Thanksgiving #2 During Pandemic: giving thanks

Dear Reader. This is an email I sent to my Large PIG (physician Informatics Group) this week. I wish you all a restful holiday. CT

Dear Provider Informatics Group members: My General Medicine Division Chair sent this today, and it makes me reflect about Thanksgiving. I wanted to pass this along to you. It has been 20 months of chaos, emergency changes and emotionally draining life at work and outside work.

“The arc of the moral universe is long, but it bends toward justice.”

Martin Luther King

It is a reminder that in our day-to-day, all we see are boulders and rockslides in our path. In the long run we are bending the path to reduce burnout, improve connection and improve care. Our work affects 6000 providers, 15,000 nurses, and a couple million patients. 

I am thankful to be on this journey with you. I hope you can take some time this week with family and loved ones. CT

—–

From: Earnest, Mark
Subject: Giving thanks 

Dear GIM Colleagues,

Ms. Sutton, my third grade teacher, taught me to start letters that way – with the word “dear.”  

Since leaving her classroom, I’ve not really given the word much thought.  Aside from placing it at the start of letters, or employing it generically as a term of endearment for my wife, I haven’t used it much.  I use it even less now since “hi” or just a stand-alone first name have become de rigueur for email greetings.  Using it less, I think, is a mistake.   According to Google, “dear” means “regarded with deep affection; cherished by someone.”

Today, I want to use the word with intention. 

So, let me start again.

Dear GIM Colleagues,

We are approaching the one day in our calendar each year that we set aside for thanks.  I’ll confess that after 20 months of the pandemic and all the associated fire-drills, chaos, and public acrimony, I’m much more facile at bringing to mind the things I’m not thankful for.  That may be the most compelling reason to devote my attention this week to its intended purpose – focusing on the things in my life that I cherish and regard with deep affection. 

I’ll not bother you with my gratitude list in its entirety other than to say how much I look forward to a house that is again filled with its full complement of family.  I do want to reflect for a moment on work.

As a young man, choosing a career path, I was clear about one thing.  I didn’t want a job.  I wanted a purpose.  I was fortunate to find that calling in medicine and ultimately in GIM.  I chose well.  I have always loved caring for patients.  Along the way, I’ve found other, related opportunities for growth and points of purpose: teaching, mentoring, helping others find and actualize their purpose…  In all honesty, work for me has been a great source of joy and satisfaction.  A wonderful side effect to finding my purpose, has been the privilege of working alongside other purpose-driven people.  If I could start from scratch and hand-pick a group of people to take this journey with, I could do no better than you – my dear GIM colleagues.  It is a profound privilege to be part of such a caring, committed, selfless group of people. 

Now – after twenty long months and in the midst of a surge – is almost certainly not the easiest time for any of us to hold our work dear.  It has been hard.  Nevertheless, it is possible to be tired, even exhausted, and thankful at the same time (ask any marathoner at the finish line).   Unfortunately, we are not yet at the finish line.  We have a challenging winter ahead of us.  That in and of itself should be reason to pause and reflect. 

I hope this week that each of you can find a moment to consider our common purpose(s) and find the space to be thankful for it.  Doing so need not deny the challenges we’ve faced or the sacrifices made.  Each day, in ways big and small, you have all made our world a little better.   Because of your work, each day there is a little less suffering, a little more hope and a little more knowledge and understanding.  Surely that is worthy of thanks. 

I am not aware of much more we can do to turn the tide of the pandemic.   Somewhere ahead of us is a finish line.  We will face more challenges before we cross it.  We cannot control all of those difficulties, but in the months ahead, we will be focusing on the ones we can change.  We will be looking closely at the circumstances and structures that impede our purpose and make our work, particularly our clinical work, more difficult and less joyful.   We will be looking for meaningful, actionable ways of rethinking and restructuring our work to make it more joyful and sustainable.

In the meantime, I hope you all can find the space to feel thankful for what you’ve done through this great time of trouble.  I am thankful for each of you my dear colleagues, and hope that this week you will enjoy rest and gratitude among those you hold most dear. 

