The "Doorhandle" moment

Peggy Zuckerman peggyzuckerman at GMAIL.COM
Tue Mar 10 23:39:32 UTC 2015


attaching the SIDM's Patient ToolKit.  Take a look and tell us if that
would be helpful--esp if the doctor looked at it prior to the appt

On Tue, Mar 10, 2015 at 3:03 PM, robert bell <
0000000296e45ec4-dmarc-request at list.improvediagnosis.org> wrote:

> Excellent point.
>
> Would remind us to get x-rays, labs, and check the books on things we did
> not fully understand.
>
> ? a place on the Portal for a patient’s agenda.
>
> Rob Bell
>
> On Mar 10, 2015, at 12:44 PM, Swerlick, Robert A <rswerli at emory.edu>
> wrote:
>
> We are essentially the only profession that routinely schedules meetings
> with no agendas. Perhaps this would be less of an issue if we made it a
> point to create agendas for our appointments ahead of time.
>
> Bob Swerlick
>
> *From:* Bruno, Michael [mailto:mbruno at HMC.PSU.EDU <mbruno at HMC.PSU.EDU>]
> *Sent:* Tuesday, March 10, 2015 3:07 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] The "Doorhandle" moment
>
> It’s a core tenet of psychiatry that you will *ONLY* get to the *real *issues
> that are on the patient’s mind at that final, “door-handle” moment, and
> somehow you never seem to hear about them in the 45 minutes of your session
> that occur before that final moment!*
>
> Mike B.
>
>
> _________
> *I’m not a psychiatrist, but I’m married to one.
>
>
> *From:* Mark H Ebell [mailto:ebell at UGA.EDU <ebell at UGA.EDU>]
> *Sent:* Tuesday, March 10, 2015 2:14 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Positive tests - surprisingly, patients are
> not always as receptive as you'd expect them to be
>
> Yes, they are dreaded, although often important and illuminating. Just
> annoying that at the end of a 20 minute encounter, you FINALLY get to what
> is really important, with a waiting room full of patients. We used to call
> it the “doorhandle moment” because your hand is on the doorhandle, trying
> to leave the room.
>
> Mark
>
> *From: *Peggy Zuckerman
> *Reply-To: *Society to Improve Diagnosis in Medicine, Peggy Zuckerman
> *Date: *Tuesday, March 10, 2015 at 1:30 PM
> *To: *"
> *Subject: *Re: [IMPROVEDX] Positive tests - surprisingly, patients are
> not always as receptive as you'd expect them to be
>
>
> I find it fascinating that patients are told not to bring up peripheral
> issues with the doctor, i.e., "what is your main complaint today?".
> However, when an lab test reveals some problem that does not yet concern
> them, or is at yet unrelated to what may well be that peripheral issue, the
> patient seems not to be concerned.  Is that because the patient has already
> been told that only the "main" stuff is to be discussed, or was there a
> barrier created by the limitations of the first visit?
>
> As a parent, I used to dread the "by the way" comments from my children as
> they left for school, I wonder if those same "by the ways" from patients
> might also be dreaded and deflected.
> Peggy Zuckerman
>
> On Tue, Mar 10, 2015 at 10:05 AM, Bruno, Michael <mbruno at hmc.psu.edu>
> wrote:
> Good points!  We are quite convinced that we know best.  But do we?
>
>
> *From:* Swerlick, Robert A [mailto:rswerli at EMORY.EDU]
> *Sent:* Tuesday, March 10, 2015 12:44 PM
>
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Positive tests - surprisingly, patients are
> not always as receptive as you'd expect them to be
>
> I agree that Dr. Bruno’s description highlights the complexity of
> information exchange. What I would also highlight is that more conventional
> venues for information exchange (patient office visits) suffer from the
> same problems. We simply were not aware of the issues to the same degree
> and/or we use a different set of descriptors to catalogue the issues.
>
> Patients come to a venue to address a problem they are concerned about. We
> deploy tools which detect a variety of signals, independent of the reason
> the patient originally sought care for. We are surprised when the patient
> has no interest for pursuing problems which they do not perceive.  Perhaps
> we should not be so surprised they do not want to buy or product or service
> that we are selling them when they see little or no value in them.
>
> Rob, I agree that  the new communication tools have not been evaluated
> adequately. Neither have the old tools.
>
> Bob Swerlick
>
> *From:* Robert Bell [
> mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG
> <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>]
> *Sent:* Tuesday, March 10, 2015 11:55 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Positive tests - surprisingly, patients are
> not always as receptive as you'd expect them to be
>
> Wow, what a great reply.
