Looking from a different view

\"Mind

This, apparently, is a map of my mind.  It\’s a little shocking to find out that my mind looks like a sea creature, a bug, or perhaps a vegetable.  Actually, \”Rob\’s mind\” and \”vegetable\” are often used in the same sentence.

Someone suggested to me that I may benefit from mind mapping.  I don\’t know how to describe it, but I think spatially; I see things abstractly as if I am pulling up from the ground and getting an aerial view of things.  I write that way, I solve problems that way, I even play music that way.  Maybe it\’s tapping on the right side of the brain that is about nuances or about how things relate to other things in proximity or direction.  Like I said: it\’s hard to describe.

Anyhow, I was thinking about task-management with my patients, wondering what\’s the best way to think about it and what is the best design for a system helping with this.  Task management is perhaps the most important thing in health care that\’s never talked about.  Maybe that\’s because it makes doctors feel less special, reducing our \”magical\” knowledge and \”miracle\” cures to algorithms and checklists.  Personally, I take great comfort in systems because they assure me I am not going to forget important things (like setting a reminder to take the trash out on Sunday and Wednesday nights).

The problem is that there are many, many tasks to consider when thinking about patient care.  For example, when test is ordered it need to be:

  1. Sent to the lab
  2. Sent back to us
  3. Reviewed, with the information used appropriately
  4. Filed into the patient chart
  5. Decided if/when the test needs to be repeated
  6. Decided if more testing or treatment is needed
  7. Sent to the patient with explanation of my interpretation and plan.
  8. Document that I communicated this
  9. Schedule any follow-up

You can see how this would quickly lead to overload, with a simple lab test resulting in 9 steps.  It is a bureaucrat\’s dream, but a busy doctor\’s nightmare.

Another problem is the complexity of the care of a patient.  There are lots of different aspects to patient care that can\’t be ignored.  This brought me back to the idea of story telling, and how it relates to patient care.

  • What is the back story?  Who is this person and what are the various things in the past that have made them who they are?
  • What is the current scene?  What\’s going on with the person right now?  What are they feeling, what medications are they taking, and what is their emotional state?
  • What is lurking in the future?  What are their risk factors?  What will need to be done and when?

Furthermore, in making a list that will work, we need to know:

  • The timing of the task.  Is it immediate or is the time flexible?
  • The importance of the task.  How critical is it to the patient\’s health?
  • What is gained by doing the task?
  • What is lost by not doing it?
  • Who is responsible for the task.  Is this something I must do, does it go to my nurse, or is it something for the patient to do?
  • Who is responsible for checking to see it\’s been done?

Heavy stuff.  How do I wrap my brain around building a task management system without making my brain turn to mush?  It was getting a little depressing.  I was tempted to shut down my brain and play Bejeweled for a few hours, but then I remembered the suggestion of mind mapping.  Why not?  Let\’s step back and get a bird\’s-eye view of the patient and what things we need to consider.  It couldn\’t hurt.

What I got was a big spider-looking thing that could probably fill the pages of a book in explanation, but it\’s the big picture that will hopefully help me decide on how to handle my patients.  Here\’s what I included:

1.  Their Situation – What is going on right now?  What things are happening of significance?  Are they going through a divorce?  How old are they? Are they in a job they hate?   Do they have insurance?

2.  Their Lifestyle – While a situation happens to the person, lifestyle is a choice (by my definition, at least).  How does a person want to live?  What choices do they make?  Do they smoke?  Do they buy expensive cars?  Do they spend their days playing the lute and drinking mulled wine?  Obviously, these choices have a huge impact on a person and our approach to their health.

3.  Their state of well-being – This is their perception of their lifestyle and their situation.  It depends on a lot of things, but is predominately a function of perception.  It\’s how they measure up to the \”should\” of life.  People with terrible disease can have a good state of being, while healthy people can be living in fear.

4.  Level of Understanding – How well do they understand their situation in regard to medical issues and others as well?  How open are they to learning new things?  Do they actually understand things, or have they convinced themselves that they do?  I value education and communication very highly, and yet there are some people who are not open to teaching at all (dogmatists) while others will devour eduction when given a chance to get it.

5.  Risk – This takes the overall situation of the patient and looks into the future.  Much of medicine is about anticipating risk and reducing it.  High blood pressure isn\’t a problem in itself, it\’s the higher risk of heart disease, stroke, and kidney damage that we are actually addressing.  In considering risk, the question always should turn to the severity of the risk (how bad of a problem), the immediacy of the risk (how soon it could happen), and the risk/benefits of intervention.

