THCB

The Great Checklisting of American Medicine

Dr DuvefeltMedical errors happen every day. Few make the headlines, but when they do, almost everyone who chimes in to comment offers the same type of solution for avoiding them. Three of the most common are guidelines, decision support and checklists.

From my vantage point as a primary care physician I agree that checklists, in particular, can enhance clinical accuracy, but some of the lists I have to work with in today’s healthcare environment are more likely to bog me down and distract me than focus my attention on the essentials. I call them choke lists.

Re-reading “The Checklist Manifesto” by Atul Gawande, published in 2010, the year before my clinic implemented their first EMR, I am reminded of how much has changed since then.

How I work and where my attention is drawn has changed because of the minutia of Meaningful Use, Patient Centered Medical Home, Accountable Care and all the other new philosophies and forces that define primary health care.

Each one has their own set of checklists, many only slightly different, and none of these lists actually improve diagnostic accuracy; this is somehow taken for granted, or perhaps not addressed because the creators of these checklists, as non-physicians, simply have nothing to say about that aspect of healthcare.

Gawande writes: “There are good checklists and bad….Bad checklists are vague and imprecise. They are too long; they are hard to use; they are impractical. They are made by desk jockeys with no awareness of the situations in which they are to be deployed. They treat the people using the tools as dumb and try to spell out every single step. They turn people’s brain off rather than turn them on.”

A very simple way to “turn on” or focus providers’ brains is to adhere to a structured format of clinical assessment, but to avoid unnecessary rigidity after that. After all, in my world we have 15-30 minutes at most with every patient for a fee of $50-150. You can only cram so many prescribed agenda items into that kind of time frame before your time is up.

Today’s checklists would have me ask every patient, apart from figuring out what is wrong with them, if they are homeless, home bound, safe from domestic abuse, if they have scatter rugs, firearms in the house (not a legal question in Florida, however), if they are a caregiver and probably several more things I can’t remember. I am sure the architects of these templates meant well, but the end result of long lists like this is that physicians risk not paying attention to the forest because of all the trees. A more appropriate checklist could summarize all these items in one question: “Have you considered the patient’s home environment?”

One item I haven’t found in my new EMR is what we in Sweden always used to include in our medical histories, “Epidemiology”. This simple word prompted the question “Do you know anybody else with the same symptoms as yours?” It is a question I overlooked at least once that I will always remember:

I was fresh out of residency, working in a small town in Maine. A middle aged man came to see me about nausea, loss of appetite and abdominal pain of more than a week’s duration. I didn’t know what was wrong with him, so I ordered some labs and an upper GI series. His CBC was mildly abnormal and while I was waiting for his x-ray to get done, my partner and employer ran into him in the grocery store one Saturday. Doctor Joe approached me the following Monday and told me not to bother with the x-Ray: “Mr. Billings’ dog was just diagnosed with lead poisoning. You might want to check a lead level on him”.

Talking to Mr. Billings, he had been scraping paint off his old farmhouse with his Golden Retriever faithfully waiting at the bottom of the ladder, inhaling the dust from the dried and cracked paint. It never occurred to me to ask about “epidemiology” the way I had been taught, because I had dismissed infectious causes of Mr. Billings’ symptoms almost subconsciously and never considered environmental exposure, which also falls under the “epidemiology” heading.

A similar but more dramatic incidence in “The Checklist Manifesto” involved a surgeon who thought he had all kinds of time to get ready to explore and repair a small stab wound inflicted at a Halloween party.

Suddenly the patient’s blood pressure bottomed out and as the surgeon hurriedly entered the abdominal cavity and found it filled with blood, he remembered he had neglected to ask about the weapon that had caused the stab wound. He later found out it was a bayonet, which turned out to have lacerated the abdominal aorta – he had only assumed it must have been a pocket knife.

Obviously, no check list can be complete enough to include questions about scraping lead paint for every person with abdominal pain and asking about having been stabbed by a bayonet in every laceration – only more general and somewhat open-ended questions will get you all the answers in a reasonable amount of time.

Quoting Gawande again, “The checklist cannot be lengthy. A rule of thumb some use is to keep it between five and nine items, which is the limit of working memory.”

As I contemplate how to continually improve the care I deliver while also addressing the increasing demands for fulfilling and documenting the Government’s requirements, I think I can use my computer and my EMR to streamline the way I meet all the requirements. But I think it’ll be up to me to create my own clinical checklists, because the Government issue doesn’t seem to be my size, which reminds me of another set of Swedish experiences I had – boot camp, blisters and learning to march in formation and follow orders without complaining.

