Morbidity and Mortality Conference 2/3/10

1. Morbidity and Mortality:Writing what’s wrong Rick Mansfield, MD MS Feb 3, 2010 The Dying Narrative The Case Example of Sylvia Plath and The Bell Jar

2. I request your feedback…

3. A history of Mansfield M+Ms P4P is Changing MeMansfield, R. Journal of Medical Economics. 5/4/07. p.56-60. (Winner of Young Physcian’s Writer’s Award) Patient flow in primary care (10/07 – 10/08): presented as a poster at the VA National Primary Care Conference in Arlington, VA July 7/29/08. Medicine and the Arts: Ethics: [Excerpt] by Dietrich Bonhoeffer: Mansfield, R. Academic Medicine. 84(7):908-9, July 2009. Virginia Woolf and PTSD:Mansfield, R. Accepted for publication in Journal of Academic Medicine: slated for 3/10. Proofs Finalized yesterday. The Dying Narrative in the Bell Jar by Sylvia Plath: Mansfield, R. Presentation at Literature and Culture since 1900 Conference pending 2/18/10.

4. outline Part one: Writing is the procedure of the pcp Intro and terms Typos and the ‘cut and paste’ [the afib/coumadin case] Timeliness and location of documentation – it’s not all medical [the BMI case] Treat writing like a procedure [the synthroid case] What our writing says about us – (a transition to the main case of the day) Part two: Narrative medicine with examples the dying narrative of Sylvia Plath

5. Health care providers are writers Patient care depends (in part) on what is written in the chart. If you don’t finish your notes – you will be hounded until you do. “If it wasn’t documented – it didn’t happen…even if it did.” Conversely, if it was documented – it happened…even if it didn’t Clinical follow up among numerous providers Billing and coding Medico-legal Performance evaluations Writing is the ‘procedure’ of the pcp

6. The Pen is Mightier than the Sword

7. One letter! “…tests indicate his liver has also been affected…”

8. One letter! “…tests indicate his lover has also been affected…”

9. One letter! “…tests indicate his lover has also been affected…” ‘we are waiting for the cultures…”

10. One letter! “…tests indicate his lover has also been affected…” ‘we are waiting for the vultures…”

11. Case example: Mr. TIA-the cut and paste error. Please don’t do this! *med review/chart review: A) the chart records this item in the history: “Atrial fibrillation… Recently converted to normal sinus rhythm after a course of anticoagulation with Warfarin (off Warfarin for approximately 3 weeks now)." THIS ITEM FIRST APPEARED IN A CARDIOLOGY NOTE DATED 1/7/02 - AND HAS BEEN COPIED VERBATIM AS RECENTLY AS 11/9/09. - MEANING THE CHART RECORDS HIM AS BEING "OFF WARFARIN FOR APPROXIMATELY THREE 3 WEEKS NOW" FOR THE PAST SEVEN YEARS…THis is relevant today as my approach to a TIA would have been different if a possible TIA occurred in the setting of just having stopped coumadin. B) many notes record the patient as taking ASA qd - he states he does not. His wife confirms this. This is also relevant since he should not be considered an aspirin failure for possible TIA.

12. If you’re going to cut and paste… Use hard dates Do not say ‘symptoms started three weeks ago…”. If you cut and paste this later – it will be wrong. Say “symptoms started on 1/15/09…”. If you cut and paste this later – it remains true. Another example: “Abx day 4” vs. “14 day course of abx started on 1/1/10 to end on 1/15/10” – more words up front; but can be cut and pasted accurately for the duration of the course. Make cut and paste work efficiently to your advantage – but make it true.

13. Cut and paste (Be a writer) Reference your source: e.g., “PMH as per Dr. J’s note of 1/21/10…[then cut and paste the PMH]” Not medical knowledge It’s technology to which we have to adapt Let’s use it to our advantage. Let’s make sure the medical record is complete and accurate. Do they teach this in med school or residency now?

