Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Archive for December, 2014

Overestimation: Two Takes

“Men overestimate their ability to fight or defend themselves by 4000%.” –Jake “Jakers” Parent

“People always overestimate their talents, always, and maybe as a consequence underestimate unexpected or unrealized talents.” –Christopher Waltz

This is interesting and, I admit, a bit scary. There’s a double negative here, isn’t there? No matter how good we might be at any particular whatever, Waltz suggests that we are never as good as we think we are. No accuracy in identifying the limit of our expertise. To make matters worse, in a world in which we are constantly advised to double-down on our strengths, both the internal and external incentives to stay in this not-as-sweet as we think sweet spot blinds us to the existence of other virtues that may actually trump our perceived alpha talent.

When I first read this I saw unexpected “consequences” where Waltz actually said “talents”, a totally different message. One only needs to glance at Jakers’ quote above to get a sense of what my mis-read might portend. Missing out on an undiscovered talent is at the same time less frightening (not learning that you can sing won’t get you beat up) and more. What if you never discover a talent that will elevate your family’s circumstances 2 or 5 or 10-fold? What if you are unaware that you can run a sub-4:00 mile if chased and instead stand and fight? What a bummer.

What’s really terrifying is the very thought of moving outside your zone, outside your lane, and exploring the thought that you might have an unexpected talent. What if you’re not as good at your present talent as you thought? What if you DON’T have another talent? This is as good as you get. If you have the courage to look into all of the corners of who you are and what you can do, you still have to have the strength to handle what you find. Some of those unexplored corners can house some pretty dark stuff.

Whether it leads to a consequence born of omission or commission, it behooves each of us to be conscious of this universal bias, that as good as we might be, we likely are not as good as we think we are.

 

Mindful Gifting (From Sunday musings…)

Me: “How’s our Christmas shopping going?”

Mrs. bingo: “Well, I’m not too sure.”
Me: “Uh oh.”

Sound familiar?

In the Western World, at least in the U.S. and maybe Canada, the “Christmas Season” has become in many ways more about shopping than about giving, don’t you think? Especially now as North America slowly crawls out of 6 years of economic doldrums, as rank and file citizens dust off the cobwebs sealing their pocket book and spend a bit extra. No data to share, just a feeling.

Time was when Christmas (or Hanukah) rolled around the excitement centered more around the gathering of family, and to be sure around the rel!gious meaning of the day. You’d spent the preceding weeks getting excited about being home. As often as not thoughts of gifting and gifts became actionable a day or two before Christmas rather than a day or two after Thanksgiving. Your buy, your gift, was a response and a result of an inner conversation about the recipient, not a reaction to either advertising or cultural momentum (like Black Friday).

Nope. When you thought about gift shopping you really thought, deeply and hard, about the person to whom you would give that gift. What makes them tick? What is it about them or their life that makes them (and you) smile? At this time of year I find myself, along with Mrs. bingo, thinking an awful lot about what the people in my life want rather than what they might need.

That sounds funny coming from me, huh? The “want vs. need” guy. Here’s the thing: a gift-giving time like Christmas is one time when we can help those we care about have a little something that they want, but maybe know they shouldn’t get on their own precisely because they do understand the difference between want and need. In order to do that you, the gift giver, must take the time and make the effort to know the gift receiver well enough to figure out that gift that, rather than making them relieved, might make them just a tiny bit happier.

In the end the real gift that you are giving is of yourself. Your time. Your care. Your love. In order to give this kind of gift it is necessary to do more than shop. When you decide to really give a gift rather than simply shop for one, what you are really doing is telling that person that you see them for who they are. You’ve taken the time to know who they really are. That you do, indeed, like and love them, at least for Christmas, just for who they are.

Otherwise, it’s just a trip to the mall.

CPOE: Another Epic Misadventure III Post-Mortem

With the launch of SkyVision Centers 10 years ago I entered the era of EMR. Our group was certainly an early adopter, but since we had chosen this path so early we were able to make our own determinations about what we valued in the technology, and what we would not be willing to give up or compromise in order to have EMR. Our choice of platforms was one that expressly sought to enhance the efficiency of a busy specialist, while at the same time allowing us to hold on to a very personal approach to the doctor/patient interaction. That experience has informed my reaction to all subsequent encounters I have had with other EMR’s, government regulations, and the like. The launch of  Epic CPOE at my World Class Hospital ASC was just the latest example.

