Our organization recently hosted Cy Wakeman, HR pro extraordinaire, on her topic of how to Ditch the Drama and Drive Big Results. Of course, I had a scheduling conflict and missed it. After hearing the rave reviews, I did what I usually do: see if she has something online. Sure enough, she had given a similar talk at SXSW 2018. Here is below.
It is 54 minutes long, so not a TED talk, but FIND THE TIME. She has a ton of great ideas, great stories from her own life, and she tells it well. My favorite points:
Ask a colleague who is having a melt-down: What does GREAT look like if you were at your best right now?
Your brain has a toggle between VENTING and SELF-REFLECTION. You cannot do both at the same time. Asking a colleague who is venting to stop and think: “What is the best thing I could be doing (for my patient right now, or for the team right now)?” flips this switch.
Nicely put. Although I’m tempted to put this in front of my colleagues and my family (we so often blame others, when we have interpersonal trouble), I think I’ll watch this again and really absorb some lessons for myself.
Many of you know that in my role as CMIO at UCHealth, I’ve stepped in my share of potholes. My Failure Resume is replete with examples (eg: my 16 year journey to implementing Open Notes). Having studied the Open Notes phenomenon back in 2000 and published in 2003, it was a big disappointment when, after presenting to the medical leaders at University of Colorado, I was soundly voted down for implementing this transparency initiative (sharing doctors progress notes with patients online) repeatedly in 2002, 2003, 2004, until I stopped asking. Then, about a decade later, AFTER the Open Notes organization (thanks, Tom Delbanco and others) formed and pushed the agenda in 2011, we gathered steam and I finally succeeded in May 2016 to implement Open Notes system-wide for several million patients). You can call it a failure or an eventual success.
Nevertheless, when we implemented our Sprint Team for EHR optimization, we were at risk of being disbanded and told to return to our usual jobs (I had “stolen” these resources from IT and informatics to “Sprint” one endocrinology clinic of 29 doctors). In defense of our program I wrote this 1 page Executive Summary. We know that readership of white papers drops by half with every additional page. I included images/graphs (internal marketing, make your document attractive and interesting), STORIES (because, what p-value has ever REALLY changed someone’s mind?) and DATA (because, what self-respecting doctor or leader DOESN’T ask for evidence?).
And no, it wasn’t an overnight success, but it was one of the core documents that drove our executive team to finally approve the budget to continue our Sprint efforts. Download the 2-year-summary version below.
We have now sprinted over 750 clinicians, hundreds of ancillary staff (MA’s, RN’s, front desk clerks), over 70 clinics, with uniformly RAVE reviews. And, even better news, we were recently funded to DOUBLE our Sprint team to 22 people. We are grateful to our leaders for such foresight.
CMIO’s take? Sometimes internal marketing can be as or more important that external marketing. Do you have success stories of how you wrote/composed documents for success? Let me know.
This is great, and timely, and something I want all my readers, my colleagues, my family to read. I need to read this again, too. This NYTimes article is about vulnerability, and the human condition, and ME not being embarrassed when (yet another) presentation or project, or idea that I have goes down the tubes.
It is particularly relevant now, as our team prepares to give a talk at the upcoming annual Epic UGM (User Group Meeting) for our Electronic Health Record. We’re going to be speaking on being “Terrified to Terrific” and our growth towards Physician Builders — physicians who are trained to develop custom content and templates for use in our EHR. It is a way for practicing docs to actually do significant customization to improve efficiency, effectiveness and teamwork in the care of patients. The RISK is: will we give a BORING presentation about establishing our team of physician builders, and then list all the BORING accomplishments over the past few years? Big deal. Instead, how do we share our vulnerabilities, our failures; the same fears that our audience will likely have about physician builders?
In short, our journey began about 5 years ago, when our IT (information technology) leaders were very hesitant to allow “those renegade doctors” into an IT shop and “hand them the keys to an expensive car” and “let them build stuff and potentially ruin everything.”
One great moment happened when our IT manager of ambulatory applications in our EHR realized that our physician builders were actually taking ownership of the EHR improvements during our “war room” day-long conference and helping to test each component of the software and ensure that things worked well. She said to me: “Who DOES that?!” meaning that she did NOT expect busy physicians to take the time and be part of the testing team and be full partners in improving the EHR software code.