14. Who else reads our writing? Letter received from patient: “Dear Doctor, Thank you for honoring my request for a copy of my medical records. I was quite pleased to see myself referred to as a ‘pleasant elderly gentleman’ in your notes. Most people refer to me as an ‘irascible old bastard’.” (thanks to Dr. Berman….that’s not Dr. Berman)

15. the BMI example: timeliness and location of documentation Evaluations and outcomes are not always based on what we actually do – evaluations and outcomes can be based only what we document and when we document it.

16. the BMI example: timeliness and location of documentation Some recent email communications: “Rick you missed 6 out of 11 patients this week for the BMI Reminder. Please call the below patients and satisfy the reminder- thanks” “This is not true! – These patients were all seen within the last 72 hours – I just haven’t finished my notes yet. All my notes prior to this are completed. These notes will be finished promptly. This is a research design flaw – this data captured is confounded by its dependence on note status – and therefore is not always an accurate measure of whether or not I addressed BMI with patients.” “Glad to hear you are completing the BMI reminder. Please finish your notes on the same day as the visit.”

17. 375 37.5 375 The Synthroid case: treat writing like a procedure

18. The Synthroid case: outcome After one month of taking the wrong dose – the pt felt his PTSD flare and the need to ‘shoot back’. Root Cause Analysis Tort case against the VA VHA NATIONAL DUAL CARE POLICY: (VHA DIRECTIVE 2009-038 - August 25, 2009) I meet with VA regional counsel at 10:00 AM today

19. The Synthroid case: treat writing like a procedure If we can’t write it – it won’t be done. If we don’t make the time to write – how can we expect things to be done correctly? What if a surgeon practiced surgery the way we write notes and orders? What have I done? I treat my admin time with equal importance to my clinic time. I don’t see two patients at once during my clinic – why should I allow interruptions while writing my notes…and orders?

20. Another Synthroid case: treat writing like a procedure "To Dr. Mansfield, I am increasing, after talking c Mr. X today, levoxyl from .025 mg to .075 mg #90 daily. Disregard note from 1-22-10." *************************************** date TSH VA dose of synthroid recommend dose by nonVApcp 8/26/09 3.00 0.025mg 0.025mg 10/23/09 0.025mg 0.05 mg (never received) 1/22/10 0.025mg 0.10 mg (received after 1/26/10) 1/26/10 0.025mg increase from 0.025 to 0.075 mg. non VA rec's for change in levoxyl are inconsistent. I have no further labs since 8/26/09. he needs to see me (with labs) before I change his dose… [this took >20 minutes to read/enter non-VA correspondence – track VA data, construct a table, make a decision, order labs, and communicate this to scheduling…20 minutes without an H+P evaluation]

21. Memorable quote from Med school: Good surgeons… Great surgeons… …Make good INcisions …Make good DEcisions

22. Patient satisfaction: “the customer is always right?” Switzer walked back into the room, having been called by the nurses. Ms. Rydel recognized him, “You again?” she tried to sit up when she said this but it hurt – she moaned and laidback down. “I want a second opinion. No one is telling me anything… I want Dr. Barr.” She pointed a finger at Switzer, “Haven’t you heard the ‘customer is always right?!’” …He pulled a chair up beside the bed; sat down so that as he looked at her, he wasn’t looking down, they were on the same level. He was calm when he spoke, “Ms. Rydel, this is a hospital, you’re not a customer, and I’m not here to sell you anything. I’m here to do everything in my power to help you as a doctor-” “Then why don’t you listen to me and do what I want? I have rights you know.” Her voice was at least a little softer. “Yes you do. You have your rights, and I have my obligation as a physician to provide for you the best care possible. I won’t deviate from that. I know you’re in pain. And I can’t cure you. It’s not that I don’t have the time to explain all this to you, it’s because you don’t have the time for me to explain it to you. You need to have surgery soon, now. Head Games: by Rick Mansfield p. 67

23. Now – more about writing… What is writing? Narrative medicine (and psychobiography) – Rita Charon Part Two: The case of Sylvia Plath and the Bell Jar

24. Strumpf and Douglas: The Grammar Bible. (p. xv) “Communication is the essence of the human condition.” The human condition is the subject matter of medical practice The medical record is our medium of communication, (dare I say, ‘essence’ of our communication?) “…even if his or her knowledge is unconscious.”

