I’m spending the week away. No email, no meetings, virtual or otherwise, phone in airplane mode, escaping the trappings of life on the grid.
We are out camping, scrounging for firewood, burning our food on camp stoves or in the fire ring, canoeing up meandering rivers, and hiking Colorado’s spectacular wilderness.
This is so fun, who cares about catching actual fish?
I’m perfectly happy to have others in the family gear up to fly fish. What I have under-appreciated is that fly fishing is also a spectator sport. To me, catching the fish is incidental: we catch and release anyway. The draw, for me, is watching the sublime curve of the line and the meditative ‘ssshhh’ as it undulates back and forth and then settles silently into the lake.
We are just car camping, but it is just out of my comfort zone, so this is enough of a stretch for me. Found a perfect hike near Vail: 6 miles up to and back from the cascading falls near Lower Piney Lake.
My favorite thing: picking a sunny boulder at the edge of a mountain stream at the turnaround of our hike, slipping the hiking boots and socks off, anticipating the bracingly-cold water. Then, easing the aching feet into the stream: the first Yelp of surprise (every time!) the almost-painful cool, the feeling of ice-cold veins rising up, developing an internal minty feeling. Clear. Clean. Rested.
Nothing like it.
Gets me recharged for the hike back.
CMIO’s take? Seek rest and moments of peace. Resilience stems from recovery in the face of change. There has been so much changed in recent months and years, and too often I see physicians not taking the hiking boots off, no time for the mountain stream refresh.
What is this round thing? Fun sculpture around campus.
We walk past these structures every day. When I ask my colleagues, none of them know the history of these objects.
The Art Walk / Globe Sculpture represents the connection between healthcare education side of the campus, and the research / clinical side of the campus. Beginning on the education side, a solid sphere is positioned adjacent to the Education quadrangle, 5 buildings where five schools share classrooms and resources (see link to walkabout blog). Down the long, uninterrupted sidewalk, you can see that the sculptures all line up, through various archways, to the final sculpture on the research and clinical side of the campus, represented by the wireframe sphere.
A nice metaphor: the undifferentiated form of a sphere could represent an the raw idea, the unsophisticated view of healthcare, where the underlying principles are unseen. On the other end, traveling through time and space, and the years of a healthcare education, the wireframe represents the discovery and use of hard-won knowledge of the underlying structure of the sphere, to be employed in the discovery of new knowledge and the use of this knowledge in the care of patients and populations.
For me, it is reminiscent of the metaphysical Fuzzy/Techie line at Stanford University, represented by an imaginary line dividing the scientific side of campus and the arts side of the campus. Ours is better, methinks.
Little known fact: All these sculptures have power outlets and free wi-fi!
Coors Field. Reds at the RockiesSo the planning went great. A day at the Rockies game with the inimitable Epic ambulatory team, a cool, hardworking group of young, fast-learning folks.
Word comes that UCHealth is a Rockies corporate sponsor and we have tickets for the team to sit in the Rockpile, centerfield, nonshaded bleachers in 92 degrees. Sign me up!
So, I came in to work early, cranked out some awesome spreadsheets, knocked off early and headed to the game.
Bonus: I planned to park near home and take the new University of Colorado RTD A-train to and from Coors Field.
University of Colorado A train Rockpile!Here we are! Time for some hot links and beans!
I wear this polo shirt every 10 years or so, whenever the opportunity arises. Union Station: downtown reinvented.Get up to the famous Rockpile…
Find my seat, settle in for a fun afternoon…
Hey, where is everybody? I’m only a few minutes late for the 3:10pm start …
Empty bleachersHmm, they’re announcing the 7th inning stretch. Something wrong with this picture. Look at the ticket again. 1:10pm start. Seems that the website was citing Eastern time. 🙁
AND, 90 degrees for 2 hours had most folks wilting and ready to head home. Rockies down 2-6 anyway… I had just missed them.
Not everything works out as planned.
