University of Illinois at Chicago
With the final day of presentations upon us, I’ve taken a few of our insights from neurology and summarized them briefly as follows:
Opioid exposure can result from poor inter-provider coordination. Over prescription doesn’t happen in a vacuum. Whereas antibiotics can be isolated to whether or not a single provider is prescribing the right drug for the right condition, narcotic prescriptions would often build because patients would arrive with multiple opioid prescriptions prescribed by a non-neurologist for neurological problems.
Quality of communication influences quality of care. As one provider noted, “80% of neurology is history taking.” However, intrinsic to many neurological conditions are limitations to patient speech, requiring that complete histories often be taken anecdotally from a family member. Furthermore, drastic changes in care—such as the transition to hospice—are difficult to navigate in cases where a patient is unable to communicate due to an expressive aphasia.
Readings/Recordings are subject to individual user bias. In the case of MRI, brighter objects are naturally perceived as being larger than equally sized dark objects. Additionally, one cannot see what is not present on the scan. If a scan is abnormal not because of an unnatural presence, but instead, an unnatural absence, a reading error is more likely to occur. There also exists conflict between subspecialties when reading scans. In the case of the regional cerebral blood volume (rCBV) exams, a radiologist may note they see tumor, while a neurologist may disagree. However, once mention of tumor growth is placed in the medical record, retraction is difficult.
With the summer winding down, the penultimate post seemed to be an appropriate time for a quick reflections note:
-Physicians are incredibly well placed to innovate. Not only do they hold the unique position of being the user, but they are also a nuanced group in a field with an incredibly high barrier to entry. The nuances that propel a high volume clinic, or a well-run operating room are anything but intuitive. A problem is incomplete without its context, and context is often foreign to an outsider in a space as noisy as healthcare.
-Problems are precious. As was noted in post 1, it’s easy to be misguided by the opportunity to “improve.” Often times we’d see a silly problem that could have a meaningful solution. But then you have to step back and ask, “What’s the consequence of letting this problem go unsolved?” If it’s large, you’ve got something worth exploring. If not, move on.
-Observe problems before you ask about them. Few healthcare workers will struggle to rattle off a list of 5 annoyances. The danger here is that they’re often framed as solutions. Claiming, “We have to wait too long for our patients to urinate for the test” masks the underlying problem of proper appointment preparation. A simple example, but the logic quickly extrapolates to the point where abstracting a solution from someone else entirely cloaks the fundamental problem, and by extension, clouds your ability to provide a true solution.
Following a morning of Physical Medicine & Rehab, we were able to swing by a company contracted to run the prosthetic and orthotic program at our university hospital (pictured).
The place was incredible.
The mechanical equivalent of medical surgeons, the group works to tirelessly outfit various patients with custom-fit prosthetics optimized for everything from walking to playing the drums. While we didn’t have much time, the visit sparked my interest in a few follow-up questions. Note-to-self, things to read up on:
-Insurance. Third party payers often don’t help patients pay for physical therapy (PT), a notion that becomes much more interesting when the patient in question just got outfitted with a full leg prosthetic. Look up if there’s any data here, because given the incredible cost of these prosthetics, I’m wondering if having PT meaningfully affects prosthetic limb use.
-Who ideates the purpose of the prosthetic? With something as specific as a prosthetic that can help the patient workout at the gym, does the patient come in with the suggestion, or does a provider make the recommendation after observation?
-FDA Approval. Does it relate to prosthetics?
-Recycling. These bad boys are expensive. Can they be recycled?
Cheers to future reading!
“The expectations are so low, people don’t even know these things exist.”
In the rehab portion of Neurology & Rehabilitation, we met with an occupational therapist (OT). While showing us a supply room filled with small prosthetics and malleable tools to help patients with activities of daily living (dressing themselves, showering, etc.), she showed us the item pictured above—a folding bottom wiper for patients who require assistance while using the toilet. While the device itself was simple enough, it had a powerful impact on patients who previously had no means of wiping their bottom, no doubt making going to the bathroom an even more miserable experience.