25. Strunk and White: the Elements of Style (p. 67) “All writers, by the way they use the language, reveal something of their spirits, their habits, their capacities, and their biases. This is inevitable as well as enjoyable. All writing is communication: creative writing is communication through revelation – it is the Self escaping into the open. No writer long remains incognito.”

26. Ex/ who is this writer? End stage metastatic pancreatic cancer He’s an old friend This is sad He’s lived a good life Request of the team: please give epo 14,000 U SC q wk Might make him feel better. J.O.

27. Ex/ who is this writer? Cc: …vague symptoms… HPI: …nothing specific… PE…CTA…RRR…. a/p: …symptoms treated in the ED…ok for d/c… …will check TSH…he can f/u with me in endo clinic A.B.

28. Zinsser: On Writing Well. (p. 5) “[writers]…are driven by a compulsion to put some part of themselves on paper…The problem is to find the real man or woman behind all the tension. For ultimately the product that any writer has to sell is not his subject, but who he is.

29. Stephen King: On Writing. (p. 101) It starts with this: put your desk in the corner, and every time you sit down there to write, remind yourself why it isn’t in the middle of the room. Life isn’t a support system for art. It’s the other way around.

30. Narrative Medicine: Rita Charon Definition: “medicine practiced with the narrative competence to recognize, interpret, and be moved to action by the predicaments of others.” (2 January 2001 Annals of Internal Medicine Volume 134 • Number 1) “With narrative competence, physicians can reach and join their patients in illness, recognize their own personal journeys through medicine, acknowledge kinship with and duties toward other health care professionals, and inaugurate consequential discourse with the public about health care.” (JAMA 2001; 286: 1897-1902)

31. Rita Charon Writing and humanities studies produce better physicians…because doctors learn to coax hidden information from patients' complaints When Medicine Meets LiteratureBy Marguerite Holloway Scientific American Magazine - April 25, 2005.

32. Sylvia Plath: The Bell Jar. “People were made of nothing so much as dust, and I couldn’t see that doctoring all that dust was a bit better than writing poems people would remember and repeat to themselves when they were unhappy or sick and couldn’t sleep.” P. 57 “So maybe doctors and writers could get along fine after all.” P55

33. The Bell Jar: 1st Paragraph It was a queer, sultry summer, the summer they electrocuted the Rosenbergs, and I didn’t know what I was doing in New York. I’m stupid about executions. The idea of being electrocuted makes me sick, and that’s all there was to read about in the papers – goggle-eyed headlines staring up at me on every street corner and at the fusty, peanut-smelling mouth of every subway. It had nothing to do with me, but I couldn’t help wondering what it would be like, being burned alive all along your nerves. I thought it must be the worst thing in the world. (p.1) 1st person/past tense

34. The Bell Jar: 1st person/present! It was a queer, sultry summer, the summer they electrocuted the Rosenbergs, and I didn’t know what I was doing in New York. I’m stupid about executions. The idea of being electrocuted makesme sick, and that’s all there was to read about in the papers – goggle-eyed headlines staring up at me on every street corner and at the fusty, peanut-smelling mouth of every subway. It had nothing to do with me, but I couldn’t help wondering what it would be like, being burned alive all along your nerves. I thought it must be the worst thing in the world. (p.1)

35. Electrocution vs. Electroconvulsive therapy. Context text The Rosenbergs. 1950’s McCarthyism. 1st U.S. citizens to be condemned to death for espionage. Executed by electrocution. “down the hall between two nurses,… with dignity, like a person coolly resigned to execution.” P.211 ECT Tx is the climax of the book.