With gratitude and thanks,

Mark

Mark Earnest from History Colorado dot org website

Mark Earnest, MD, PhD, FACP|Professor (Pronouns: he, him, his)
Division Head –  General Internal Medicine
Meiklejohn Endowed Chair of Medicine

An AI-human bill of rights?

https://www.wired.com/story/opinion-bill-of-rights-artificial-intelligence/

Read the Wired.com article. In brief, it outlines the emerging risks of relying on AI (artificial intelligence) tools that can unintentionally create bias and other consequences.

This is a nascent class of technology that, at its root, is often a black box: what is inside, is opaque to us, the users, and often to us as the designers.

I feel this critique personally. Having participated in the design of several AI tools in healthcare, I worry that, although we do our best, we don’t know what we don’t know.

CMIO’s take? I have no “best practice” lessons to impart here, on bias and the unknown. Do you? Please share. This is a big mountain we are about to climb, and we need to help each other.

The pandemic, patient messages and phone calls: Octopus or Starfish?

Here we are 19+ months into the pandemic. Time to look at our (unvalidated) trends within our 12 hospital, 1000 clinic health system in Colorado.

Top (blue) line indicates outpatient visit volume monthly from Sept 2019 through Sept 2021. Over 2 years, we saw that dramatic dip in volume in March. That was followed by a gradual recovery and a 10% sustained increase in volume since then. We have added some clinics to our system in the meantime.

Magenta line indicates online messages. We started at 58,000 monthly messages in September 2019, and have sustained 180,000 messages in the most recent 3 months of 2021, a 3 fold increase in patient messaging. OK to ignore that weird peak in Mar 2021, related to a one time system broadcast. This is a real concern for provider workload.

Orange: Surprisingly, we also see an increase in telephone messages (triage-type phone calls): from 23,000 to 35,000, a 1.5 x increase. This means that online messages have NOT replaced phone calls since the onset of the pandemic. This could be related to the growth in percentage of our patients who now have a portal account (growth from 70% to 85% of our patients enrolled in a portal account, over 1.6 million accounts), as well as existing portal-using patients sending more requests and messages, wanting to avoid in-person visits.

Red: Additionally, Scheduled Phone Calls (non-existent prior to pandemic) are now at 5000 monthly messages, and

Green: video (virtual) visits went from nearly zero, up to a peak of 70,000 a month, then stabilizing at 23,000 monthly.

It is an interesting, evolving picture. We have not formally changed staffing or workflow to accommodate this change in message and visit volume, and it has resulted in a massive increase in inbasket messages for providers and staff, with concerns of an unmanageable burden and real risks of burnout for providers and clinical staff.

We believe that, at its root, patients want care, are more anxious about their health during a pandemic, want to avoid in-person visits, have learned about our online tools, and are unclear as to the best way to interact with us.

We could: improve our “front door” experience “Here is how best to contact and work with us”. We could improve our triaging of incoming messages to find the right location/time/place (online message, eVisit by messaging, online chat, scheduled phone call, virtual visit, urgent care, emergency department, other innovative approach).

We could ensure our teams know the best practice for: handling patient questions, prescription renewals, referral requests, outreach programs, remote monitoring, when to suggest video or phone visits, huddling in-person to replace unending back-and-forth messaging.

OCTOPUS

As a result, we are kicking off a major Inbasket redesign initiative. Although our inbasket settings were carefully considered and modified over the years since 2011 (our original Epic go live) with careful feedback from our physicians and informaticists, we still have opportunities:

Inbasket TECHNICAL changes:

  • Eliminating “messages > 12 months old”
  • Reducing the “FYI” and not-actionable messages
  • Auto-deleting some categories of messages after some period of time
  • Creating smartphrase responses to improve thoughtful responses to team mates and to patients
  • Streamlining the ‘response buttons’

Inbasket WORKFLOW changes:

  • Creating best-practice teamwork for “top of license” work
  • Considering innovation tools to “auto-reply” to common questions
  • Moving complex conversations away from portal messages to scheduled phone calls, virtual visits, in-person visits, urgent care as appropriate
  • Considering billing for complex portal messages with patient consent

Just like with Physician Burnout and Wellness in general, there is plenty of work for everyone in Inbasket improvement: there are at least 8 arms to this octopus. Even if we can just “hack off” some of the arms (hmm, perhaps not the best metaphor for healthcare), we can certainly reshape the octopus into something more manageable (a starfish?).