In describing its simplicity, she noted, “The expectations are so low, people don’t even know these things exist.”
It was incredibly well said.
Yes, for patients utilizing occupational therapy services, but also for surgeons and nurses and technicians. As our summer of needs assessments comes to a close, the OT had articulated so quickly what we’ve seen time and time again. Too often does a very large-scale problem with a very small-scale source go unsolved because there exists no positive inertia to seek out what helpful things already exist. As a classmate of mine once observed, much of medicine is learning how we’ve always done things. We have high expectations for outcomes and surgical devices and providers themselves, but our expectations fall short for the simple things. A surgical tray not being sent to the correct operating room. A specialist failing to coordinate the use of narcotics with a patient’s primary care provider. A patient slipping through the cracks as two departments share her care. Solutions for so many of these communication-based problems exist. But if we accept them as they are, we’re not demanding enough.
Too often, our expectations are so low.
One of the most common tests we’ve seen done so far is the Video EEG. The apparatus (shown above) is an electroencephalograph coupled with a video recording of the patient. Often used to capture brain wave recordings to explore weather a patient is having true seizures, the technology seems to be a commonly used one in the neurology department. A quick overview of some Video EEG observations can be found below:
-Capturing. First and foremost, the test is only useful if you actually record an episode. Often times, there’s not much one can do if a patient has been recorded for multiple days in the hospital without an actual episode. At that point, the attending essentially makes a judgment call on whether or not to curtail the test.
-Reading. While some Video EEG’s call for short observation periods, others span days. That’s a lot of data. We visited the EEG lab and saw how demanding parsing 4 days worth of data (imagine multiple layers of a continuous line graph for hundreds of pages) can be on the technician. The physicians we spoke with noted that EEG’s were too nuanced to teach to a computer. However, given its pattern-based nature, it seems like it could in fact be a great process to couple with some sort of machine learning/software solution, where you’d imagine the computer would just get better and better with each successive EEG that it reads.
-MRI-compatible EEG leads. There exist MRI-safe leads whose safety and efficacy has been confirmed by much literature. However, they haven’t yet been FDA approved, an obstacle that (understandably) keeps some from embracing their use.
We’re a few days into our neurology rotation, and it’s becoming clear that angles matter. Each day, we’ve been rounding with the morning team after the course of treatment has already been more or less finalized.
Let’s quickly consider the picture above. When seen from the side, it would appear to be a thin black line segment (side of the frame). Nearly flawless, two endpoints, with a perfect line connecting them, the side angle doesn’t include much noise to sift through. Rotate the frame ninety degrees, however, and you’ve got a wealth of different hues, all combining to form an image that informs a story as seen above.
The neurology team is an incredible group, communicating effectively and swaying between patient rooms with an admirable efficiency as rounds are completed. After a few days of the same morning routine, something didn’t seem quiet right. It was almost uninformative to see daily updates on care during rounds, as opposed to full start-to-finish delivery of care and the corresponding decisions that go into such a process. As each of our 4 team members seemed to come to this conclusion independently, we became more proactive in our discussion with the team to see where the problems they encounter arise. After doing so, it became clear that much of their frustration could be found at the interface of their own patient plans and the care plans of other departments managing the same patient. I was surprised after a few specific conversations to realize that being so deeply embedded into a certain team actually had drawbacks—it was constraining to only see the frame from the side, and not the actual photo.
As we move forward to the final two weeks of our rotation, we’re coming to appreciate the context in which observe nearly as much as what we’re actually observing.