CMIO’s take? It is “aha!” moments like this that make the journey worth it. We make assumptions, sometimes we’re wrong. It is vulnerable moments of letting others see when we’re wrong, when we fail, that we see each other as human, and we are more likely to help each other out. This sort of vulnerability builds our team. We are always stronger as a team.
Our smart colleagues have published in JGIM (Journal of General Internal Medicine) and have updated the classic study: how long does it take for a doctor to interrupt the patient at the beginning of the interview, when patients begin their opening statement about “why I am here today.”
In years past, we found that the time it takes for a doctor to interrupt the patient used to be …
18 seconds! Then 23 seconds (hey! we’re getting better!) and now … 11 seconds?!?! That is, IF the doctor asked an open-ended question AT ALL. Yikes.
Seriously disappointing. But, are we surprised? The time pressures on doctors have increased over time. More regulation. More required elements in the documentation. Meaningful Use requirements of Electronic Health Records. Decreasing reimbursement. Not sufficient time or effort dedicated to redesigning the exam room, or to redesigning teamwork so that doctors can be doctors and not clerical workers.
Beyond that, we have an internal clinician retraining program at UCHealth to improve communication in healthcare encounters between patients and physicians, we call Excellence In Communication. Led by our inimitable Patrick Kneeland, executive for Patient and Provider Experience, and a team of a dozen physician coaches (myself included), we are teaching our docs highly effective communication strategies. In a four hour workshop, we can improve clinician experience, patient experience, and reduce physician burnout. Who doesn’t want that?
Of the many techniques and tips, here’s a trio that work particularly well:
Open ended inquiry “How can I help you today?”, and then WAITING UNTIL the patient is done with their opening statement. The published data on this indicated that the vast majority of patients complete their opening statement in far less than a minute, and the exception will go up to maybe 3 minutes, if uninterrupted. The trouble is that docs feel like they’re under so much pressure that every second of listening is excruciating, and the other parts of their brain are already; categorizing, creating a list of possible diagnoses, worrying about completing checklists, wondering about quality metrics, and are too “full” to be present in the moment. We train docs to practice listening for up to 2 full minutes to a colleague’s statement and committing to trying this in an exam room with a patient. Simple, but the behavior change is IMMENSELY challenging and yet IMMENSELY rewarding when done well.
The second technique is “What else?” That’s it. Just keep asking “what else” until the patient runs out of stuff. This, of course is the petrifying fear that docs have: “But that opens Pandora’s box and I’ll never get it shut ever again!” and “But then they’ll bring up stuff that I can’t help them with!” and “OMIGOD this will be 75 things and we’ll be here all day and night!” Yes well, we also know that the FIRST thing that patients bring up with their doctor is only 10% to 50% of the time, the most important thing they want to talk about. So, guess what, if we RUN with the first thing patients say, we’re going to be wrong 50 to 90% of the time. So there.
Finally, and this is the piece-de-resistance, say: “Well, we have discussed quite a few things so far. Which of these topics would you like to cover today in the time that we have? I would like to discuss A, and sounds like B is also important to you. How does that sound?” Negotiating the agenda is a critical skill, and makes items 1 and 2 really useful, creates a win-win agreement between patient and physician, and EVEN SAVES TIME. Imagine: a tool that increases patient and physician satisfaction, and saves time.
Notice that this has NOTHING to do with the EHR being for good or for evil. This works regardless of what you have in the exam room, as long as you have the presence of mind to remember to practice and use the tools.
In this, the winter of our discontent, when everything seems to be going in the wrong direction, when all of our institutions are under attack, and public courtesy and discourse seems to have gone awry, and everyone has a complaint, it seems that so few have ideas to help us climb out of this morass.
These tools could be a glimmer of hope.
CMIO’s take? Use these three tools in the exam room (or the meeting room, the board room, any professional or personal setting where important conversations occur), see what transpires. They are EASY TO understand, but require discipline and hard work to make them work for you. Persist, and they will pay off in large ways for you and for your patients.
Yes, I firmly believe this. We are starting to mine our EHR data. We can begin to see prescribing patterns, and how they affect patient vital signs (blood pressures, heart rates, pulse ox). We can look at aspirin prescriptions in patients with coronary disease. We can look at steroid inhaler prescriptions in patients with persistent asthma.
But what about patient experience? Those who have conducted Group Visits can begin to see patients educating each other, in ways that physicians, staff, educators don’t understand. “How do you manage your insulin dose when you work swing shifts or night shifts?” “When you catch yet another cold, how does that affect your liquids intake and medications for heart failure?”