STARFISH

CMIO’s take? Is your inbasket an octopus or starfish, or some other marine animal entirely? It is time for a wholesale re-imagining of our messaging and communications with patients and with each other. What are you and your teams doing in this area? Let me know.

Canyonlands, the Zen of Sand, and my most embarrassing moment

Canyonlands Utah in the 1990’s was a beautiful getaway for me and my then-fiancée. Having heard of this wonderful mountain-bike mecca, we had come, bikes-on-top of my subcompact, met up with our tour group, a diverse crew of men and women of various ages.

100 miles

It would be 100 miles in 4 days across rugged terrain on mountain bikes with a group of 12, a couple of guides and a required-escort (at that time) park ranger. Check it out for yourself, it is a quintessential southwest wonderland.

https://www.nps.gov/cany/planyourvisit/whiterimroad.htm

We begin with a 1000 foot descent into the canyon along a jeep trail. We had brought our old unsuspended bikes with hand brakes. Although the ride was hard on our bodies, we were pleasantly surprised that our equipment was up to the task.

wildflowers from nps.gov
from nps.gov

Our ride was a blast: wildflowers, spectacular vistas, and good company, with mostly flat single track.

Great Canyonlands photography at traveldigg.com

Our guides drive a 4×4 SAG wagon with our gear and food and set up not only our first lunch, but all our meals for the coming days. We have gallons of water that we don’t have to carry! Our camelback hydration backpacks are fantastic for on-the-bike refreshment. This is the life.

Glamping (glamour camping)

At about 25 miles into the trip, at the end of the first day, we get to camp: our guides have driven ahead, set up our site. Dinner is ready and all we have to do is pitch a tent, grab a plate and a folding chair, sit and eat. So awesome. And after dinner, a campfire (apparently forbidden in recent years in the park) and then the Milky Way. Canyonlands, and other national parks, are famous for the lack of light pollution and the spectacular view of the night sky.

photo by the author on an iPhone (!), but in Gunnison National Forest, not Canyonlands

At the end of our third day of riding, as we set up camp, our guide tells us: the Green River is about 4 miles away for anyone wanting an extra excursion. Only I take up the challenge, others choose to rest at our campsite. At the time, I was training to ride my first (and only) double century later that summer (200 miles in a day: the Davis Double, but that is a story for another day), and I was anxious to get in some additional miles.

The Zen of Sand

Solo, I head out. We had learned from our guides about long patches of deep sand on the trail, and the “zen” trick of sitting back, focusing on being “smooth and circular” on the pedals, having a fingertip light touch on the handlebars, and gazing far down the track to improve balance. If done just right, one could “float” over deep sand on the trail. Turns out, this guy agrees with me (youtube).

I actually had a few moments of success doing the sand-float in the shadow of the Airport Tower formation, entirely alone with the crags and formations of the Southwest landscape. Other times, I did the meditative sand-bike-walk.

Sun God

Arriving at the river, I stash my bike in the shrubbery. I see a flat rock jutting out into the river and I determine that I’m going to skinny dip, be clean for the first time in days, and sun myself dry on the rock. Should be great.

To my parched, sand-and-sunscreen-caked, sun-blasted body, splashing in water is heaven. I soak in the cool, rub off the grime, submerge my head and hair and luxuriate.

Then I climb out into the rock, buck naked and unafraid. It has been days since I’ve seen more than our merry biker band, and they’re all kicking back at camp. I shall air-dry, sensually alive and glorious.

Author sitting on a rock outcropping. But not naked. And not the same rock.

I am a glorious human form.

I am one with nature.

I am a Sun God.

Tinnitus?

In the back of my head, I begin to hear a buzzing. What is that? Do I have tinnitus? Odd.

It gets louder. Hmm. A washing machine? Absurd.

Yet louder. An airplane? I look overhead. No contrails. Nothing. Clear blue to the horizon.

Unmistakably the sound of machinery. Rrrr-rrrr-mmm-mmm.

cdn.getyourguide.com

… and around the bend of the river, a 20-seater tour boat, 20 feet away, a gawk-fest of tourists, with a couple kids pointing out the naked man with a bike-shorts-tan splayed out on a rock in the river.