Hot tip: do not add insult to injury by missing your train stop on the way home, whilst writing your self-pitying blog post. It could happen.
Wrong station on the way home.
CMIO’s take? just like in informatics, ‘The best laid plans of mice and men go oft awry.’ Several examples come to mind:
–Issue: University specialist physicians often forget to write referral letters back to referring physicians and patient’s primary care physicians. Idea: why don’t we automatically route a copy of their note to the referring physician and PCP? Unintended Consequence: nicely formatted, custom-built sub-specialty letters with names and contact info are replaced with the generic letter necessary for the automatic process. After some scrambling, things are getting better.
–Issue: physicians often do not record ‘exercise as a vital sign’ in the patient’s medical record despite exhortations by experts that this could help prompt Americans to exercise more, and track healthy habits. Idea: One of our cardiologists helped build a module to remind docs to do so: type of exercise, days exercised per week, minutes exercised per session. Simple! Elegant! (He wanted to set this as required for all outpatient visits across our system: all 2 million of them per year). Unintended Consequence avoided: our physician informatics team informed him that, until he gets agreement from physician leadership representing the many physicians who would be affected by this one change, we would NOT turn this module ‘on’ as a required element. Whew!
Any recent unintended consequences come to mind? Leave a comment. Happy July!
If you’re a parent, think of putting aside your own harried life and occasionally accepting the random invitations that come your way. In my case, that’s an invite from my teenager: “Hey, Dad, lets head over to Red Rocks and see the sun come up this weekend!”
Suppressing my instant “Are you KIDDING?!” response, I thought about it, rolled my eyes, and eventually said “yes.” Sure, the getting up at 4:30am, the inevitable LONG midday nap that follows, the exhaustion… it is worth the look of joy on the face, the teaching of the life lesson, that it can be more important to say yes, to be the ‘first follower‘ (don’t miss this video!) can be powerful, life-affirming, and a way to create a stronger bond with those soon to leave the household.
And, just maybe, the sights are spectacular. Leaving aside the gas-powered air blowers and the leftover “aromas” of excessive alcohol and perhaps other substance use of the night before, its good to appreciate how beautiful a life surrounds us.
CMIO’s take? Despite the grumbling from teenagers about “life lessons from Dad … again,” sometimes, “life lesson” come from following your teens, being open and being willing to be surprised by them. Maybe even substitute the phrase “team members at work” for the word “teens.”
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.
At UCHealth, our multi-million dollar robot train allows us to run the top 50 types of test results as “stat.” This means when the blood arrives in the lab, it takes about 10-15 minutes, tops to run the blood test and report it into the Electronic Health Record so that doctors and nurses can act on that information.
This robot combines with a fancy multi-channel pneumatic tube system that spans across multiple buildings, and transports blood samples drawn from patients in our Cancer Center, about a quarter mile away. Furthermore, our nurses print pre-barcoded labels specific to the patient and the request lab order, so there’s no mix up during transport.
The 3 technologies together make it so that from lab draw to test result is typically less than 30 minutes. Compare this to the “old way” of human transporters who walk around between buildings every few hours collecting specimens, and lab technicians who run tests in batches, by hand, with lots of err0r-prone human transcription. You’d be lucky to see an 8am blood test return a result by mid-afternoon.
This is amazing on many levels, and so few people know about it. I bring students, residents and colleague down for a show-and-tell tour any time that I can.
Our lab technicians simply transfer the pre-barcoded tubes from the pneumatic transport canister to the robot intake rack. An articulated arm with camera spots the tube, grabs it, scans the barcode, puts the tube in a carrier slot on the railroad, and sends it down the track to the right machine in real time.
Once at the machine, the centrifuge has 6 slots. At busy times, all slots fill up quickly and the spin begins. If there’s a backlog, additional tubes are re-routed to an alternate machine to start a new load in-parallel. If there aren’t enough samples to run a full load after 5 minutes, water-filled tubes are selected automatically to fill empty slots and the centrifuge runs. Brilliant!