Companies like “PatientsLikeMe” are beginning to look at this information as well. It is about time that our EHR vendors (or maybe startup companies) start helping us unlock the knowledge inside our own medical records for the benefit of other patients.
FOR EXAMPLE, in the screenshot above, in a presentation that I give, consider a 55 year old man with worsening knee arthritis. How hard would it be for us to find “patients like me” treated in the past few years with similar symptoms, similar age/sex/activity level/health status, who were faced with a similar decision about choosing an orthopedic operation and physical therapy?
We could say several really interesting things:
-See how many chose each option
-Compare the 3, 6 and 12 month outcomes of each choice, for pain and function
-Evaluate PROMIS (patient reported outcomes) of each option for: overall health, anxiety, depression, functional status.
Who would NOT want such information? Local, recent experience of other people like me, facing a similar challenging decision.
Our EHR’s are often way too antiseptic, full of words, graphs, numbers, and not enough about the person of the patient. We’re working on fixing this in a number of ways, but one way we can ALL do something immediately is to re-introduce the Social History, not just as a tool to detect genetic pre-dispositions, behavioral risk factors and social determinants of health, but also as a simple tool to connect us with our patients.
In my sordid past, I was the subject of some ridicule from my Chief of Service, as well as my fellow residents. You see, in 1990, I was on-call during my internship year at UC Davis medical center. The Department Chair routinely rounded each morning at 6am with the post-call team, and the intern would gamely present a patient he/she had “worked up” from being on call overnight. “Dawn Patrol” with the Chief was a uniformly feared, but nevertheless educational experience with the Chief, and it was to be my turn.
So, I was excited to find that one of my newly admitted patients in the Emergency Room that night had a pneumothorax, from injecting a needle into his neck! In my interview, I asked how this happened, and he explained to me: “So, you know how, when you bite your own thumb and blow, you can look in the mirror and see that one of your neck veins pops up, right? It’s a great place to put your needle if you have run out of spots in your elbows and such.”
What could I say? “Yeah, I know how that is.”
So, he showed me how he did it. It worked pretty well most of the time. But, this time, it seemed, his needle went a bit too far and … he developed shortness of breath. Seemed like his needle poked into the top of his lung and he “dropped his lung.” While driving. He was pulled over by some astute cops, and brought to the ER to be treated, handcuffed to his ER gurney.
Great case, I thought to myself. I got to put in a chest tube, and learned lots of interesting pathophysiology. Perfect for Dawn Patrol. My resident encouraged me to go back and take a very thorough history and detailed exam for the inevitable grilling from the Chief. I did so, and I was ready.
6 AM, and Dr. Silva walks up. “Good morning! Who’s got a case this morning?” I smiled brightly and launched into my polished presentation:
“This is a 39 year old prisoner and IV drug user, brought from jail for a chief complaint of shortness of breath, and admitted for pneumothorax. He was previously healthy until the morning of admission when he …”
“Stop there. What’s his educational level?” said the Chief.
“What?” I was taken aback. I had memorized my presentation and was on a roll, but…
“Education level?”
“He’s a prisoner.”
“I see. So he could be a medical student and you wouldn’t know. Perhaps that’s how he has access to needles.”
“No, sir. But…”
“So, has he recently purchased a truck from the Forest Service?
“Um, he’s a prisoner.”
“Because, those trucks commonly carry loads of dirt and scraps from the Central Valley, and he could have Coccidiomycosis, Valley Fever, that sometimes results in spontaneous pneumothorax.”
“Um…”
“Any travel to the Ohio river valley? Histoplasmosis? Exposure to Tuberculosis in an immigration center?”
“…”
“Is he a rose gardener?”
“Um. I don’t know”
“Because sporotrichosis is a disease commonly acquired by rose gardeners, and THAT is associated with spontaneous pneumothorax. Okay, what DO you know about his social history?”
“He’s a prisoner, sir.”
“I see. Okay, C.J., lets do this. I’m tired of interns presenting cases and not obtaining an adequate social history, either for diagnosis or for communicating and connecting with patients. From now on, Dawn Patrol will begin with a presentation of the patient BEGINNING with a detailed social history. Are we clear?”
“…. Yes, sir.” I was too flustered even to correct my own name “No, not C.J., I’m C.T.”
Over the following months, every single other intern at UC Davis personally THANKED me for my performance that morning. “Thanks C.J. Really appreciate it. Social History starts EVERY Dawn Patrol. Great.”