36. Present tense

37. Present tense

38. Next present tense example: For a long time afterward I hid them away, but later, when I was all right again, I brought them out, and I still have them around the house. I use the lipsticks now and then, and last week I cut plastic starfish off the sunglasses case for the baby to play with. (p. 3)

39. Change in verb tense? For a long time afterward I hid them away, but later, when I was all right again, I brought them out, and I still have them around the house. I use the lipsticks now and then, and last week I cut plastic starfish off the sunglasses case for the baby to play with. (p. 3)

40. Does she give away the ending? For a long time afterward I hid them away, but later, when I was all right again, I brought them out, and I still have them around the house. I use the lipsticks now and then, and last week I cut plastic starfish off the sunglasses case for the baby to play with. (p. 3)

41. The baby? For a long time afterward I hid them away, but later, when I was all right again, I brought them out, and I still have them around the house. I use the lipsticks now and then, and last week I cut plastic starfish off the sunglasses case for the baby to play with. (p. 3) How easy having babies seemed to the women around me! Why was I so unmaternal and apart?...If I had to wait on a baby all day, I would go mad. (p.222)

42. …that after I had children I would feel differently, I wouldn’t want to write poems anymore…when you were married and had children it was like being brainwashed, and afterward you went about numb as a slave in some private, totalitarian state. P.85 “I’m never going to get married.” p.93..p.26;83 Children made me sick. P.117 I didn’t want to give my children a hypocrite for a father. P. 119 More on Babies

43. Next example: the Bath and Baptism Whenever I’m sad I’m going to die, or so nervous I can’t sleep, or in love with somebody I won’t be seeing for a week, I slump down just so far and then I say: “I’ll go take a hot bath. I meditate in the bath…I’m never so much myself as when I’m in the hot bath…I don’t believe in baptism…but I guess I feel about a hot bath the way those religious people feel about holy water. (p. 19-20) The longer I lay there in the clear hot water the purer I felt…I felt pure and sweet as a new baby.” (p.20)

44. Baptism – the very last page! There ought, I thought, to be a ritual for being born twice – patched, retreaded and approved for the road.” (p.244)

45. Plath’s Only Novel “Secretly, in studies and attics and schoolrooms all over America, people must be writing.” P. 102. “Then I decided that I would spend the summer writing a novel. That would fix a lot of people.” P.121 A feeling of tenderness filled my heart. My heroine would be myself, only in disguise. She would be called Elaine. Elaine. I counted the letters on my fingers. There were six letters in Esther, too. It seemed a lucky thing. (p. 120) There are six letters in Sylvia, too. (It seems a lucky thing.)

46. The Bell Jar I saw [these girls] on the sunroof, yawning and painting their nails and trying to keep their Bermuda tans, and they seemed bored as hell…bored with skiing in Switzerland at Christmas and bored with the men in Brazil. Girls like that make me sick. I’m so jealous I can’t speak. (p.4) …Those girls, too, sat under bell jars of a sort. (P. 238)

47. The Bell Jar To the person in the bell jar, blank and stopped as a dead baby, the world itself is the bad dream p. 237. I would be sitting under the same glass bell jar, stewing in my own sour air. p. 185. I felt surprisingly at peace. The bell jar hung, suspended, a few feet above my head. I was open to the circulating air. P. 213. How did I know that someday…the bell jar with its stifling distortions wouldn’t descend again? P. 241.

48. She uses the present tense to: Compare ECT to electrocution Discuss babies/children Desire for new life/baptism Writing Understand other people Depression: The Bell Jar.

49. Conclusions: Writing matters It is the procedure of the pcp What we write says something about who we are ‘Write what you know’ – the age-old writer’s adage is just as true for the health care provider writing in the chart. Narrative Medicine: Understanding the patient’s story IS caring for the patient. (present tense)

50. Upcoming installments Heisenberg : The Uncertainty Principle (as it applies to health services research) Ben Franklin: Autobiography (cognitive behavioral therapy) Edgar Allen Poe: The Raven (psychosis) Robert Louis Stevenson: Jekyll and Hyde(alcoholism)

51. The END