I believe all parties were mortified.

What was there to do, but wave? And then =plop= back into the river.

author, hidden

I am a bottom-dwelling salamander.
I am a shrinking violet.
I am an overexposed slide.

Oxygen masks, John Hodgman, and a hotdog?

This was a good week. Like many of my medical colleagues who are plowing through our next surge of Covid patients, we have feelings of exhaustion, angst and sadness, or as one of my Twitter colleagues on #medtwitter calls it, a new emotion called ‘emptysad.’ So apt.

So it was great to get out of the house, and learn to occasionally ‘put my own oxygen mask on before assisting others’, as our airline colleagues would say. Today, I’d go for a 35 mile loop around Denver. Come along on my visual travelogue!

There’s lots of construction on the Highline canal, the Sand Creek trail, and the Cherry Creek path. I can’t wait to see what turns out. Meantime, we have detours upon detours. Here’s one near Northfield, an expanse of wild sunflowers illuminating the margins of I-70.

This is a 3.5 hour loop for me. The great thing is: very little bike or foot traffic even on a holiday weekend. The smoke is less noticeable today, the sky is blue, the Colorado zephyr winds still cool through the day.

Then, the Confluence of Sand Creek and Platte River, both the wild fowl that frequent the area, and also the industrial ‘aromas’ of Commerce City and the Purina Puppy Chow plant. Such a juxtaposition.

Then it’s a quick dash upstream along the Platte, to Confluence Park, where Cherry Creek meets the Platte. Here, see the crowds for REI and the splashy mess of shore that is kid and dog and kayak friendly.

The hot dog stand is reliably yummy.

On the way home, I found my informatics and physician colleague Steve Rotholz at his outdoor photography booth at the Cherry Creek Arts Festival. Further surprise: he’s reading our book club book for the month: You Look Like a Thing And I Love You. A great explanation of AI and the weirdness that ensues in the development of these tools.

On the quieter parts of the trail, I listen to my current audio book: Vacationland, by John Hodgman, read by the author. I have loved his previous stories on The Daily Show and on public radio. He doesn’t disappoint in this autobiography.

I hope you’re finding ways to have a restorative summer. Go out and do something you love.

How to Get Things Done When You Don’t Want to Do Anything (NYTimes)

How to Get Things Done When You Don’t Want to Do Anything – The New York Times (nytimes.com)

from nytimes.com, George Wylesol, article by Cameron Walker

This spoke to me. Maybe it speaks to you. This pairs well with another recent NYT article by Adam Grant on Languishing:

by Manshen Lo, NYTimes, article by Adam Grant

Feeling Blah During the Pandemic? It’s Called Languishing – The New York Times (nytimes.com)

It is okay to forgive ourselves this feeling, that we’re not 100% on our game, that we’re not giving 110%.

CMIO’s take? I’m taking more breaks, connecting more with friends outside work, disconnecting from work tasks more, finding small, enjoyable things, reading more books for fun. How about you?

All successful projects have a great story. What is yours?

Anyone out there trying to get a project funded?

Maybe, some of you are trying to get the attention of leaders in your organization to try an idea that is important to you?

Perhaps you’re frustrated that colleagues don’t agree with your viewpoint, and no one seems to listen?

Or, some say “your explanations are just so dry, we miss your entire point.”

Yes?

Consider: that in healthcare, and as scientists, we are taught to memorize our facts, build on scientific principle, and be rigorous. We rarely take the time to learn storytelling and communication. In fact the phrase “tell a story” in medical interview implies that you are lying.

Well, time to change all that. As informaticists, as medical professionals, as scientists, we need to be masters of storytelling. It is the ONLY thing that changes minds.

‘Sure, keep doing the great science that we all do, but let’s learn to communicate.

One of my favorite instructors in communication is Andy Goodman. At his website, you can sign up for his newsletter (and read archival issues, here is a good example about SMALL stories, and another one about Powerpoint use). His center is dedicated to improving the communication of all-important non-profit companies.

Here’s an example of his paradigm shifting ideas: “Why are non-profits named after things they are NOT? Why not name them for things they are FOR? Non-profits should be called “Public Interest companies.” Huh. How about that?

And, watch his talk above.

CMIO’s take? We all need to talk gooder.

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