Just to pile-on, turns out the New York Times recently wrote about a medical mystery, wherein the SOCIAL HISTORY is the hero.
CMIO’s take? CJ sez: It is time to re-emphasize Social History in our record-keeping. It has the potential to generate helpful clues about patient illness, transform patients in to PEOPLE in front of our eyes, and improve our connection, our communication, and our own joy in the practice of medicine.
As of last week, I created a one page handout for my Medical Assistant to hand out to every patient she rooms for me:
Where did you grow up? Are you married? have kids? What do you do? What are your hobbies?
And, it is quite astounding what kind of responses I get. I’ve heard:
Well, back in the day, I used to box with Joe Louis!
Now, I will use my Speech Rec tool and place this into the Social Documentation section of the chart, and using a smart-link, ALWAYS display this prominently in my progress note, to humanize the patient, to avoid the risk of my thinking of “the gallbladder in room 3.” These random and often amazing connections are some of my favorite moments in medicine.
Perhaps this has some impact on resilience, burnout, the joy of medicine, the human connection, the ability to distinguish patients on their human stories.
Turns out there are several types of stories to tell in presentations. Dan speaks to the idea of understanding your audience, understanding your purpose for a presentation, understanding what goal you wish to achieve: informative report, imparting a skill, overcoming an obstacle, etc.
Dan writes (and I love this):
“When we tell the truth, we connect with our audience, we become passionate, and we find self-confidence. When we tell a story, we make complex concepts clear, we make ideas unforgettable, and we include everyone. When we use pictures, people see exactly what we mean, we captivate our audience’s mind, and we banish boredom.”
CMIO’s take? There are a number of good books on presentations, like Presentation Zen, Death by Powerpoint, and anything by Ed Tufte (starting with Visual Display of Quantitative Information). This book is a quick read. Powerpoint is DEATH unless we use it with skill. Most have no skill. This is a tiny book, a quick read. Get skills here.
Sometimes it is good to be humble and facilitate the work of smart, innovative colleagues. I recently had the opportunity to meet with some amazing nurse leaders at UCHealth and talk about improving the work life of nurses. We spent two hours white-boarding (or in this case, large post-it boarding) our ideas. They spoke too quickly for this novice doodler to add anything more than a couple of rudimentary doodles, but I very much enjoyed the interaction and capturing the free flow of ideas. In this session, I served purely as facilitator, and had little to contribute from a content perspective. It is remarkable how effective and refreshing this is: to remove oneself from the details of the discussion and purely think about categorizing, shaping, guiding a discussion to a productive conclusion.
Although I’m a fan of Edward de Bono’s books on Serious Creativity, and Six Thinking Hats, I don’t claim to be an expert practitioner of his ideas. I do, however, often use the Thinking Hat colors to easily redirect comments during meetings that threaten to derail conversations, for example:
“This will never work, because ….” (“Thanks! That’s black hat thinking, and we’ll get back to that later in this meeting, meantime, lets ….”)
“Hey, what about this other idea that I had” (“Hold on, let me jot that down on this other sheet. OK, with your permission, lets return to our current discussion on …”)
“Are we even thinking about this right? because …” (“Great point. Do we want to pivot and discuss this now? Or shall we finish our current discussion?”
At the right time, these are crucial inputs. At the wrong time, it can derail a nicely-unfolding sequence of collaborative comments. So, to guide our conversation, I set up a couple of items:
We were scheduled to meet in our fancy 10th floor Board room, a room with a large projection screen, lots of hanging art, and NO WHITE BOARD. So, I requested a tripod with large post-it notes. Although I’ve not seen it done, I asked the attendees to remove all the meeting-overflow chairs lining the windows and use the windows themselves as my massive white board (so satisfying!).
Arbitrarily, I suggested that “Low hanging fruit” would be a discussion category, written in green. “Blue Sky” thinking would be generating ideas about the ideal day for nurses. “Red hat” would indicate the things nurses hate about their working day. And so on. I very much enjoyed running back and forth and placing comments in the right spots on the wall so that threads of conversation did not cross, and to allow older threads to be resurfaced smoothly. And, it was easy to see where we needed to fill in more details as the meeting went on.
