Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Archive for November, 2014

CPOE: Another Epic Misadventure Begins I

It’s my own fault, really. I admit that I had allowed myself to believe that the uneasy peace I’d made with Epic, the EMR utilized at World Class Hospital, would be a lasting one. A peace for all time. I would interact with the beast on a quarterly basis, signing verbal orders that kindly nurses had accepted and op notes for surgeries that deviated just enough from the routine that they needed to be dictated fresh. In return I would be allowed to simply sign orders, op notes, and other sundry paperwork as I had been doing for the last 24 years. Simple. Everyone wins. My OR days run efficiently saving me, my patients, and the institution countless hours of wasted time, and I continue to bring the majority of my cases to one of the outpatient surgery centers owned by World Class Hospital. (It should be noted that I am the lowest cost eye surgeon in the entire system, thereby generating the greatest per/case profit for WCH). I truly believed that I would still find sanctuary in the OR from the thousands of chickens pecking away at my professional satisfaction and by extension my general degree of happiness.

BzzzzzzPfffffTttttt…sorry Doc, that’s the wrong answer. Johnny, tell our contestant about his lovely parting gifts.

For the first 16 or so years of my post-residency career literally every process change in which I’ve been involved has had a direct, positive effect on outcomes or safety, patient experience, or my efficiency. About 8 years ago tiny little negative things started to creep in, some of which chipped away at that efficiency. A few more forms to sign. More pre-op checkpoints for my patients to pass on their way to the OR. Along with this came the madness that arises when a huge organization plays defense against an unregulated regulator like CMS (medicare) or JCHO (the hospital regulator). Not one, not two, but three personal checks by the surgeon to confirm the surgical site. A pharmacy either running scared or run amok that demanded a brand new bottle of eye drops for every laser patient despite an industry-wide infection rate on lasers of 0.00000001%. It was mostly piddly-diddly stuff, and the OR staff did their very best to run interference and preserve our efficiency.

Now? Oh man. The introduction of the Epic EMR into the OR has turned our 2-nurse room into a 2.5-3 nurse set-up. There is so much dropping down and clicking necessary to fulfill the beast’s demands (man, would this analogy be perfect if they still let us call them Computers On Wheels?! Feed the COW!). Previously, one circulator could do all of the paperwork, prep the patient, and have time to spare to facilitate room turnover. Admittedly I move pretty quickly as I do cataract surgery, but it’s impossible for just one person to do all of these tasks now that Epic must be served, without all of the rest of us sitting on our hands and waiting. The local administration and the staff have rallied around me and my patients and for most cases an extra pair of hands is there to keep things moving. Heck, I do my part as well by taking the trash out of the room and bringing the used instruments back to the sterilization room.

With the introduction and implementation of CPOE (Computerized Physician Order Entry) all of our efforts to improve efficiency, with all of the wonderful things efficiency brings, will be for naught.

How can I possibly know this before experiencing it even once? People talk, and doctors are people. I’ve chatted with a score of surgeons about how long it takes for them to do what Epic and World Class Hospital requires of them, and I’ve got a bit of experience just signing stuff after the fact. It just simply takes a lot of time. Add to that an institutional indifference to the psychological effect of hoovering  time out of a surgeon’s day and you’ve created the world’s biggest, most frightening chicken peck.

Tell you what, let me share a few numbers with you before we make the switch, memorializing them here, dated, before the transition, so that there’s no possibility that I made stuff up after the fact. The baseline numbers I am about to share admittedly are rosy in part because everything that can be done to/with the paperwork by someone NOT me happens as part of well-established routine. Details such as start/stop times, IOL serial numbers, etc. are filled in by support staff; there is little to no chance that this will be the case when everything moves from paper to screen judging by other surgeon’s experiences.

95+% of my cases are either cataract surgeries, post-cataract lasers, or lasers to treat dangerously narrow anterior chamber angles. Through a combination of fortunate genetics and hard work I have become very good, and very fast, at all of these procedures. My team and I achieve enviable outcomes and microscopic complication rates despite the fact that we move very, very quickly. A patient having cataract surgery spends approximately 15 minutes in the OR. For comparison sake, a study from a prestigious eye hospital recently posted an average time in room of ~33 minutes for its top three cataract surgeons. Turn-over time (patient out/next patient in) is 6-7 minutes. On average it takes me 26 seconds to complete ALL of the paperwork that must be done in the OR. It takes another 9 seconds to sign the op note when it is returned from transcription; this is important because Epic will require either finding, editing, and signing an op note in the OR, or dictating one on the spot.

