I have surrendered to my brain and admit that however I try I will not be able to remember everything. My brain is a powerful processor of information but for organizing and storing it I need an online, easily accessible notebook. Google Docs is exactly that and has become an indispensable tool in daily clinical work. Everything I have learned the years - tips, links, references, quotes, statistics - I have noted in a well organized collection of text and images for easy retrieval bedside or at computer.

Besides being a huge personal notebook, Google Docs will forever change the use you approach information and data - ultimately leading to the 'mobile, paperless office', essential for organizing and accessing your work from wherever you are.

# A vodcast/post about Google Docs in clinical practice is just around the corner - stay tuned! #

3. Social media

Social media for doctors is essentially
1) Great educational material coming online (and free) through blogs and related technologies.
2) Communications platforms (Twitter, Google+ etc) for expanding your contact network - where your colleagues sharing their most valuable learning points and lessons.

Learning to use social media is not about any one technology, like starting Twitter, it is a new lifestyle. It may not be for all but for those who master it I can promise doors opening to a completely new world of e-learning, yielding clinical skills not possible before. Almost every day I find my self implementing something learned from my social media network to patient care. Learning ultrasound would have been impossible for me without social media as it has provided me with teaching material to support me.

4. The web browser

Doc wrote a coffe and drank some emailSoftware installed locally on your hard drive is becoming a thing of the past as data cloud and web-applications take over. The heart of this revolution is the web browser and it is the one software you really have to know inside and out. Tabbed browsing, using the Omnibar (for Chrome), knowing the keyboard shortcuts, working with text (special copy & paste functions), synchronized preferences etc... Mastering these will give you maximum performance while doing your work. And for a busy doctor, productivity is everything!

5. Genuine interest!

Just as the best doctors are those who are genuinely interested and active in their field - the same goes for IT skills. Strive to always become better and have open eyes for improvements, acknowledge that your way of doing things today may not be the most efficient one. Most of your daily tasks involve IT in one way or another and you will find lots of colleagues, especially younger ones who're born with IT at their hands, who are willing to teach you and help you.

An everyday example of IT in use!

Finally, an example from work - a serbian patient who repeatedly came to the ED with mostly non-compliance based problems because he didn't understand his medication list. Problem solved with a simple IT tool, Google Translate!
Being a tech competent physician is key to productivity and efficiency at work, a win:win situation for you and your patients. In the menu above you will find a list of some 10+ posts about technology, IT and social media for doctors. I highly encourage you to check it out!