Blog | Tuesday, July 12, 2011

Useless charts and fresh eyes in handoffs


Last month, I was a speaker for the American Medical Student Association on their patient safety webinar. This was the brainchild of Aliye Runyan, a fourth year medical student at University of Miami and her colleagues, to expand the patient safety taught to medical students. They are not alone. The IHI Open School also virally spreads patient safety training where traditional med schools failed.

My topic was handoffs, and they asked me to talk about it. I wondered what could I tell mostly preclinical medical students, some of whom may not have even entered the clinical arena, about handoffs. Would what I say be over their head and irrelevant if they had no clinical context? I was also hoping there were some fourth years on the call who could offer their experience doing handoffs as subinterns.

But, I forgot the importance of fresh eyes, a concept that is sometimes used to describe the one positive aspect of a handoff, that sometimes the best insights come from someone who is not well acquainted with the case. I had a lot of fresh eyes (and mostly ears) on the call. In the vibrant Q&A that followed (and continued via e-mail), one of the things the medical students brought up asked me about something I said is sometimes bad in the signouts: TMI, or too much information. This often happens when the signout is used to help the primary team track the patient and it loses its function for the receiver. In hospitals with electronic health records, TMI is often a symptom of "CoPaGA" syndrome, or copy and paste gone amock.

But, this led to the most interesting debate of the night: Why has the medical chart become so useless that people feel they need to use the sign out this way? I was asked to think about this question again later in a meeting with our Epic, staff who are working to create an automatic signout system for our residents. They really wanted to know why we needed a separate system. Since our residents have iPads, why couldn't they just look at the record?

I had to think about that one. I said that the chart is a document that is an archive that is most helpful for those people that know the patient. It is also one large medical bill. And yes, Dr. Verghese makes excellent points about the iPatient, but the truth of the matter is that the medical record is not all that helpful when you don't know a patient and you have to make a quick on-the-spot decision. So, this is why we can't ask busy residents to pause to look in the electronic health record to answer the clinical question of the moment when they don't know the patient. The information there is overwhelming. Our chief resident had a better answer. The night resident needs the Cliff notes to answer the question since they weren't assigned (and don't have time at that moment) to read the full text.

Of course, handoffs are more than just the written information. A handoff also has to include a verbal interactive component. As the implementation of shorter duty hours is looming, so too is a requirement that all residency programs make sure their residents are "competent in handoff communications." I was asked about this by Dr. Bob Wachter in an interview that was just released on AHRQ Web M&M last week (disclosure, I am on the editorial board). Because programs are looking for a way to meet this requirement, I have racked quite a bit of frequent flyer miles visiting residency programs. But, after I give a talk, I know that they may talk about it for a bit if I'm lucky. Once, I actually witnessed residents putting some of the principles I taught them into action shortly after I spoke at their resident report. However, these moments are isolated and as you can guess, education by itself will not translate into practice change (We could talk to the handwashing people all day about that!). So, like handwashing, a monitoring plan is also needed. And yes, that is also part of the new requirement, that programs actively monitor resident handoffs.

So as we head into July 2011, here's to more fresh eyes ...

Vineet Arora, MD, is a Fellow of the American College of Physicians. She is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist, supervising internal medicine residents and students caring for general medicine patients, and serves as a career advisor and mentor for several medical students and residents, I also direct the NIH-sponsored Training Early Achievers for Careers in Health (TEACH) Research program, which prepares and inspires talented diverse Chicago high school students to enter medical research careers. This post originally appeared on her blog, FutureDocs.