Wednesday, February 3, 2016
Multitasking and not taking time to think
How could a blog post titled Learn how to think avoid my praise? This post made the Farnam Street Blog top 10 for 2015. The post refers to a wonderful essay, Solitude and Leadership By William Deresiewicz. On first reading (and this essay deserves several reads) 2 concepts resonated strongly.The first is, “Multitasking, in short, is not only not thinking, it impairs your ability to think. Thinking means concentrating on one thing long enough to develop an idea about it.”
We know that multitasking does not really work. This concept has great importance in medicine. We have added so many tasks to the patient interaction that the thought process can suffer. Our focus can get split often.
The second is, “I find for myself that my first thought is never my best thought. My first thought is always someone else's; it's always what I've already heard about the subject, always the conventional wisdom. It's only by concentrating, sticking to the question, being patient, letting all the parts of my mind come into play, that I arrive at an original idea. By giving my brain a chance to make associations, draw connections, take me by surprise. And often even that idea doesn't turn out to be very good. I need time to think about it, too, to make mistakes and recognize them, to make false starts and correct them, to outlast my impulses, to defeat my desire to declare the job done and move on to the next thing.”
All too often we see diagnostic errors occur because we do not take the time to think. We substitute algorithms for thinking. Here are some recent examples:
1. Patient comes with a heart failure label. She has some basilar crackles. Her echocardiogram suggests diastolic dysfunction. Her discharge orders include daily furosemide. On readmission she has significant volume contraction, and a completely normal echocardiogram. Her cardiac exam is unremarkable. The instinct to treat crackles with a diuretic occurs because the physician involved did not take the time to think carefully about the patient's clinical presentation.
2. Almost every patient with hyponatremia gets immediate treatment with normal saline. Too often, physicians do not consider making a diagnosis until the treatment does not work.
3. The same situation occurs with elevated creatinine levels. Again some unknown algorithm tells many physicians to give saline without considering why the creatinine is elevated.
4. I have written about several patients with decreased bicarbonate. The instinct and first thought is that the patient has a metabolic acidosis, but sometimes the patient really is compensating for a respiratory alkalosis. Making the correct diagnosis requires that we take the time to understand what has happened to cause the lowered bicarbonate.
5. A patient gets admitted to our service with multiple vertebral fractures. A very good resident does not focus on a variety of laboratory abnormalities, because being “on call” is a multitasking nightmare. The patient was anemic and had a slightly elevated calcium. That should have triggered at the globulin gap. The total protein was greater than 10 and the albumin was approximately 3.5. Once the clues get presented, the likely diagnosis becomes very clear. Focusing on each laboratory test and trying to understand the abnormalities requires time.
For years I have written about the importance of taking time in medicine. Our payment system discourages thinking time, because we do not get paid for thinking. Our payment system is perfectly designed (albeit not consciously) to discourage thinking. And now the IOM has discovered diagnostic errors.
Excellent medicine requires thinking. We need to develop systems that give our physicians adequate time to think rather than to react. As Deresiewicz writes, “I find for myself that my first thought is never my best thought. My first thought is always someone else's; it's always what I've already heard about the subject, always the conventional wisdom. It's only by concentrating, sticking to the question, being patient, letting all the parts of my mind come into play, that I arrive at an original idea.”
Practicing medicine as a reactive activity results in cognitive errors. Very often we need to spend the time to concentrate on a clinical situation. Our patients deserve our focus.
db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, 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.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
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Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
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One of the most popular anonymous blogs written by an emergency room physician.