Hopefully, the “official” checklists will evolve over time as people have a chance to assess their impact. Again, quoting Dr. Gawande:

“…no matter how careful we might be, no matter how much thought we might put in, a checklist has to be tested in the real world, which is inevitably more complicated than expected. First drafts always fall apart….and one needs to study how, make changes, and keep testing until the checklist works consistently.”

Welcome to the real world, any time you wish to see what it’s like, Mr. President, Ms. Congresswoman, Mr. Insurance Executive, Ms. EMR vendor!

Hans Duvefelt, MD is a Swedish-born family physician in a small town in rural Maine. He blogs regularly at A Country Doctor Writes, where this post originally appeared.

 

Livongo’s Post Ad Banner 728*90

Categories: THCB

Tagged as: , ,

23
Leave a Reply

14 Comment threads
9 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
14 Comment authors
ElidaAlexRobert Spaulding@BobbyGvegasPerry Recent comment authors
newest oldest most voted
Elida
Guest

I’ll immediateely take hold of your rss feed as I can’t in finding your email subscription link orr newsletter service.
Do you’ve any? Please let me realize in order that I coud subscribe.
Thanks.

Feel free to surtf to my blog post … sensitive (Elida)

Whatsen Williams
Guest
Whatsen Williams

Checklists would not have helped the ER docs to judge Thomas Eric not fit for discharge

What they needed was a full deck of data, but the EHR impeded their being able to silo search to find the full deck. All EHRs treat all data the same way, whether it be relevant or not: mundane, vanilla, verbiage, jabberwock, mind numbing, unreadable due to tiny font…you get the picture.

If that ER did not have a EHR running the show, Mr. Duncan would have been admitted.

Hans Duvefelt
Guest

My example of the “epidemiology” question in the post WOULD have nailed the diagnosis, and it is now on my personal checklist ever since I missed that lead poisoning diagnosis.
Doctor: “Mr. Duncan, have you been around other people with similar symptoms?”
Mr.Duncan: “Yeah, I took care of someone who died from Ebola….”

Alex
Guest

Fast & Natural Recovery From Anxiety,

Panic Attacks, OCD, Agoraphobia & Depression

http://bit.ly/lindedmethod

Robert Spaulding
Guest

What I never understood was the doctor patient relationship and what medications the patient was taking at the time. Only when my grandmother moved into a full time nursing care did they scrutinize each and every prescription for all possible drug interactions. Nothing could be given without doctor approvals. Before that time, she was getting one thing from one doctor and another from somebody else. If there was a central database of who is taking what, maybe some of those interactions should have been minimized. It’s up to the patient to disclose such but it would have been nice to… Read more »

@BobbyGvegas
Guest

Great discussion here. I’ve just finished Nicholas Carr’s intriguing new book “The Glass Cage: Automation and Us.” A bracing, cautionary read. I will be reporting on it on my blog shortly (Blog.KHIT.org) “This is a book about automation, about the use of computers and software to do things we used to do ourselves. It’s not about the technology or the economics of automation, nor is it about the future of robots and cyborgs and gadgetry, though all those things enter into the story. It’s about automation’s human consequences. Pilots have been out in front of a wave that is now… Read more »

Perry
Guest
Perry

” It may also, in the long run, hinder doctors from developing the intuition that enables them to respond to emergencies and other unexpected events, when a patient’s fate can be sealed in a matter of minutes. ”

A critical statement. This is why doctors do residencies and train under older experienced doctors (and nurses), to help develop these little voices and gut grabbers that make them stop and think. I too am concerned that overreliance on tech and screens between doctors and patients will erode this very important part of a physician’s ability to process important information.

Perry
Guest
Perry

By the way Bobby, thanks for bringing up that book. I heard about it on NPR a few weeks ago and would like to read it myself.

@BobbyGvegas
Guest

It’s a great read. I will be reviewing it at length. Chapter 5 goes into great detail about EHRs.

Saurabh Jha
Guest
Saurabh Jha

“but there is also a more important place for judgement that can evolve into ‘your own’ checklist.”

This is exactly what I tell radiology residents. Have and develop your own personal checklists. You’ve taken the words out of my mouth!

