“This bus has been checked for sleeping children.”
What, you may ask, does this have to do with patient-centered care, or healthcare in pretty much any sense?
Last week as I was heading into work, I noticed a school bus parked on the side of the road, awaiting the start of its early morning pickup of students heading off to school. A piece of paper with the above message about checking for sleeping children was laminated to the inside of one of the back windows.
Laminated. Permanently stuck on there. Not in some kind of slip-on holder, not taped to the window, but clearly meant to be a permanent message.
An Actual Process Is Needed
I understand that checking buses for sleeping schoolchildren is an important safety measure. At the end of a shift, after picking up or dropping off children along their route, if a bus returns to its depot with a child sleeping in the back and shuts down the bus and the driver goes home for the evening, then there is certainly a risk to the child that makes checking the bus a worthwhile effort. But if we have a sign that’s permanently there, that always says that someone has already done this task, then it’s pretty likely that this is not being used in the right way, and maybe even not being done every time.
One would want a safety measure like this to be done as we think of the process for most safety measures: The driver finishes their shift and drops everyone off back home with their parents. Then, when they’ve finished their route and returned the bus to the parking lot, they make a final sweep of the bus, checking on all the seats and underneath them and whatever else they need to do, then mark off in some sort of safety log that they’ve checked the bus for sleeping children at 5:34 p.m. on March 11, 2022, and then and only then can they safely hang a sign specific for today’s shift in the window.
This would allow some supervisor who’s making rounds of the bus depot to feel confident that there are no sleeping children among all of the buses gathered together for the night. If, in fact, the bus driver never actually really checked, but the sign was there, a supervisor can safely say that they saw that the sign said that the bus had been checked, thus removing any responsibility on their part for a child left overnight in a school bus.
Did It Really Get Done?
Over and over in the electronic health record, when we see templated material that’s been dropped into a patient’s chart, we all wonder how much of this is being done reflexively, through muscle memory, because we have to. Because there are so many bureaucratic rules and regulations, so many things that we are required to document in the chart — for medico-legal and other reasons — providers, as well as the systems that back us up, have built an enormous number of these templated items.
Whether they are surgical operative notes, consent information, disclaimers about risks and benefits and alternatives, and any number of other things that we do, it often feels like you’re reading a block of templated fiction, that no way could all of this stuff actually have occurred.
I know we’re never going to return to a completely kinder and gentler way of doing things, where we are free to simply record in the chart what actually took place between us and our patients, because when a bad outcome occurs, someone’s going to go in looking at the chart, looking to see: Did you explain to the patient that this was a risk of this procedure?
Everything from drawing blood tests, ordering imaging, referring to a specialist, starting a medication, and not starting a medication, requires a long discussion of risks, benefits, alternatives, and a process of shared decision-making where a patient truly understands what they’re getting into, and why.
In the incredibly short appointment times we have, we are all guilty of occasionally flipping into paternalism, telling our patients that their blood pressure remains high, so it’s time we start a medication to get this under control. Their diabetes is just not at a safe level, and they’re going to have to start taking medication, and checking their sugars more regularly. Their cough has persisted, and they need imaging and further evaluations.
Reasons for the Shortcuts
It’s true that having a quick and easy shortcut makes us all feel better, serving as a stand-in for whatever actually took place between the patient and their doctor. “Return to the emergency room if your symptoms return/worsen or you develop fevers, chills, shortness of breath, or chest pain.” When patients come to all of us after surgery and say, “The surgeon never told me that I might feel X or Y or Z after the surgery,” we always can take a peek back through their chart and see that it says that all potential outcomes and possible complications were discussed with the patient and all questions were answered to their satisfaction.
When our patients speak a language that we are not comfortable communicating with them in, there is a long elaborate process involving offering a translator, explaining to them the benefits of using a medical translator (all of which needs to be done with a translator), and documenting that they decline and want to use a family member to communicate with us today. There’s a macro for that.
When our patients call up and schedule a video visit with us, they need to sign an electronic consent online saying they agree to do a video visit. Then when they log on to the video visit through their computer or smartphone, we need to include in our note that we’ve explained to them the limitations of a video visit, and that they agree to do a video visit. A templated macro for that.
Perhaps there’s some way that we can build out these systems that will provide our patients with the information they need, the opportunity and the time to have all their questions answered, to get the medical education about every topic they need in ways they can understand, to fully participate in shared decision-making for every single part of their healthcare.
For now, we’re probably going to have to continue doing much of this, but maybe we can move a lot of this stuff out of the medical note and into some sort of administrative spot where it doesn’t clutter up what we are trying to learn as we review patient’s charts?
Maybe I’m asking too much, maybe I’m stirring the pot too much, maybe I should just let sleeping dogs lie. But we don’t want to let sleeping schoolkids stay overnight in the back of the bus, so let’s wake up and make some changes.
Fred Pelzman of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what’s going on in the world of primary care medicine from the perspective of his own practice.