A tip of the hat and heartfelt thanks to the folks at the ASC who took such a personal interest in my experience. To my surprise and near delight, the CPOE intrusion in the OR during cataract surgery (in a single room) was negligible. There’s a lesson here for implementing EMR changes: do your homework. The reason my day went so smoothly in the OR is that the people who were thinking about me spent the time necessary to head off problems BEFORE I showed up that day. Two sessions with me, both of which occurred AFTER examining my pre-CPOE processes and paperwork, helped to head off predictable and preventable frustrations.

Having said that, a pox on the houses of all who created the tragedy that is the post 2008 EMR. That means both the government “know-betters” who shower all of us in the trenches with dictums on how it’s supposed to be, as well as the EMR software engineers and execs. Never mind that not a one of them could possibly have ever manned a bedpan, let alone a needle-driver, the arrogance of simply declaring what should be without looking at what is continues to be appalling. To a person every single one of my patients complained about being ignored by the ASC staff on CPOE Day One. Heck, there was literally no way for me to position my Pig, “Babe”, so that I could have eye contact with my patients when they entered the laser room; I was just like every other physician lemming with his eyes glued to a screen when they walked in. I at least have 10 years of goodwill built up with my patients so that I might be forgiven for the insult delivered by Epic.

While I’m at it, can we talk about the arrogance of the programming…ahem…experts, the Cave Dwellers at World Class Hospital? Do they work for Epic, World Class Hospital, or some outside agency? I asked for an order set for a particular type of procedure, one that would more exactly represent what and how we do it at our ASC. I was told in no uncertain terms that the Cave Dwellers had already declared that they had done more than enough for me and us, and that I should feel very lucky that they did as much as they had. Seriously. Never mind that my request would have saved me time, saved the staff time, and made for a better experience for the patient. The Cave Dwellers had spoken. These people have as much power to inflict unnecessary pain on productive folks like doctors and nurses as the pharmacists at World Class Hospital (remember a brand new bottle of eyedrops for every patient for every laser to avoid infections that had never happened in the history of laser surgery?). Here’s hoping one of the Cave Dwellers doesn’t recognize some very important name and drops that same load of attitude on that Very Important Person. Kinda makes a lie of the whole “support” part of “tech support”. This is fixable, by the way, if anyone’s listening, especially if they work for World Class Hospital.

In the end there remain two very critical problems with CPOE in general, and EMRs of the Epic ilk in particular. The first and most problematic is that at their heart they are not medical records at all, they are billing and compliance systems. The primary customer is not the physician or the patient but an accountant, and the outcome that is maximized is not a medical outcome but a financial one. These systems will always be a time suck for both doctor and patient (and nurse, and receptionist, and…), and with that will come an inevitable happiness suck. I had a full hour stolen from my day; this isn’t going to get any better. Every one of my patients had an unsatisfactory experience as ASC staff paid more attention to their Pigs than to my patients; this isn’t going to get any better, either.

The second issue reflects the end of my first day with “Babe” and it is the only issue that could possibly get better: computers and software of any sort are only as good as the people using them. Despite all of our planning, all of the preparation that happened before I arrived at the ASC, everything came to a screeching halt when I tried to plug in my orders for next week. The poor woman whose job it was to enter the patients into the system was simply overwhelmed with work. On top of her regular job and her regular duties she was now not only responsible for the additional task of putting patients into the Pig Pen, but she also had a very hard deadline to beat. At the moment of truth it was her failure, but just as it isn’t the waitress who is at fault when she delivers the overcooked steak, neither was it the poor clerk’s fault that I sat and stewed while she completed her task under the baleful glare of her boss. Just as it is the chef who is at fault for the burnt steak, so too is it the fault of management upstream for failing to give a frontline worker the time necessary to feed the Pigs.

Here, at last, is hope. Faint hope, but hope nonetheless. Someone, somewhere in the chain of command at World Class Hospital may realize that they can make this whole CPOE mess a little bit better for at least some of the folks who are affected by it. It won’t be me, or anyone like me; it’s clear that physicians are just interchangeable cogs in this machine–the noisy ones will be replaced. It surely won’t be patients; that ship left port way before Epic arrived, no matter how many ads World Class Hospital takes out declaring fealty to “patient-centered care”. My hope, and my new crusade, is that the non-physicians on the front line who are taking a beating from this will be acknowledged and given the resources necessary to NOT be the fly in the oink-ment (couldn’t resist). They don’t deserve to end up in the crosshairs of a doc looking for a place to put his unhappiness.