Chandresh J. Shah
Guest

When vendors try to sell you an EHR, sales people use a ‘checklist’ that is imposed by their organization. Are you the real buyer? Do you have authority to sign a check? What is your Specialty? You buy from a human being that is able to connect with you and ‘diagnose’ your aspirations and afflictions. Give you a solution that matters to you. It is not about technology, it is about solving your ‘case’. Not to different from what providers do is it? If EHR software sales people have a long irrelevant checklist of questions to ask you, what happens?… Read more »

Hans Duvefelt, MD
Guest

The Institute of Medicine tells us that. People think Mr. Duncan’s case was one of those errors. More government imposed minutia represent one vision of how to reduce such errors. I don’t think that strategy will work.
Just hoping won’t help. But I agree with you, it would be nice if things got better.

John Doe
Guest

Hello Hans,

It makes me sad that there are so many medical errors committed everyday. I do hope that things will get better in the future.

John Doe

William Palmer MD
Guest
William Palmer MD

Isn’t medicine partly artistic? This at the very least means that all practitioners would not always treat the same way nor obtain the same results…if e.g. everyone treated identical clones of patients. Wouldn’t checklists be anti-innovative and anti-creative in this thought experiment? Is there some value for the patient and for the society in having it partly artistic? Perhaps the tip of the spear in research, the cutting edge, advances faster if medicine is partly artistic? Perhaps the patients are more comforted if medicine is partly artistic? Perhaps its practitioners feel more satisfaction if they use their creativity?

Perry
Guest
Perry

I fear the “art” of medicine is dying out.

Saurabh Jha
Guest
Saurabh Jha

You are correct. But it’s going to take a long, long time of sterile medicine for people to get this.

@BobbyGvegas
Guest

“Isn’t medicine partly artistic?” ___ What does that MEAN to you? The phrase “art of medicine” has always made me a bit uncomfortable. But, then, I’m aware of the term “scientism,” too — the epistemological assertion that western reductive algorithmic science is the ONLY way of knowing. See, e.g., the prefatory story in one of my 2009 blog posts: http://bgladd.blogspot.com/2009/05/us-health-care-policy-morass.html “Art” implies making intuitive, heuristic, “creative” cognitive leaps via which to arrive at positive results, be they aesthetic or clinical, right? As I wrote in my 1998 essay about my late daughter: “Every discipline has its share of the “arrogant… Read more »

Hans Duvefelt
Guest

Thanks for the comments. I think checklists made by clinicians for clinicians can be effective tools also outside the operating room, like Dr. Jha’s X-ray example. The problem is that so many non-clinicians feel entitled to set the agenda for ordinary office visits and the daily work of physicians. I can see governmental and public health agendas needing to be addressed by healthcare organizations in some fashion, but in the precious fifteen minutes we as primary care providers have face-to-face with our patients, the agendas need to be clinical. Our checklists need to be relevant to the clinical decisions doctors… Read more »

Peter1
Guest
Peter1

“The problem is that so many non-clinicians feel entitled to set the agenda for ordinary office visits and the daily work of physicians.”

Who are these “non-clinitions” and what “checks” do they impose? Surely administrative checklists can be done by office staff, some medical checklists by nurses, even the patient fills out a checklist.

“but in the precious fifteen minutes we as primary care providers have face-to-face with our patients,”

This is the real failure of our system, supporting specialists and not PCPs. A strong primary care doctor relationship will trump any checklist.

Rob
Guest

The problem is that while we need checklists to keep us away from errors of neglect/carelessness, we have become awash in checklists to the point that it obscures the patient. I think this is for three big reasons: 1. computers are very good at checking boxes and have made massive checklists easy to fill; 2. Checklists have become the means of care measurement; and 3. Non-clinicians are making most of the checklists. The medical record has become the place where checklists are stored, proof of the quality of care that was given. The problem is, of course, these checklists are… Read more »

Whatsen Williams
Guest
Whatsen Williams

Consultation and discussion with colleagues and nurses has always been the best checklist. It is amazing how many brilliant ideas arise from simply having a conversation about a case.

But, nowadays, health care professionals do not have time for conversations as they are busy clicking away on CPOE or checklists, silo searching data, or answering inane clinical decision support questions.

If there was conversation in the Dallas ER sitting around the table writng a note, I bet someone would have said, “hey, what do you think about this case from Africa?” And then, voila, the answer to the riddle!