6.  New Problems – these usually drive the most items in a care plan, as assessing each of the above come into play with a new problem.  The key is to understanding overall impact of the problem on both length and quality of life, as well as the benefit of investigation and treatment.  First off, we need to understand the nature of the problem.  Is high blood pressure a problem needing treatment, or is it simply that they are totally stressed out about the weight we just checked? Please note that, as opposed to our beloved health care system\’s view, the patient is the focus, not the problem.  Everything has a context on which it exists, and problems happen in relation to a patient.  Do always treat diabetes in a patient?  What about in my Mickey, who turns 100 today?  How big of a problem is a sugar of 200?

7.  Intervention (labeled as \”treatment\”)  –  We don\’t think of problems for the mental exercise, we do so to intervene where appropriate or to understand future risk.  Interventions are often the things next to the check boxes on the task list.  Sometimes we choose to observe.   Intervention always comes with a cost, but non-intervention may cost more.  All intervention must be weighed, considering all the factors listed above.

8.  Chronic Problems – This is the \”management\” portion of medicine that plays well to a task list, and the one that folks measuring the \”quality\” of care don\’t get beyond.  All medical care is not boiled down to meeting metrics, but the metrics are not unimportant.  The key is, like with the rest of this exercise, to consider the situation, risk, understanding, well-being, lifestyle, priorities, and other problems the patient has.  This doesn\’t play well with the bean-counters of medicine, but it\’s the reality that docs and patients face.

So, does this help?  It sure looks fancy, and sounds all TED talk-ish.  It scares me that I may be advocating something \”holistic.\”  I may just get a call from Oprah because of it.  Scary.

The benefit to me is that it pulls me away from the seductive simplicity of cookbook medicine.  In the end, medical care is a human interaction that is designed to result in health gain of the patient.  This is far more complex than a set of checkboxes or a bunch of criteria to assign meaning; in it\’s best form medicine is very much right-brained.

And that, my friends, proves that I my just be in my right mind.

6 thoughts on “Looking from a different view”

  1. saralyn collins

    This is absolutely amazing. I wish all doctors -at least mine – thought this way. Health care could be revolutionized with this type of thinking.

  2. Dr. Rob, for the 99.999% of us who do not have a primary care doctor who is thinking as progressively as you, what advice can you give so that we can get our doctors to be treating us in the manner in which you are treating your own patients?
    This past December, I was told by my primary care doctor that I may have PAH, based on how he and the cardiologist interpreted my stress and echo tests. He referred me out to a pulmonologist for further testing, but I have not received a single follow up call from him since then. If the possible dx of PAH isn’t enough to keep a patient on a doctor’s radar screen, then what is? What can I do as a patient to get the requisite level of attention to definitively rule in/out this very serious condition? I have learned from prior experience (taking trips to multiple doctors over multiple years before finally getting diagnosed with a connective tissue disease) that when a patient gets angry or defensive at neglect or mistreatment, that simply makes the physician and his staff angry and defensive. Yet, if I follow all the “rules” and act in the passive manner expected of me, I find myself in my current predicament.

    Any advice you can provide would be greatly appreciated.

  3. I remember when we did mapping in nursing school. It was a very revealing process for me. I like order and the way I was taught to do it was in a very disorderly fashion and then draw connections after the data has been splayed all over the place. Yours looks more like something my mind could wrap around quite well. And what a wonderful way to look at the WHOLE person with their specific set of circumstances. Very insightful! I thank you for sharing!

  4. That’s a tough question. The tagline from my practice is “Expect more from your doctor,” which relates not only to the service offered, but to the quality of the medicine practiced. I think patients should expect explanations and access to information. The problem is that the system discourages good docs from doing the right thing and almost encourages the bad docs to not improve. That’s why I ended up leaving for my new practice. I felt that I, a doc who wants to do the right thing, was being prevented from giving good care by the system. Finding a caring doc in a system that penalizes caring is a tough thing to do.

  5. A useful, beautifully written piece. My guess is that most docs would aspire to know their patients in this depth but…”Jeez, I just don’t have time.” Well, that truly is today’s pathetic state of affairs. Forty years ago I found myself in a group medical practice that allotted fifteen minutes per visit. I hung on for three weeks, and finally determined that I couldn’t begin to know a patient in fifteen minutes. Now what’s the average visit time? Seven minutes? The way things are going, we’ll eventually “provide healthcare,” as the current phrase goes, through vending machines. All I can hope is that our abused colleagues learn to take Rob Lamberts’ observations seriously, along with Mohandas Gandhi’s advice, “Always do the right thing, even when the authorities forbid it.”- Jeff Kane MD
    bedsidemanifesto.com

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