Last week we concluded our 3-week urology rotation by presenting our final deck to the department residents and the medical students on service. While we highlighted the process by which our observations were recorded, as well as the insights that came from them, I thought it’d be appropriate to share 3 of the major themes of our needs assessment below:
[As a quick aside, while these were extracted from our time in one specific department, many of these are well-accepted trends in delivering care, rather than localized themes from one corner of a specific health system]
1. Miscommunication between staff members or between patients and their providers can lead to lower patient satisfaction and avoidable return visits. Communication is integral to success in any field, and medicine is no exception. Whether it be instructions on where to go next, how to use a certain implanted device, or coordinating prescription availability with the pharmacy, many of the opportunities for improvement we saw were less technology-based and more communication-dependent.
2. Practice begins on patients. The technical expertise developed during residency is by no means small, and much if not all must inherently come from practice in real time while delivering real care under attending supervision. However, we saw an opportunity to create outlets for more simulator-based practice for those looking for additional training opportunities.
3. Effective care is slowed by non-comprehensive technology and equipment. Often times, test 1 is only useful if results from test 2 exist, thus capping the value either can have as they depend on each other. Furthermore, if the process/machine that yields results for test 2 is unavailable, then test 1 becomes uninformative. In that way, we saw great value in the potential for more comprehensive technology that would lessen the time it took to compile desired results, as well as limit invasive procedures that may not ultimately inform the final diagnosis.
With our deliverable shared and feedback received, we feel prepared to go forth and begin our next and final rotation!
As documented by many of my colleagues, observing a robotic-based operation was something I was looking forward to from the first day of our urology rotation. While seeing the da Vinci system in action raised many unanswered questions (what does training look like? If the same procedure is done both with and without the robot, what governs when either occurs? How much does it cost to set up the entire room?), I’ve compiled a few notable points below:
-Learning. There exists a feature that allows the attending to annotate directly onto the tv screens that display what the camera inside of the patient is broadcasting. While simple, I thought this was an incredibly powerful teaching tool—it allowed the attending to give specific guidance without physically taking the reigns from the resident.
-Degrees of freedom. Ask any surgeon what they love about the robot, and someone is bound to mention mobility. When you stick your hand into an open body during a traditional surgery, you simply can’t manipulate the surgical tools at the many angles and directions that one can when using the da Vinci robotic system.
-Less blood lost. With smaller incisions and greater dexterity, many da Vinci operations don’t even call for extra blood to be in the room because so little is lost compared to traditional operations.
-Traditional requirement. The system still requires one surgeon to scrub in and manually manipulate certain tools during the procedure. Put otherwise, the procedures are more robot-assisted then they are robot-run.
-Operational cost. In a stroke of malicious genius, Intuitive Surgical designed its da Vinci system so that certain parts have to be replaced every ten uses, thus limiting the number of surgeries you can do without repeat purchases.
These of course were observations based on the Si system. In knowing that the OR possesses multiple models, I look forward to observing the others in use.
We’re here to observe. To be the relentless shadow that absorbs everything without actually making its presence known. It’s often too easy to note the mistakes, the gaps in processes that could use fixing. As an observer, it’s just as useful–sometimes even more so–to find the most fluid (successful) and seamless processes. Identify what makes them so great. Apply to other situations. Repeat.
A bright spot from early this week was the Tumor Board, a weekly group that meets in the pathology department. The board had multiple players, including doctors from a specific specialty (in our case urology), radiation oncologists, techs, pathologists, and others. The group conferenced around a set of shared microscopes (pictured above) to investigate the nature of various tissues that had been previously biopsied. A few quick notes on what made the board so effective within the hour or so we met:
-Expectation. All parties came in with a clear list of the cases to be discussed and the nature of each one.
-Coupling Expertise. There were many questions, from what specifically allowed one expert to classify a certain cancer as stage 4, to requesting input from colleagues regarding an image interpretation. What made the session impressive to watch was that each physician from a different field was able to simultaneously explain his or her rationale while also teaching a colleague from a different specialty.
-Uniformity. Everyone was viewing the same image at the same time, with only a single case being discussed at any given moment (in the clinic or the OR, multiple individuals may be running between multiple surgeries at once).