Sometimes tubes are needed in separate machines with different processing needed. The robot is smart enough to split off and label “daughter tubes,” pipette out the right quantity, and send each one to the right destination.
At the end of the line, lab tubes are stored in the automated Stockyard for 3 days in case of needed “add-on labs.” The seamless interface between the EHR and the lab system allows ordering physicians to be reminded “Do you want to add your new order to the existing specimen?” If yes, the robot retrieves the blood, runs it back up the railroad, processes the new order, with no human intervention.
This ONE IDEA has saved 30,000 repeat lab draws on patients, in ONE MONTH, at our University hospital. Astounding. Faster for doctors receiving important results, cheaper for the lab, one less “stick” for patients.
A true win-win-win.
CMIO’s take? So cool. I wish =I= could ride the railroad. Or maybe it is time to retire and take up model trains. Does your organization have one of these? Or maybe you were a model train enthusiast? Let me know.
In a surprise event, our Anschutz Medical Campus in Aurora, Colorado announced an amazing art exhibit comprising Rodin sculptures, Monet, Renoir, and various other paintings, drawings and sculptures from a private collection. I discovered this in a small news blurb, left my office, and walked down the street to the single-room art gallery in the Fulginitti pavilion.
I spent some time picking my jaw off the floor. Then I took my sketchbook out and begin trying to capture some of what I saw.
What’s terrible is how infrequently I stop to smell the flowers. What’s mediocre is how poorly I draw. What’s fantastic is putting aside all concerns and focusing on one painting for half an hour.
Claude Monet
A few years ago, I very much enjoyed art exhibits AND I wanted to stretch myself, BUT I was afraid of being criticized, THEREFORE I silenced my inner critic and started sketching.
What’s important is NOT the finished piece (thank goodness), but the experience of spending quiet time really LOOKING and SEEING and BEING PRESENT. It is incredibly peaceful and rewarding.
CMIO’s take: Slow down, you move too fast. You’ve got to let the morning last, now …
Let me know if you’ve experienced something like this.
Doodling. I recently gave a talk at the Health Evolution Summit conference in Dana point California. It was a humbling experience, as I was expecting to give the standard PowerPoint presentation, and was told: “no,” that instead, I would be out on the lawn in front of the wind and surf and be giving a talk on a flip-chart.
This provoked a great deal of anxiety, and prompted ego- and personality-rebuilding. Then I thought of my sister’s book recommendation “The Doodle Revolution.” And so I took my story, boiled it down into symbols, and give a talk, which was not unsuccessful.
Turns out, googling any concept attached to the word “symbol” allows you to see what other people have used for symbols, such as for “strategy” or “manager” or “project manager” or “consensus”. Try, for example, googling “consensus symbol.” Well, at least it starts the creative juices flowing.
I challenge any of you to understand my chicken scratch doodles and interpret them into a coherent narrative. The good news is, I’m no longer afraid that my terrible chicken scratch will be criticized. I know that it will, and it’s still helpful to me and to my audience. I’m learning to get over myself.
For those of you interested:
The “upside down spaceship” in the corner is really a handshake symbolizing “partnership”
Lets be clear. I AM an EXCELLENT SHEEP, and saw myself critiqued in the pages of this insightful book.
My college-bound daughter discovered this book on the bookshelf of her college counselor, with whom she meets regularly in this, her junior year. I graduated, according to her, back in the paleolithic age, from a school in Tallahasse, Florida, that requires meters of excavation to uncover from the archeological record. Surely NOTHING I learned applies in this accelerated, Modern era.
[Actual quote from, at-the-time-7-year-old daughter: “That was back in the age of dinosaurs, when =I= wasn’t alive, but you were.”]
So, I dutifully picked up this book, as she found it too tiresome to have to explain to me what Modern high schoolers were facing, and how many misconceptions I had carried and how many opportunities I had missed during my own Jurassic years. She was certainly NOT going to replicate my folly.