>
> Beautifully expresses all the complexity of medicine and the challenges to
> reduce error against a relentless sea of obstacles that helps create error.
>
> Speaks to patient communication and Portals being adequately evaluate
> prior to introduction.
>
> Well done Michael Bruno.
>
> Rob B
>
> Sent from my iPad
>
>
> On Mar 10, 2015, at 6:38 AM, "Bruno, Michael" <mbruno at HMC.PSU.EDU> wrote:
>
> Thanks, Tim,
>
> It’s great to hear from a fellow “Quality Officer” in a medical practice.
> I’m also a quality officer, for a large academic department of Radiology.
> This particular issue, of communicating effectively with our patients, is
> near & dear to my heart.  I’d like to briefly share our own experience in
> alerting a subset of patients to their test results, an experience which
> surprised me and my team here and may surprise others on this listerv as
> well.  We were surprised to encounter a population of patients who were
> remarkably disengaged, and who weren’t particularly receptive to hearing
> from us with their test results.  This was quite the opposite of what we
> expected.
>
> In the practice of modern radiology, we encounter a good many unexpected
> findings—items of varying importance that are turned up on imaging tests
> that need to be followed up (often after a suitable delay to allow us to
> better characterize them).  While such findings need to eventually be
> addressed clinically, they are not the immediate reason for the patient
> coming to the doctor or undergoing their imaging test.  We dutifully report
> all of these “incidental” findings to the ordering physician—phoning them
> when the surprise is a critical one—and trusting them to read our written
> report when it is not.  As a corollary, there’s quite a bit of pressure to
> make our reports timely and clear, and these days our formal, signed final
> reports are predominately delivered electronically through the EMR in a
> matter of minutes, although providers outside of our center may still get
> their radiology reports via fax or even through the regular mail.  The
> issue is particularly problematic for us in Radiology where Radiology
> intersects the Emergency Department.  We invest a lot of resources to the
> E.D., and most of our final, written reports on E.D. patients are delivered
> literally within minutes, plus we always have someone (a faculty member,
> resident trainee, or both) physically stationed in the E.D. itself to
> provide immediate availability for consultation.
>
> That’s all well and good for the acute findings, *i.e.,* those addressing
> the clinical question that brought the patient into the E.D., but it tends
> not to work all that well for those incidental findings unrelated to the
> immediate problem and that require a medium to long-term follow
> up—follow-up which is outside of the purview of the E.D.  In such cases, it
> falls to the patient’s primary care physician (if there is one) to follow
> up on the incidental findings, and it’s almost useless for us to even alert
> the E.D. physician to those findings.  In many cases when we report the
> findings to the ED physician the patient still isn’t even told of them by
> that E.D. physician.  Rather, patients are directed to sign a form at the
> time of their discharge from the E.D. in which they promise to “follow-up
> with PCP.”  This promise to follow up is generally little more than a
> charade.  From the patient’s standpoint, they often feel that they’ve (1)
> just SEEN a doctor, and (2) been SCANNED from top to bottom, and therefore
> they should be “all good.”  At least until their next acute problem arises
> and they return once more to the E.D.  In a handful of cases, depending on
> the nature of those incidental findings, that is a very dangerous
> complacency.  Their PCP, if they even have one, may never learn they were
> even seen in the E.D., much less that there were CT or x-ray findings from
> that E.D. visit which will need to be worked up or at least followed.  So
> you see the problem.
>
> To address this, we’ve developed a “failsafe” plan to alert the patients
> directly to their incidental findings requiring follow-up, and to encourage
> them to obtain the recommended follow-up with their PCP.  We also direct
> them to our Dept. of Family & Community Medicine in the event they don’t
> have a PCP (which is unfortunately a fairly frequent situation in the E.D.