Now, the Cave Dwellers on the other hand…

 

Another Epic Misadventure II: CPOE Goes Live

Boy oh boy, was it crowded in the Ambulatory Surgery Center on Tuesday. The place was crawling with techie types in outfits that looked an awful lot like Walmart uniforms, bumping into a cadre of Suits who were there doing…well…I’m not sure what the Suits were doing. They were mostly in the way of productive people doing useful stuff. My day started off with an almost immediate case of miss met expectations as the tech support person who’d promised she would be there to guide me on Day One, since she’d spent so much time personally preparing both me and Epic for our first CPOE date, was nowhere to be found. Sadly, it was apparent that the otherwise quite lovely and very talented woman who was there instead, let’s call her my “Doc Minder”, was going to need some catching up on what had gone before, despite her assurances that she’d been fully prepared by Top Tech, the Doctor Whisperer.

“Dr. White, I was led to believe that all of your pre-op orders have already been entered into the system.” Uh oh. I spent 2 hours the prior Thursday afternoon with the head honcho “Doctor Whisperer” entering all of those orders. My first thought was “why don’t you know this already, since you have access to all of my charts today and could have looked?”, followed by “How is it possible that you didn’t look so that you could head off any problems before I got here?” What I said was: “they’d better be.” Ugh. Was this a sign? Given my state of mind heading into this day you can imagine the kinds of thoughts going through my head when the first mobile computer brought to the OR for my use didn’t work. Like, not at all. Rough start.

Turns out that I have some history with these mobile computers and World Class Hospital. They were originally called “Computers on Wheels”, which I instantly renamed “COWs”. Makes sense, right? Easy. Cute. Man, did that get shot down fast. Something about cultural sensitivity, or, really, I have no idea, but calling them a “COW” was verboten. I’ve been using that “Lipstick on a Pig” analogy when discussing everyone’s sensitivity to my unhappiness about Epic in general and CPOE in particular. My new four-wheeled “Pig” arrived and to my surprise things actually started to look up. The computer worked so well that I found myself calling it “Babe”.

Having all of my pre-op orders already in the system turned out to be a critical step in giving the day a fighting chance to succeed. All of the orders had, indeed, successfully made their way from the chart to the nurses in pre-op, and from there to what seemed to be a fairly regular implementation for my surgical patients. This is important because patient preparation starts well before I arrive in the morning for surgical patients, and begins for lasers while I am toiling away in the OR. The fact that it took some 2 hours to get these orders entered last week (total of 19 cases), a process that had heretofore occurred entirely without needing me to engage, was momentarily lost in the euphoria that I didn’t need to put out any pre-op order fires (hmmm…would that be a Pig roast? Sorry.).

Although this was day one for implementing CPOE in this particular ASC, the fact that the main campus of World Class Hospital, as well as several other WCH ASC’s had already made the transition, meant I really wasn’t truly a guinea pig (too much?). Standard order sets already existed for eye surgery, and it was relatively simple for the behind-the-scenes cave-dwellers to create both order sets specific for our ASC as well as templates for my op notes (more on the cave-dwellers in Part III). As I noted in Part I our turnover time in a single OR for cataract surgery is ~7:00. With some gentle and kind prompting from my “Doc Minder” I was easily able to do everything “Babe” asked of me between cases in addition to my usual duties (chat with the family, etc.). My kindly “DM” agreed that “Babe” would probably slow me down on busier days when I hop between two OR’s, but for today at least there was no time suck for cataract surgery. I even did one fewer dictation because the “Doctor Whisperer” had helped me create a template for “Complex Cataract Surgery”.

I may or may not have said “That’s some Pig!” out loud.

Alas, everyone involved knew that the happiness was fated to be short-lived. The efficiency bar is so high when we do ophthalmic lasers that there was simply no way that “Babe” was going to be able to keep up; he was back to being a Pig as soon he moseyed over to the laserium. Because every patient’s chart must be completed before they are allowed to leave the facility–images of armed guards wearing Google Glass running Epic and manning the exits filled my head–I had to attend to all of “Babe’s” needs before starting with the next patient. This process took 1.5-2X as long as usual, increasing the time it took me to do my lasers and making it a bit less convenient for my patients.

Then everything went off the rails.