Our team of nurses and doctor has achieved an even more enviable efficiency when doing lasers. The average time it takes for a patient to have the entire laser experience–enter the laserium, be seated at the laser, have the laser successfully performed, and leave the room–is 3 minutes. That is not a typo. The average set-up in the United States is closer to 15 minutes or more for this procedure. At the conclusion of the laser it takes me on average of 17 seconds to complete all of the paperwork that is required, and again 9 seconds on average to sign the op note when it becomes available.

You’re probably thinking why this is a big deal, aren’t you? That I should stop whining and just get on with it. Here’s the rub: I do lots of these procedures each time I go to the OR. Any additional clerical time must be multiplied by the number of cases done that day, and all of that time will be stolen from my day. When I finish in the OR I then do other stuff that’s pretty important. Sometimes I go back to the office and see patients, patients who may have had to wait a long time for their appointment. On really good days I get to go to my beloved CrossFit gym to get a workout in. An even better day is one on which I get my WOD in and then sit down in front of the computer to write. These latter things, especially, make me happy. They make it worthwhile to work as hard as I do. Every extra minute it takes me to do something I already have to do not only brings frustration in the OR itself but also keeps me from parts of my life that bring me happiness. A happier doctor is generally a more effective doctor.

We are establishing a baseline today, and that baseline includes a certain degree of happiness. What do you think the chances are that CPOE will increase my happiness? Stay tuned for Part II.


Why “Fran” Still Matters

“Fran” came up as the WOD on CrossFit.com a couple of weeks ago. Then it came up at my son Randy’s Affiliate, CrossFit Bingo. For the umpteenth time since 1/1/06 I saddled up and did “Fran”.

I got crushed.

It’s funny…well, it’s always funny when someone ELSE gets crushed by “Fran”…but I was just talking with my friend Jeff about programming in general, and programming for old Guys like us in particular. We’re kinda wonky nerds when it comes to CrossFit programming, and we talk about this stuff all the time. Jeff said he no longer does “Fran” at all, so frustrated is he that he will never even approach his lifetime PR that he finds no value in doing “Fran” as Rx’d. Instead he does all kinds of variations on the theme as a pure training exercise, seeking the value of the work and not necessarily the comparison to a previous set point. I get that, at least to a point.

In that response lies the answer to a plethora of questions about CrossFit programming, and indeed CrossFit training itself. A benchmark workout by its definition is meant to provide a marker against which one might measure oneself. This is one form of the competitive nature of CrossFit, my beloved “you vs. you”. It is also a source of continued attack from outside the CrossFit community, that all CrossFit programming and training is necessarily performed in “attack mode”. Every WOD is only a successful endeavor if you go to that “dark place” in which PR’s are found. This is a gross over-simplification of not only CrossFit but high intensity exercise in general because it implicitly ignores the fact that the definition is “relatively high intensity”. There are some days in the gym when intensity is relatively not very high at all. Sometimes even on purpose.

While I fully understand Jeff’s sentiment (I will never get within two zip codes of my “Fran” PR), and I do find myself looking for “Fran Proxies” for most of my training, I still do “Fran” in both “as Rx’d” and scaled forms. Getting crushed by “Fran” the other day was just as important as a measurement as were each iteration on my way to that PR so long ago. IMO there is a definite value to knowing and understanding where your fitness stands at any moment (mine is challenged by the time issues of not enough time to train, and too much life stress affecting the quality of my non-training time), and “Fran” is as good a metric as any. I had little to give that day, but I still got back value from my training–I went to the gym and moved both my body and a bit of extra weight instead of just heading home from the OR.

We all lose a little bit of our objectivity when it comes to “Fran”, though. It’s the original WOD, after all; every CrossFitter in the world not only knows exactly what you are talking about when you say “Fran” but they can tell you pretty much every time they’ve ever had with her. There’s still much we have to learn from “Fran”, both about ourselves and about high intensity training in general.

“Fran” is pure CrossFit, a couplet that combines gymnastics and barbells in a time domain that allows us to work almost completely within the glycolytic energy pathway. Each time we are about to transition to the oxidative pathway we change exercises. Doing “Fran” is a worthwhile training exercise done as part of a fitness program that emphasizes variance as well as intensity. Even if your fitness has crested, if you are on the back side of the mountain in some way like my friend Jeff and I are, returning to a well-known benchmark to provide a measurement of your moment is still instructive. Knowing where you are at any given time gives you an important compass point that allows you to objectively evaluate why you are there and how you will get where you wish to be. Doing “Fran” as your WOD is step one on your way.

