unless it’s the tail rotor. They will straight up kill you.
Ramblings of an Emergency Physician in Texas
unless it’s the tail rotor. They will straight up kill you.
And then forgot to check this one.
It’s not dead, it’s just being left fallow. You have my apologies.
It’s fallow as I’m in one of those weird career places, where I’m doing just enough interesting things that are fun but that I cannot talk about, and so rather than screw up I self-censor. Long-form blogging isn’t dead for me, but now really isn’t the time.
I missed posting this last year!
My yearly Christmas favorite, reposted:
Courtesy of the British National Health Service (click the banner):
NSFW. Funny, but Unsafe for work,unless your work involves STD’s in which case it’s required.
It’s my seasonal favorite post, and I hope it’s one of yours.
Not the STD’s, the funny song with equally amusing illustrations. The backstory, from a previous blog post:
I have seen several searches of this blog for the British National Health Services’ “12 STI’s of Christmas“, and wondered why. The answer: the NHS site no longer carries the wonderful show, for reasons unknown to me. As for the searches, I guess the Christmas season has people thinking about sexually transmitted infections (diseases on this side of the Pond) set to Christmas tunes.
For my little brother (who’s taller and smarter than me, thank goodness I’m better looking):
He’s a touch older than in this picture (he was the lead mechanical engineer making this thing fly, in one year):
And, to my niece Annie! I have no pics of her with an airplane, but when I get one, I’ll keep it for her next birthday.
I had the good fortune to visit the Museum of 1990s Trauma Care over the past two days. It's called #ATLS. Fascinating historic artifacts.
— Bill Hinckley (@UCAirCareDoc) December 5, 2014
I frequently order from you (check my records, I’m not exaggerating). I’m giving you this feedback just as the Christmas shopping season starts to help you, not out of spite.
First, had I wanted USPS to deliver my packages I’d order from someone other than a class act like Amazon. So, please don’t use an organization that’s dying for a reason (inability to get the job done).
Second, if you’re going to use USPS (and see #1, you shouldn’t), please don’t ask for a signature on a $50 order. UPS and FedEx know us quite well, and know our neighborhood is remote and really really safe, so they know where the packages should be placed/hidden. USPS apparently doesn’t.
In fact, they have failed to deliver my package twice now, twice sending me an email that they left me a note (they didn’t) and telling me when they tried (when we were home, both times). Getting the picture? USPS isn’t reliable, or trustworthy. So stop trusting them with our business.
Think back to the last time you had to navigate a customer-service situation. Perhaps you were trying to make a doctor’s appointment when few convenient times were available, or you may have been speaking with a credit-card rep in an effort to get a onetime waiver on a late payment charge. Maybe you were speaking with an airline representative in hopes of finagling priority seating. Did you adopt a warm tone and play nice? Or did you raise your voice and speak aggressively? You are a nice person, so you probably chose the kind route. The tough pill for most of us to swallow is that those overbearing screamers often get their way. Feisty personalities, although unpleasant, can be tremendously effective.
I am vindicated!
Here’s to all those in the Sea Services. There’s a nice writeup on Navy history at Military.com.
A modern parable.
RICHARD GUNDERMAN, MD
Not accustomed to visiting hospital executive suites, I took my seat in the waiting room somewhat warily.
Seated across from me was a handsome man in a well-tailored three-piece suit, whose thoroughly professional appearance made me – in my rumpled white coat, sheaves of dog-eared paper bulging from both pockets – feel out of place.
Within a minute, an administrative secretary came out and escorted him into one of the offices. Exhausted from a long call shift and lulled by the quiet, I started to doze off. Soon roused by the sound of my own snoring, I started and looked about.
That was when I spotted the document on an adjacent chair. Its title immediately caught my eye: “How to Discourage a Doctor.”
I’ve written about scribes in the ED before (here’s one from 2007) and continue to utilize their services. Did I say utilize? Wrong thought: enjoy and marvel in their help is more my experience. I’m spurred to extoll their virtues and my experience after reading “Attack of the Scribes” by the great twitterer @SkepticScalpel (he also blogs at SkepticalScalpel.blogspot.com ).
Read the article, it’s well written though more than a touch odd; why’s a doc who’s never worked with scribes editorializing on their pluses and minuses? The literature review is fair, and there probably isn’t enough scholarship on the issue of whether scribes can have a measurable impact on physician productivity. I think we’ve only scratched the surface with scribing in the hospital, as I think every nurse should have a scribe. Imagine, nurses nursing rather than staring at screens, checking boxes! It would be hugely liberating for them.
I’m going to insert some quotes from the article then answer them:
“The emergence of the electronic medical record (EMR) has spawned a new occupation—the scribe.”
No, scribes have been around since ink and paper, and maybe before. I would accept that the EMR has spawned a new medical occupation, though we used scribes in the paper chart world before the EMR. It is certainly true the EMR has facilitated the explosion of scribe utilization (and companies to fill that need).