OK, so I attended Harvard University as an undergraduate and Stanford University for medical school. We will just leave aside the snarky comments of “Ohhhh, you went to Haaahhhvahhd. I’m surprised you even talk to little people like us.” This lead to the decades-long behavior of being vague about my undergraduate career: “Oh, where did you go to school?” “Um, back East.” “Oh, where back East?” Um, Boston.” “Oh, Boston U?” “Um, no.” “So, where?” “Harvard.” “Ohhhh, Haaahvaahhhd! …”
But I digress. The Daughter has informed me that she will NOT be looking at Harvard, not interviewing, not planning on attending there. Instead, she’ll be seeking a college “experience” that is challenging, a smaller school with excellent teachers in smaller classes, a breadth of liberal arts subjects, as she is currently interested in EVERYTHING, good sports, great art, strong science, math, engineering, a place that will give her a chance to discover and grow, and not a treadmill rat race.
Compare that to my upbringing. I do recall the strong suggestion from my parents that “being a Doctor” seems like an excellent career choice to support a family and at least a few grandparents… Interestingly, my over-the-top uncle always insisted that the hard-working Chinese immigrant would “take over America” in several waves: First generation: study math and science, become Engineers! because poor language skills are not a handicap in this field. Second generation: continue math and science, but now, you have better language skills: become Doctors! Third generation: who cares about math and science, because with outstanding language skills: become Lawyers! Time to Take Over the government! So, 3 generations until the Immigrants run the place. Sure, I played my part.
Where was I? Oh yes, and that First Generation drive to excel pushed me into the biggest name University that my parents could think of: the big H. In the years since graduation, I must say that although quite a number of my classmates have gone on to do great things and look back with fondness on those years, a surprising number have mixed memories and some consider it a mistake: a roiling cauldron of 5000 high powered, driven students looking for a stepping-stone to a professional degree: MD, JD, MBA. And on the flip side, did Harvard open doors that were closed to grads from other schools? Perhaps a Stanford Med spot? Possibly, but not for certain. Would I have become a physician regardless? Almost certainly yes.
Big H was big. Economics 101 in Sanders Theater: 1000+ students in one class. Never met the professor. Psychology 101: more than 800 students. Inorganic Chemistry: 400 students, and I approached my first college exam, being ready to regurgitate, as my high school well taught me, the facts I had stuffed in my head. Instead I was faced with 5 impenetrable essay questions: “Let’s theorize a new universe where instead of the usual S and P electron orbitals, there are now 13 electrons in a shell. Hypothesize how molecules would form differently?” Just as I was flipping through the pages, realizing that I could answer NONE of the questions, one of the students in the front row (whom we later understood had taken too many NO DOZE the night before), began to have a seizure. He was carried out by paramedics. We looked at each other in a panic: apparently college exams KILL STUDENTS.
The pressures then were intense, and now that it is several times more difficult to navigate the waters to an admissions letter, I imagine the pressure is even greater. Reports of suicide and high rates of anxiety and depression seem to confirm these fears.
I think I was lucky in my ancient days: finding a small cadre of like-minded students, forming what we called the “Oligarchy” and causing all sorts of pseudo-governance shenanigans. For example, using my new Macintosh to print posters taking credit for social functions organized by others: “The OLIGARCHY welcomes you to tonights’ Dance.” “The OLIGARCHY invites you to come to a screening of Ingmar Bergman’s latest masterpiece.” “The OLIGARCHY is sponsoring the French Accent Table tonight at dinner.”
You see, amongst the pompous French, Spanish, German language tables at dinner at Dunster House, we formed the “French Accent” table, sat one row over from the French table, and proceeded with our best, overly-loud Monty Python accents to overwhelm, dismay and ultimately dismantle and chase away the overly serious. Seriously, though, finding a group where you can belong, can make all the difference in a large University that is seemingly uncaring, and too large to look after all the students all the time.