Finally, having ended up with dozens of possible projects, I asked the participants to “put your nickel down,” something I learned from a physician attending when I was a resident. Often during rounds, we would generate numerous possible diagnoses for a patient. Part of the learning process was “committing” to a specific diagnosis. So, he would ask us to “put your nickel down” on the ONE diagnosis, of all those discussed, and to see in the next couple days as test results returned, which diagnosis was correct, and see how our intuition and diagnostic skill performed. One learns SO MUCH from committing to something rather than “seeing how it turns out.” Similarly, “putting your nickel down” allowed us to choose the 1-3 ideas that we would put our collective efforts into.
One of the nurse participants let me know: (1) “Your handwriting is too nice for you to be a real doctor” and (2) “Can we do this more often? It is a good feeling to have a doctor scribing comments for a meeting of nurses.”
As Maui would say from the recent movie Moana, “You’re Welcome.”
So many scientists and doctors I know are terrific at science, and SO impressively smart. Kudos to their years of training, discipline, self-sacrifice. And yet … many (perhaps most) have no idea how to tell a story. In fact, “telling stories” is often construed as lying, or at the very least, being unscientific, and not “evidence-based.”
It is a terrible tragedy, therefore, as the Internet echo chamber relentlessly promotes those who can write a tagline, a teaser, a STORY (autism and vaccines, anyone?), and those scientists and researchers with deep knowledge and expertise, have no effective training to fight back, and are drowned out in the hue and cry.
Michaelangelo said: “I saw the angel in the marble, and I carved until I set him free.”
Reminiscent of the great artist, this book laid out 3 techniques to help me see the narrative inside our lengthy, cluttered, many-faceted, detail-oriented scientific pursuits. This book was written by a dissatisfied, tenured Marine Biologist, who quit his job to go be a screenwriter in Hollywood. Screenwriters, he says, are the “working class storytellers of our age.”
CMIO’s take: I thoroughly enjoyed and devoured this book, and now, like the ageless Hero described by Joseph Campbell, and with the aid of such books as this, I will face my personal limitations, and transform myself in order to face and overcome my challenges.
Increasingly, I am frustrated and dismayed that one of our presidential candidates had to profess: “I BELIEVE IN SCIENCE.” Has it come to this? Does a democracy necessarily give such freedom as to devolve to the “freedom to be ignorant and believe whatever you read on the Internet”?
Over the years I’ve gradually improved the presentations I’ve given, by reading and hearing great speakers. Steve Jobs at Stanford, Barack Obama, Ken Robinson (on education), Jill Bolte Taylor (a neuroscientist’s personal stroke story). And I contrast them with the presentations I’ve heard in college, medical school, from physician colleagues and scientists. And the difference is … STORY (or lack thereof).
I believe this is also true to some degree among physicians. Even though all humans think in Narrative, we confuse it with our many meanings of “story.” Scientists demote “story” and “narrative” to second class citizens, in favor of dry statistics and ‘p-values.” WHY? I think it is to the detriment of our purpose: to FIGURE STUFF OUT, to TELL PEOPLE ABOUT IT, and to HAVE IT MAKE A DIFFERENCE IN OUR LIVES.
This is a long (and far from complete) journey for me, but some of the books and website I’ve read and would highly recommend, include:
in which the author indicates that there is a way to boil down stories to: one WORD, one SENTENCE or one PARAGRAPH. He also references Joseph Campbell’s The Power of Myth and the Hero’s Journey, and many other time-tested narratives, and claims (very successfully) that story and science belong together, and all of us need both to survive into the future. I hope you get as much out of these as I am starting to (referring to myself as the flawed protagonist, who faces a daunting challenge, and must solve his personal flaws to overcome this challenge; read the book to understand).
So cool. Just like learning how human anatomy works in medical school: you never look at other humans the same way again.
The Sacred Bundle, for example, describes how American Indian tribes would constantly relocate. At every new temporary settlement, the chief would carefully unwrap the cloth sack, gather the tribe around him, and take out objects from “the sacred bundle” one at a time. He would hold each one up: “this stone was from the river where our tribe first came together.” And he would tell that story. “This feather was from the head-dress of our bravest warrior. He died protecting …” and so on. This retelling at each new location made that settlement home, and the common knowledge ran through the tribe, and all members grew to know it by heart.
What an incredible, simple thing. I am striving to create this sacred bundle, for our large and growing organization. In our Digital age, is it sufficient to have a “virtual” sacred bundle? Do we need physical, tangible objects to remind us from whence we came? Can storytelling save science and healthcare?
image: http://firstpersonarts.org/storytelling/