“I have no personal experience with scribes, but I suspect their notes would tend to be too long rather than too short. Do we really need longer notes in charts? No. Residents need to learn how to write concise progress notes that do not duplicate what is already in the chart. This would require a culture shift by faculty and senior residents who tend to expect voluminous notes.”
Scribes document something like doctors without scribes: all over the map for volume. Some distill the history in a few sentences, some type verbatim, and there’s a mixture between. In the ED, as the note is pretty heavily templated, and so much fluff and junk are automatically stuck in there, an extra sentence or three isn’t contributing to note bloat. I would never scribe any other than a Senior resident, as learning what and how to document is part of the education.
Additionally, docs 40 and above didn’t grow up with keyboards like our scribes did; that means less information added by poor typists, which isn’t good for the patient or the documentation.
“The presence of a third party during the doctor-patient interaction has not been an issue so far, but it is conceivable that some patients might feel uncomfortable.”
I’ve had one patient ask the scribe to leave the room. I introduce myself, introduce the scribe as ‘my assistant’, and it’s not an issue otherwise. (We do excuse them for the more intimate exams).
“When a scribe enters a note in an EMR, it must be cosigned by the physician. Experience with dictated H&Ps, notes, and operative reports shows that most of these entries are not carefully proofread before they are signed. Using scribes opens up new vistas for plaintiffs’ attorneys if patients experience bad outcomes.”
I disagree; the issue is the quality of the documentation, and it’s irrelevant who pushes the keys. The name at the bottom of the chart is responsible for the content. Before Texas’ Prop 12 several of us were sued, and the use of scribes never came up as a problem in depositions or trials.
“True story. I know someone who had pain in her arms. The scribe documented the doctor as saying “consider a mass” instead of what he actually said, “consider MS.””
Professional transcriptionists get words wrong frequently, and the speech-to-text used by our radiologists is often inadvertently hysterical (‘Sono: Renal and Nasal’ was a recent report header), so communication errors happen. That’s why we read and edit charts.
I don’t need a study to tell me scribes make me more efficient, but we did one anyway. We were very efficient on paper charts, with scribes, and the EMR showed up. We went through the training, and had people time scribe-on-paper vs the EMR for time; the EMR was tremendously slower (40% more time required), which was a big hit in an efficient system. We’ve gotten better, but several of our docs use two scribes to get their speed back (and more; I now see more per hour than I did on paper). We didn’t publish our data. Maybe we should have.
Our scribe company* has gotten a whole lot bigger, and a lot more corporate for better and worse. They turn out trained and enthusiastic scribes, and they’re still wonderful to work with. I showed up very early for work the other day and decided to start early, which reinforced that I can manage the EMR and do my own documentation, and I’m terrifically glad I don’t have to.
Dr. Henry has also been quoted (though I cannot find it) as saying ‘the ER doctor should be a free floating brain’, meaning let the doctor do the thinking they’re trained to do and let anything that not that be done by someone else. It makes zero sense for the highest compensated in the department to be the typist (not a slam on typists, it’s about the best use of time and talents).
Scribes. If you use an EMR, or don’t, get them. They’ll make you money, and they’ll make your day way, way better.
*Full disclosure: I independently contract with a CMG that supported and then spun off our scribe company. I’m also friends with the scribe company senior management, and they’re good folks. I’d say nice things about our scribes if none of that were true, but don’t want my relationship to be an issue.
We remodeled our kitchen 16 months ago.
Today, my wife decided to pull out the broiler pan.
We don’t use the broiler, obviously.
It did answer the question ?Why didn’t it come with a temperature probe?! The red is plastic that was holding some nice black trim screws.
So, we now have a temp probe and I have some plastic-coated screws.
I kinda like surprises. Sometimes.
Which is terrible, yet predictable.
ACEP Now | The Official Voice of Emergency Medicine.
Yeah, it’s completely devoid of interviews or conversations with the purported future leaders of Emergency Medicine.
Again, if you’re running for President of ACEP but abide by the Gag Order, you aren’t worthy, and we (as a specialty) shouldn’t support them.
Posted by Ryan Radecki
It’s been 5 years since the last Cochrane Review synthesizing the evidence regarding tPA in acute ischemic stroke. Clearly, given such a time span, in an area of active clinical controversy, a great deal of new, important, randomized evidence has been generated!Or, sadly, the only new evidence available to inform practice is IST-3 – a study failing to demonstrate benefit, despite its pro-tPA flaws and biases. So, it ought not be a very exciting update, considering the 2009 version included 26 trials, and the 2014 update now includes only 27 trials. Their summary conclusion, with only additional evidence of regression to the mean, ought remain essentially the same, or even less optimistic, right?
Of course not:
Read, and enjoy. Excellent analysis.