> population).  We do so by mailing them a letter.  This is an unusual type
> of direct communication for Radiologists.  In the U.S., we Radiologists
> have traditionally been the “doctor’s doctor,” communicating our findings
> and opinions only with the referring physician, who then relays our
> impressions to the patient (who, in turn, generally assumes that it was
> their own doctor who interpreted their CT scans and generated the
> diagnostic opinions).  The idea for our “Failsafe” program came from the
> Joint Commission NPSG about involving patients in their own care as a
> specific safety strategy—and it puts the patient in the middle of the
> communication chain between us and their PCP.  When we proposed the idea of
> having Radiologists send letters *directly to patients* – letters
> addressed to specific patients and signed by a specific Radiologist(!) –
> with the purpose alerting patients to abnormal findings on their scans
> without any intermediary physician there to explain the findings, it raised
> a lot of eyebrows, not least among the Radiologists themselves.  Many
> worried that the clinical physicians would not appreciate our getting
> between them and their patients, and others were worried that patients
> would call us incessantly with questions and consume too much time,
> destroying our RVU-based productivity.  We also worried that receiving a
> Failsafe letter would be unduly frightening for patients.  But none of
> these concerns turned out to actually be a problem.  Our faculty physicians
> were very receptive to Failsafe, and they universally appreciated the added
> measure of safety for their patients that the new program provided.  If
> anything, they wanted to see the program expanded.  And very few calls from
> patients came to us.
>
> Our Failsafe letter does not attempt to explain the findings or their
> significance to the patients.  Rather, it merely alerts them that “their
> Radiologist” found something on their scan requiring follow-up, and urges
> them to see their doctor to discuss the findings (or call the Family
> Medicine office to arrange a follow up if they don’t have their own PCP).
> We have so far limited the program to E.D. patients, based on the rationale
> above, and currently we send out about 6 – 8 letters per week, and have
> been doing so for about three years now.   But when I phoned bunches of
> these patients to see what their reaction to the letter had been, and to
> ascertain whether it had achieved its intended purpose, I discovered that
> patients were fairly uniformly *disregarding* the letters.  Most never
> even returned my calls.  Those who did seemed completely unconcerned and
> none even asked me what the findings we were pursuing were!  They simply
> did not care to know—they were feeling well, and they were not receptive to
> any potentially worrying information.  Far from being frightened by the
> letters, they were not even concerned when the letter was followed up by
> some doctor (me) phoning them *repeatedly*, leaving multiple voicemails
> and messages with their family members at home and co-workers at their
> places of employment.  It was clear that these patients could not care less
> about our findings, our letter, or whatever it was I may have had to say to
> them on the phone.  In short, we encountered a large group of patients who
> were *so unconcerned* and *unfrightened* about their test results that
> nothing we tried could frighten or concern them!
>
> This situation was essentially 180 degrees diametrically the opposite of
> what we had expected—which was that patients would be highly invested in
> the results of their studies, that they would be anxious to learn what
> their imaging showed, and would be pressing their physicians for answers.
> We expected the phones to be ringing constantly once the first batch of
> letters went out.  What we found instead was that, at least for the
> population seeking their medical care in the E.D., with a few notable
> exceptions, our patients were pretty much un-engaged with their own care
> beyond the acute episode of care.
>
> We have been struggling with this patient engagement issue and are now
> working toward developing more effective ways to augment our program and
> try to reach these patients.  But I would suggest, based on our experience,
> that merely sending patients the results of their lab tests by mail is
> simply NOT going to be adequate across the board.  Some patients are
> turning out to be very hard to reach.
>
> All the best,
>
> <image002.png>
> Michael A. Bruno, M.D., F.A.C.R.
> Professor of Radiology & Medicine
> Director of Quality Services & Patient Safety
> The Milton S. Hershey Medical Center
> Penn State College of Medicine
> 500 University Drive, Mail Code H-066
> Hershey, PA  17033
>
> Phone: (717) 531-8703
> Fax:      (717) 531-5596
>
> e-mail: mbruno at hmc.psu.edu
>
>
> <image003.png>
>
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>
> *From:* Timothy Stevenson [mailto:Timothy.Stevenson at SSWAHS.NSW.GOV.AU
> <Timothy.Stevenson at SSWAHS.NSW.GOV.AU>]
> *Sent:* Monday, March 09, 2015 4:50 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* [IMPROVEDX] FW: [IMPROVEDX] Positive tests
>
> It is interesting, and yet a little disconcerting, to see the variation in
> perception as to how important and/or necessary it is to provide the
> patient with results from tests ordered that are “good news”. From the
> patient’s perspective, “no news” does not necessarily mean “good news”.
> Rather, it means “What did the tests show?” anxiety. Remember that the
> patient came to see you because “something was wrong”. The fact that the
> test comes back with a “There is nothing wrong” result does not answer the
> question the patient originally came with. As a Quality Assurance officer I
> regularly talk to patients who either have not heard the results of any
> tests they were sent for, have not had the results of the tests clearly
> explained to them or have been told “the tests show nothing is wrong”.