Viewed as either a pure training exercise or a near existential benchmark, “Fran” still matters after all these years.


Earn It.

“Enjoy the weekend off; you deserve it.” How many times have you heard something like that? “They need to give you X; you deserve it.” Statements like that confuse me. What does it mean to deserve something? In a roomful of people how does one determine who deserves what? “He got what he deserved.” Says who?

I like accuracy in my language, at least when considering prose as opposed to poetry or koan. The concept of earning something is much more comfortable for me, much easier for me to get my head around. Whereas there’s a real sense of entitlement in the concept of “deserve”, coupled with a whiff of helplessness in that one must be granted the state of deserving by another, to earn something is a little more like math. 2 + 2 = 4. If you do this you have earned that. This week I earned my days off by doing well at my day job, leaving few to no loose ends that required weekend tying. I earned my keep, if you will, earned the ability to take 2 days away from what provides me income. At every encounter along the way I worked to the best of my ability to earn the respect and trust of those who purchase my particular skill.

Do I deserve any of that? Well, that’s where the idea of entitlement comes in, hand in hand with the subservience inherent in the fact that someone else gets to make that call. If you ask me, not only did I deserve all of that, but there should have been more! What I did should have earned me more of all of that. There’s a fine line between “deserve” and “earn” it turns out, even for one such as I who understands the difference. In certain circumstances the hand of others, seen or unseen, pulls on strings that determine whether you do, indeed, receive that which you have earned.

As Scar so famously said: “Life’s not fairrrrrrr.”

There’s the rub. Fairness. Is what you’ve earned fair? It’s maddening, isn’t it? Even if you foreswear all sense of deserving this or that in favor of earning whatever you are still at risk of falling for the fairness trap. The reality as far as I can see is that, on balance, we all get pretty much both what we’ve earned and what we deserve; it kinda all evens out in the end. What makes it difficult is that at any one time there may be a disconnect in one particular place where you think you’ve earned it–whatever it might be–and yet it’s not coming your way. No way around it, that’s really hard. Unfair, even.

The lesson here, I think, is that pretty much everything in life is to be earned. Food, shelter, clothing. Respect. Trust. We have within us only the ability to go about our best in order to earn any and all of these. To put it another way, our best good-faith effort is all we have to contribute to the equation; acknowledging that it is on us to earn these things is in itself a demonstration of good faith, a repudiation of entitlement, and a clear statement to all that what we receive in the end cannot be justified by some outside agent declaring that “we got what we deserved.”

We deserve to be loved. Everything else we deserve only the opportunity to earn.


Sunday musings 11/9/14

Sunday musings…

1) Barbara. I have a love/hate relationship with “Fran”. I just hate “Barbara”.

2) WiFi. At this very moment I am hurtling along I-71, riding shotgun as Mrs. bingo drives us home after our visit with “The Heir” and his Princess. I’m musing.

This tech stuff is pretty cool, eh?

3) Big Data. Many years ago now a CrossFitter from VT sent me a note and asked me to look at a little project he was working on. Guy named Bill. That little project turned into what we all now know as “Beyond the Whiteboard.” They’ve just put out the first results of studying the data so many of us put in. Turns out that to achieve a particular degree of improvement in fitness you get there faster if you work out more frequently, though you do get there even with a program that includes fewer workouts each week (at least when evaluating As Rx’d results from CrossFit.com WODs).

It’s cool on its face that we learn a) this stuff works and b) if works faster if you do it a bit more frequently. No question. Looking at it from 30,000 feet rather than 300, this is the first real instance of formal data collection on a mass level that has looked at a measure of fitness with stated objective parameters and controls. This is cool. It is also an affirmation of the most basic premises put forth early on by Coach as he launched this phenomenon.

Good on ya, Bill.

4) Inconvenience. “Inconvenience is only adventure wrongly considered.” C.K. Chesterton (1908). Promised you I’d return to this.

This is all about attitude, and to some degree I guess it’s about expectations. You could just as easily substitute “boredom” for inconvenience; Mrs. bingo has oft said “boredom is a choice”, which I think fits here, too. There’s a tiny, or maybe not so tiny, aspect of entitlement in both inconvenience and boredom, don’t you think, if you are one to take a more critical view of these states of mind or being.