-Familiarity. It was clear that the majority of the personnel worked with each other on a consistent basis, allowing for a routine that seemed to make things more fluid.
When looking for ways to improve, it’s easy to start with that which seems most broken. And yet, sometimes it’s even more useful to identify what works well and why.
Start with the bright spots.
Bundle of wires in the OR, 1. Everyone else, 0.
After seeing an anesthesiologist trip over a wire in the OR, I remember thinking of the mini wire covers (the ones that look like speed bumps!) that you often see at concerts or events backstage that use a lot of wiring. I quickly scribbled a note to look into the use of similar material in surgical rooms as I moved onto the next operating room.
And of course, the first thing I saw was the cover pictured above.
A common theme this week has been that a problem in one OR is clearly and actively prevented in another. The variability is something I’m excited to use as a learning opportunity. Does the variability rise as a function of personnel (different staff, different likes)? Was it specific to the procedure being used? Is it simply a matter of “nice-to-haves” vs. “need-to-haves?”
On the other hand, the wire cover is just one example. The lack of consistency could be traced to other observations including counting lap tissues used in procedures, as well as the availability of different surgical trays for more complex cases. With the covers, it seems as if they should always be used if people do in fact trip on wires, and if it’s not so much of a problem, it seems irrational to spend any funds purchasing the covers in the first place.
With the examples above, it’s more the frequency than the scale of the problem that I find interesting. As an IMED student, we often discuss innovation in terms of technology, and technology in terms of sexy devices and software. However, it’s important to remember that sometimes the most creative answers are rooted in how we use the resources we already have.
A week into our clinical immersion program, it’s become clear that no process, no procedure, is quite perfect. Our group has been lucky enough to begin with Urology, a unique specialty in that it demands two unlike environments—outpatient clinic and the operating room.
While the majority of our first week was spent quietly observing procedures (quiet being code for trying not to interfere in the operating room, a near impossible goal in a room with 15+ attendings/residents/nurses/students/techs) and follow-up visits in the clinic. When you’re a hammer, the world is full of nails, and when you’re a clinical immersion student, the process of care is full of solutions waiting to be had. While it’s all too early to thematically organize any observations we’ve made, I’ve been trying to push myself to organize that which I do see against a few questions:
1. If this problem goes unsolved, to what extent is patient care actually harmed?
2. If there exists a better way to do this, how are we defining better?
3. If a solution didn’t exist, what answer would I dream up?
The first has been incredibly important in that the small things—a process tweak or new device that I can be fooled into thinking will be life-changing—that I’ve observed this week have often times been isolated inconveniences that don’t necessarily affect patient care.
The second provides a proper framework to not let the initial goal get lost in noise. With its many users (providers, patients, payers), it’s easy to get lost in the noise of healthcare. Just a personal opinion here, but it seems important to keep in mind if better means an improvement for providers, patients, payers, or all 3.
Finally, the third is powerful for two reasons. As the inexperienced ones, a team strength is that we’re blind to what has always been done. While that may lead to some silly-sounding questions, it also is a great strength in that we get to see things for the first time, allowing the suboptimal to appear a little brighter than it may for folks who’ve been staring at the same picture for many years. Secondly, we often underestimate how powerful seemingly antiquated technology is for its users. Take the beeper, the cockroach of medical technology. Seems odd to carry a brand new iPhone 6+ in one pocket, with an old beeper in the other. But if asked to create a solution for reliable hospital-wide communication, the function of the beeper and the updates it carries seem to make a little more sense. If you measure the difference between the solution you drafted and the one currently being used, you either come up with a great idea, or have a stronger appreciation for the process in place.
With the sprint that has been week 1, many observations were had and many opportunities for progress were recorded. But as 2 of my teammates pictured discovered, sometimes you just have to sit patiently and wait for the right topic to tackle.
Problems are precious. Choose yours wisely.