> Their original question of “what is wrong with me” or “what is causing me
> to feel like this” remains unanswered.
> Perhaps we need to go back to the original discussion with the patient
> where *informed consent* was obtained to undertake/ refer for the test.
> Receiving the results with an explanation as to what they show or don’t
> show must be a part of the overall process. I would disagree that simply
> sending the results to the patient in the mails is adequate. I have been
> handed copies of my blood test results with “These show everything is
> alright”, only to see **hi** and **lo** next to some results. If the LAB
> flags these areas, then these results are “not okay”.
> I appreciate that explaining all results will put extra strain on the
> already busy medical practitioners, but perhaps testing will become more
> targeted.
>
> Tim
> *Timothy Stevenson*
>
> Quality & Safety Manager | *SWSLHD Community Health*
> Executive Unit, 1 Bolger Street, Campbelltown, NSW 2560
> Tel (02) 4621 8767 | Fax (02) 4621 8775 | Mob 0455 075 055 |
> timothy.stevenson at sswahs.nsw.gov.au
> http://www.swslhd.nsw.gov.au/CommunityHealth/
>
> <image001.jpg>
>
> *From:* Maureen Cahill [mailto:MCahill at NCSBN.ORG <MCahill at NCSBN.ORG>]
> *Sent:* Tuesday, 10 March 2015 6:48 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Positive tests
>
> Would it be possible to negotiate with a practice’s  laboratory provider
> that at a minimum all results are mailed and then abnormal results could
> have an additional faster track notification?
> Maureen
>
> Maureen Cahill [Associate] 312.525.3646 (D) mcahill at ncsbn.org
> National Council of State Boards of Nursing (NCSBN) 111 E. Wacker Drive,
> Ste 2900, Chicago, IL 60601-4277 312.279.1032 (F) www.ncsbn.org
> Our Mission – NCSBN, Leading in nursing regulation
>
> *From:* Avrum H. Golub, M.D., J.D. [mailto:avrum_h_golub_md_jd at ME.COM
> <avrum_h_golub_md_jd at ME.COM>]
> *Sent:* Monday, March 9, 2015 11:14 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] Positive tests
>
> Lest we forget, patients are people and physicians may be patients.
>
> Please consider the “Golden Rule” and good manners.
>
> And, of course, the reassurance to a patient that we can convey.
>
> If not the physician, perhaps the ministering angel of the bedside (nurse)
> or another physician extender who has empathy and compassion.
>
> Some of the incomprehensible telephone reports (or not report) that I, as
> a patient, have received from physicians’ staffs are rude and anxiety
> provoking, at least.
>
> I am a Pathologist.
> Avrum H. Golub, M.D., J.D.
>
> On Mar 8, 2015, at 8:10 PM, Pauker, Stephen <
> SPauker at TUFTSMEDICALCENTER.ORG> wrote:
>
>
> In my experience and writings , negative or normal test results can be
> quite important in making a diagnosis, so not communicating them to the
> patient can be withholding key information. All results positive or
> negative should be communicated. Further withholding them can sometimes
> lead to repeating the test
>
> Steve
>
>
>
> Sent with Good (www.good.com)
>
>
> -----Original Message-----
> *From: *Robert Bell [rmsbell at ESEDONA.NET]
> *Sent: *Sunday, March 08, 2015 01:33 PM Eastern Standard Time
> *To: *IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject: *[IMPROVEDX] Positive tests
> Many doctor's offices only call or mention to patients positive test
> results that have been undertaken (particularly lab tests). Is that a good
> thing and does it in any way impact diagnosis?
>
> Also, what are the effects of the new electronic portals on diagnosis. It
> is a big change in medicine.
>
> Rob Bell
>
> Sent from my iPad
>
>
>
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> --
> Peggy Zuckerman
> www.peggyRCC.com <http://www.peggyrcc.com/>
>
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>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>
> ------------------------------
>
>
> To unsubscribe from IMPROVEDX: click the following link:
>
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>
>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>
> ------------------------------
>
>
> To unsubscribe from IMPROVEDX: click the following link:
>
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
>
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>
>
>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>
>
> As of 1.1.2015 my new email address is: rmsbell200 at yahoo.com
>
> Please update your address books accordingly
>
>
> ------------------------------
>
>
> To unsubscribe from IMPROVEDX: click the following link:
>
> http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
> or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>



-- 
Peggy Zuckerman
www.peggyRCC.com






Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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