I hope you’ve enjoyed the series and it’s made you think a bit about health care, health policy, and how difficult it is to come up with solutions to our health care problems. I appreciate the civil discussion and debate, and continue to welcome any other feedback!

A few topics I wanted to cover but didn’t have time to:

• Science education – If we want our patients to understand medicine and the science behind it, they need to understand (and accept) the basic tenets of science — randomized studies, for example — and perhaps that’s where we’re failing. People seem to have a miraculous ability to accept the science they have chosen to believe (antibiotics for bacterial infections, germ theory) while ignoring rigorous science that doesn’t fit with their world view (thiomersal is not responsible for autism).
• Patient Autonomy – Has it gone too far? By asking patients or their decision-makers to decide, “Do you want to keep trying failing treatments or terminate care,” perhaps we’re putting too much decision-making in the hands of a person who clearly doesn’t want to feel responsible for “pulling the plug” on their mother (who would?)? While no one wants to die or wants a loved one to die, is it fair to other people who have a better chance of hope of recovery to take up a hospital bed to treat a demented 95 year-old man who won’t get any better?
• And many more!

On that note, it’s been a pleasure writing about my journey through medical school, and I appreciate everyone who’s joined me and supported me along the way.

I’m heading to Xela, Guatemala (aka Quetzaltenango) tonight for two months with Asociación Pop-Wuj to do some intensive Spanish and medical Spanish training (as well as seeing their cigar-smoking saint, Maximón , and hiking and exploring) before heading back to be in a friend’s wedding. I likely won’t be blogging much, but hey, who knows. Since I now have an official job as a doctor (scary), I’ll be wrapping Over My Med Body up in time for Graduation in June. Stay safe and healthy and I’ll see you on the flip side!

yours,
graham

Me on Match Day, blogging away:

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You knew it was coming, my single-payer post. It’s a nice wrap-up to the series. (I figured since I was agreeing with KevinMD and Panda so much I had to do something .)

I could make my argument for single-payer in any number of ways, but you’ve probably already heard them:

• Human dignity. Everyone should have health care as a human right. That people deserve health care, and as a wise family practice doc from Idaho wrote, the uninsured pay for their health care with their dignity. That almost all of the uninsured and underinsured are hardworking, tax-paying people who either make “too much” money to qualify for programs for the poor like Medicaid or don’t make enough for their employers to also provide health insurance. Or that health insurance is often way too expensive for their families, or even if they bought health insurance, it wouldn’t cover their major problems, like their kid’s asthma (sorry, pre-existing condition).
• We the taxpayers and insured are already paying for the uninsured in the form of higher taxes, higher insurance premiums, and longer waits for our own health care (remember, we’re all connected). Since we’re humane enough to have EMTALA and not let people die on the streets, people are going to get some level of care, no matter how poorly planned, poorly organized, or terribly chaotic it is. We might as well just pay for everyone and get a better bang for our buck, no? Isn’t that the American way, to at least get a good deal?
• Economic growth is seriously stunted by our current non-system. Why did the Jelly Belly factory cross the border? To get cheaper health care costs in Canada. (True story.) In our global economy, take a look at any American industry and you’ll see our health care costs stick out like a sore thumb–and this makes American companies have higher costs and are therefore less competetive. US automakers currently pay more for their employees’ health insurance than the steel to build their cars (which is why renowned health care economist Uwe Reinhardt refers to the American car companies as health insurance providers financed by selling cars).
  Many people–especially potential small business owners/entrepreneurs–simply forget any aspirations they have of starting their own business because of health care costs. If you quit your job and lose your health insurance and then get sick, you’re screwed. So there’s an incentive to stay in a job one hates, no matter how unproductive the worker is, because it provides them with health insurance.
• We already ration care. Many people cite a valid concern that single-payer would lead to ominous “health care rationing.” They do not realize that we already ration care: based on ability to pay, not health care need.
• Single-payer will save us money. Take a look at any proposed health care scheme, as many economists have in multiple previous studies ( California Health Care Options Project , The Vermont Single-Payer Study , The Maryland Single-Payer Study , Massachusetts Health Care Studies , and Maine’s Single-Payer Microsimulation . Just to be clear, these analyses were done by The Lewin Group and Mathematica Consulting , two economic analyst groups. Not single-payer supporters), and you’ll see that single-payer is the only one that provides health insurance to everyone while actually costing overall less. It does this by doing bulk-purchasing of products, just like you do at Sam’s Club. It also majorly simplifies administrative overhead–think of the billions spent on duplicate forms a doctor has to process from the thousands of health plans out there–and the costs of increased health care usage are still absorbed in the savings. (I’m not about to deny that Medicare has paperwork requirements, but they’d be one set of paperwork requirements only.)