Computers are computers, and software is software. They are both heroes or goats depending on how well they fulfill whatever task they are assigned, but they are prisoners of the people who operate them. The plan that all stakeholders had agreed on was for ASC staff to schedule all surgeries booked by SkyVision as of Monday by the time I finished lasers on Tuesday. I would then do all of the pre-op ordering for the following week before leaving for the day. Under the best of circumstances every minute I spend doing this is both a time and a happiness suck for me because, as I noted above, prior to CPOE I didn’t have to do ANY of it. Naturally, more than half of next week’s patients had not yet been entered into the system making it necessary to not only stick around to pet my Pig (I know) but also wait for the overworked WCH staff to complete their tasks. All in all it cost me about an hour, stealing my workout and rushing my lunch so that I could be in the office and start clinic without making my patients wait.

What’s the take-home? Tune in for Part III. For the moment let me just say…that’ll do Pig, that’ll do.

Another Epic Misadventure: Interlude

It’s really quite flattering, all the attention. The cynic would say that it’s all really just an attempt to keep my business, and I’m sure there’s a bit of that going on. After all, even though my surgical volume is down since my I left my original practice to start SkyVision, I still do a rather high volume of surgery at a very low cost/case. Still, the sheer number of folks, not to mention who they are, who have gone out of their way to try to make my CPOE transition go smoothly is impossible to ignore. Folks really do seem to be sincerely concerned about me as a person, someone they know and have come to like enough over many years, not just a surgeon bringing business. If only it wasn’t all so…so…useless.

I know, I know, I sound a bit petulant, but I’ve watched this movie before. I know how it ends. It may sound somewhat ungrateful, what with the head of physician training, Chief of Surgery, and Head of Outpatient Surgery and local administrator among those taking an open interest in my journey. It’s just that the story only ends one way, with a great big time suck that undoes a decade and a half of ever increasing efficiency (and with it patient satisfaction) and the associated assault on my emotional well-being.

All these people walking around with lipstick thinking…hoping…maybe just one more coat and he’ll smile when the pig kisses him.

 

Your Selfie is Stealing your Memories

Like the Babe Ruth or any other home run hitter I’ve taken my swings, often and hard, at the corrosive effects of communication technology on human communication. For every time I’ve hit it out of the park–face to face over a glass of wine with Beth, a close friend, or one of my kids–I’ve whiffed on one that was low and outside hurled by new tech. For instance, Snapchat came and went and got sold for a Bazillion $$ before I even really knew how to use it.

Now, I’m hardly a Luddite. I’m sitting at a kitchen table littered with droppings from Steve Jobs’ imagination, pecking away at one of them while another serenades me, yet one more beckons for a response. It’s all really pretty OK though, because there’s no one here, really physically here, who wants or needs to talk to me at the moment. Even Abby, the world’s most curious Border Collie, isn’t interested in chatting.

This is not a “be here/be now” lament about focusing on the real, live person who is physically with you rather than your phone and its irresistible access to someone who is somewhere else. Nope. I lost that battle as spectacularly as any swing and a miss by the Bambino, at least on a societal level. For sure, every now and again, I hit a bloop single and get one of my kids to put down their phone and “be there” for a whole meal, but no grand slam big picture win on that one. (As an aside, who wouldn’t love to see a Sesame Street re-do of “Put down the Duckie” substituting “iPhone” for Duckie? Google it.)

This is about the most recent tech attack on the human experience as we know it–the “Selfie”. It’s not real unless you took a picture of it. You weren’t there unless you have a picture of wherever there was, whatever what was. And the most damaging of all, it wasn’t significant enough, it wasn’t truly magnificent or epic, unless you shared it with at least your first 4 degrees of separation.

The camera on your phone is stealing your memories.

But how can that possibly be? How can memorializing the momentous make my memories disappear? There are two insidious effects of the nearly compulsory grab for the phone and the shutter. The first is simply that you’ve stopped the moment in question, interrupted whatever is wonderful about that singular now. Everything stops for the camera. You’re frozen, right then, right there, in that exact click. Your flow is gone. What might have come next, following as naturally as your next breath, is forever lost as soon as the camera appears. The re-boot is as jarring as emerging from the breath hold of a frozen dive.

Memories, the good ones at least, are like poems. Returning to those memories over time is like re-reading a beloved verse. The basic facts, like the words in the poem, remain the same; it’s around the edges of the memory that we find the smiles. In poetry it’s the message between the lines. In music it’s the space between the notes. For our memories it’s the space filled by our emotions. This is where the magic lives. We shrink these spaces in the memories that hurt but won’t fade, and we spend as much time as we can engulfed in the happiness that lives in the space around our best memories. The foundation for growth here in this space is being fully engaged in simply living in each “now” rather than engaging your cellphone camera and Instagram.

You can’t really take a picture of how you feel, and in the end isn’t that what makes the memory?

 

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