Excellent Sheep describes the slow evolution of students being shaped by geologic forces into perfect specimens, designed specifically to assemble the perfect high school resume: over a dozen AP courses, straight A’s, months of SAT and ACT prep, a collection of club presidencies, a collection of varsity sports lettermen jackets, and oh, yes, don’t forget those few months spent with the Peace Corp.
Julie Lythcott Haimes, freshmen dean at Stanford, writes in “How to Raise an Adult” that every year the Stanford freshmen class is more impressive than the last. Have we not perfected the high school resume? Justin Hoffman’s The Graduate was a perfect specimen, only to realize he was disenfranchised and fossilized in the older generation’s expectations.
Malcolm Gladwell notes, in his book “David and Goliath” that students with comparable SAT scores who attend the best school they can get into and graduate in the middle of their class, do far worse in their subsequent career (sometimes even quitting their chosen field because of overwhelming competition) than students who go to a strong, smaller school, find a good mentor, a comfortable yet challenging culture in which to excel and graduate nearer the top of their class.
I think I’m taking all this time, reminiscing about my pleistocene years, to meander around to my point. I’m actually fine NOT having my daughter attend Harvard. There are thousands of excellent schools that do not cater to, and do not want Excellent Sheep. They intend to grow strong adults, with a sense of identity, of curiosity, of perspective. Did Harvard serve me well? Sure, and maybe I was lucky. Do I want to use my advantages and push her into a Legacy spot in the Harvard Admissions queue? Surprisingly, I think my answer has become “no.”
Ms. Lythcott-Haimes perhaps should have the last word. I (ineptly) paraphrase: “Our children are NOT hot-house orchids, requiring perfect care and feeding. They are instead wildflowers of an unknown genus and species.” And it is up to all of us to help them discover what they will become.
There was a time when the last major industries using a pager were: drug runners and physicians. But then, drug runners switched to disposable, cash-purchased “burner” phones. Apparently, Breaking Bad and The Wire taught us about this. Having seen neither show (yet: saving up to “power-disk” them some day), I’m still faithfully carrying my pager around.
Why are physicians the last ones? I’d have to agree with other articles that reliability (signal penetrates buildings where cell signal might not), flexibility (don’t have to give out personal cell number, and don’t ‘have to’ respond to a page), low maintenance (change the AA battery once a month, so what if hospital power goes out), and low cost ($10 per month or less) are the main drivers. That, and massive inertia.
I’ve been in healthcare since 1985, and in that time, I remember wearing audio pagers (bee-doo-bee-doo! *static* Doctor, please call *static* 347 *static* Come QUICK! *static*). Sigh. What was the full phone number? Who? Where?
I’ve seen some services try to transition to texting (Please come tell Mr. Jones in 307 that he is HIV positive). Sigh. What was that thing about privacy? Did you really just tell AT&T about Mr. Jones?
I’ve seen other physicians miss critical messages because texting did not work in certain internal locations in hospitals. Gives a new meaning to “dead zones.”
With a growing number of hospitals installing internal cell-signal repeaters, it is possible that pagers are finally on their way out. I will miss them, when they’re gone. They did inspire an entire range of emotions over my career.
PRIDE: Hey! You mean medical students get to wear one?!
FEAR: Oh, man, this thing never stops. Can I just eat/pee/poop without being disturbed?
JOY: Finally, I have graduated residency and I am TURNING THIS DAMN THING OFF!
RESIGNATION: Oh, I have to wear one as an attending physician?
HOPE: Maybe, just maybe we can get rid of it and use our anticipated secure texting system
Finally, I recall my favorite research article, published in JAMA in 1992: BEEPER OBLITERANS. It references the older style “audio” pagers with a small “test” button on the top surface that was easy to accidentally “set off.” I won’t ruin it; you have to read it: http://www.neonatology.org/pearls/beeper.html