Chesterton is more than a bit more positive in his approach. Take for example the inconvenience of being forced to spend a night in your layover city because a flight has been canceled. Monkey wrench city, that one. Just happened to my brother-in-law, Pete. Not a one among us prepares for that, and I’d venture to say that an equal number of us views that scenario as something positive or something to look forward to. Pete was not amused.

My bet is that Chesterton would take a different tack in similar straights. Perhaps he would do what Mrs. bingo and I once did, staying in the airport and enjoying a 2 hour meal at a minor miracle of fine dining found in a corner of the terminal. All of a sudden you are presented with 8, 10, 24 hours of opportunity that you have no choice but to exploit. Inconvenient in this day of internet in an auto, schedules as tight as a post-dinner belt? You bet. But when would you have checked out the Liberty Bell in Philly, or the Museum of Natural History in NYC? Heck, if you brought your Nano’s you are probably only a short cab ride from visiting a Box.

You could even choose to luxuriate in being bored.

I’ll see you next week…

Posted by bingo at November 9, 2014 8:05 AM

Sunday musings 11/2/14

Sunday musings, thinking about fitness (go figure)…

1) Design. “It’s much more interesting to upgrade the ordinary than to design extraordinary things that don’t make sense.” Ilse Crawford.

Functional design.

2) Carbs. The inter webs and traditional media outlets are awash in people not awash in carbohydrates. The most famous among them, of course, is one LeBron James, “savior” of my fair city, Cleveland. LeBron got all lean this summer by supposedly forswearing all carbohydrates. The problem is that every picture of his meals shows a plate chockablock filled with, you guessed it, carbs. Same thing with celebrity chef Michael Selco in Boston. Lost 95 pounds by cutting out carbs and is now famous for his new restaurant the specializes in…wait for it…carbs.

Makes me crazy.

What they mean is that LeBron, Mr. Selco, and all of the ‘B’ list celebrities who have lost weight and leaned up have stopped eating grains such as wheat and rice, and probably dropped most other starches as well. The fact that myriad nutritionists, chefs, and food writers have all willfully, nay gleefully, joined in the misinformation campaign only makes it that much more annoying. Come on people. They’re eating fruits and vegetables. Those contain CARBS! Grrrr.

Ten plus years after the seminal essay “What is Fitness” all of the fancy people have discovered the glycemic index and declared it their own. It’s as if one of the Kardashian’s strode down 42nd St. and planted a flag to claim Manhattan for the clan. Add in all of the wonder in Hollywood at the discovery that fat might be good for you (Bacon. Who knew?) and you have the perfect storm. But you already knew all that. “Eat to promote performance in the gym, not production of fat.”

Seriously. Makes me want to curl up around a bag of Cheetos.

3) Strength. As long as I’m venting my spleen over artificial controversies and fake issues let’s take on the “strength is the most important part of fitness” canard. Again. It just ain’t so. Being strong is important, but if you seek a broad, inclusive fitness you seek to balance all 10 Essential Skills or Attributes of Fitness. If your goal is to maximize Work Capacity Across Broad Time and Modal Domaines then strength is no more or less important that cardiovascular endurance, and vice versa. The various and sundry bleatings and brayings from internet warriors near and far continue to beat against the collective CrossFit brain. Makes my eyes hurt and stomach sore.

I know, I know…you’re probably gonna wonder how a guy who works out in a Box that does supplemental strength work can take this on with a straight face. Quite the contrary, Mon Frere. The reason to do extra work to increase strength of all kinds is not because of some inherent superiority of strength, or because disproportionate strength is necessary to be a good CrossFitter. In reality the vast majority of the denizens of the universe are under-strong relative to the other 9 Essential Attributes. If one advances in all 10 at the same rate from doing a program that could be described as CrossFit, from CrossFit.com or an Affiliate gym, then this imbalance wherein strength continues to lag will be propagated. In CrossFit-speak, ya gotta train your goats, and your goat might not be some highly technical movement like a Turkish Get-Up, it might just be strength in general.

I’ve said it before and I’ll say it again: if you have a goal for which an over-emphasis on strength is the appropriate training modality then that’s precisely what you should do. But if you seek a type of fitness that prepares you for tomorrow, whatever tomorrow might bring, then you should choose a program that balances all 10 of the Essential Attributes of fitness (this is your cue to download the .pdf). Once balanced, if you continue to put a greater emphasis on all things strength you will necessarily suffer a deficit in one or several other areas. Usually cardiovascular endurance, or perhaps speed. Then, me Druggie, you’ll be forced to do more running.

Now THAT’S simply madness.

I’ll see you next week…


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