Like I said. Probably really nothing new if you’ve ever read any single-payer stuff on the Internets or my blog in particular. But I’m here to propose a different, and much more important reason we should adopt single-payer. We can’t afford not to. On To Single-Payer, Part 2

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America loves to medicate its problems away. Can’t sleep on a plane? Take a pil. Nervous? Take a pill. We want to be in control of our bodies to the nth degree: we’re too busy to be sick, just give us antibiotics that may or may not work; we shouldn’t be fat, just give me a pill to make it all better. We get to have our coffee any way we like it, so why shouldn’t we get to have our bodies however we want them, too?

The problem is that pills don’t work that way. Our pills are, for the most part, chemicals that muck with cells’ pre-existing hardware often by altering how a certain protein interacts with another. But because all our cells generally contain most of the same ingredients, our pills end up poisoning other unintended cells, causing collateral damage. (This is why chemo kills cancer but has such severe side effects: it works by killing cells that grow rapidly, as many cancers do, but other body cells grow rapidly too–the hair, the gut, the immune system–and so these cells die too.)

It would be much cheaper for society–and healthier–to prescribe “exercise” or “a healthier diet.” Often this is what we physicians do prescribe, but our patients do not (and often cannot) follow through. Exercise, diet, and other things that can have a major impact on health are often lumped together as simply “lifestyle,” and are often viewed as individual preference and choice. It’s often easier to simply prescribe a drug (even though we realize that lifestyle changes would be much prefered). The Happy Hospitalist often rants about this–how much money would we save if people just ate healthier and exercised instead of taking pills?

Well, people should eat better, have less stress, and exercise more. Duh.

Some of this might be improved by better city planning and social policy: encouraging walking and public transportation, changing our farm subsidies around to encourage cheaper produce and more access to it.

But the larger social change (and therefore, less likely one) is changing our lifestyles. If you want people to eat better and exercise more, you have to give them more time to do these things. In the short run, sure, it’s easier to medicate the problem away. But in the long-term, I think healthier lifestyles beat polymedicated Americans anyday.

Again, this would require massive changes in our culture and society. To lose our obsession on material goods and consumerism, to realize that taking care of ourselves should take priority over a nicer car or more stuff. To have a greater distribution of wealth . But I illustrate this “solution” more to suggest how difficult it might be to make inroads in this prescription mania in America than anything else.

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Primary care in this country is dying. There are fewer available primary care doctors in this country, as more and more physicians either go directly into specialty care or choose a specialty after completing one of the primary care tracks (internal medicine, pediatrics, family practice, obstetrics and gynecology).

Why is this a problem? Primary care is the foundation of a health care system. Most problems and illnesses most people have can reliably be treated by a primary care doctor. When Iran wanted to develop its health care infrastructure, for example, they asked a family practice doctor to fly over and work with their medical leaders, not a urologist or cardiologist. If you don’t have primary care in your health care system, you end up way overpaying for unnecessary specialist care (think of sending a person to a urologist if they have a urinary tract infection instead of going to their family doctor, for example). You also can’t effectively triage people and get them to the right doctor. If someone is short of breath, do you send them to the cardiologist, the pulmonologist, the allergist, the rheumatologist, or the infectious disease doctor? Lose primary care and you lose the basis for your medical decision tree.

And it’s not just that physicians aren’t going into primary care, it’s that primary care doctors are often actually stopping practicing primary care. They find there are other ways they can make better money (or lose less money). When you see this in a health care system–that DOCTORS are quitting medicine, for whatever reason–think bad, bad health care system future.

Why is this happening? A number of reasons, but I’d argue it depends on who you ask:

• Primary care doctors: Money. All about money. Low reimbursement rates for seeing patients (especially compared to specialists who get paid much more handsomely for procedures). Long hours, relatively low pay compared to your colleagues. Lots of paperwork.
• Medical students: Time. All about time. 15 minutes to see each and every patient, no matter how sick they are? No matter if they’re crying for the first five minutes of it, or if they walk in having active chest pain and you need to get them over to a hospital via ambulance right away? 15 minutes even if they’re asking you to fill out 5 forms that take 5 minutes each? That makes no sense. (Primary care docs certainly care about time, and medical students certainly care about money, just illustrating two of the big issues for primary care today.)

I’d like to discuss each of these issues–money and time–a bit further, because I believe they have wide-reaching consequences on our health care system (since, as we said above, primary care is the foundation of a health care system):

Money. While you might just say, “Well duh, doctors, like everyone else, want more money,” it’s more significant than this. We pay doctors a certain amount based on what they do. Medicare sets these amounts, and most insurers use Medicare’s rates on which to base their own. The way that we pay physicians today, doing is rewarded much more than thinking is. Extreme example: A doctor who performs a surgery is paid much more than another doctor who sees a child for a rash and knows the rash will soon go away, since it’s just a virus. An even more real-life example: a physician gets to bill for a more complex visit (and better-paying one) by prescribing a medicine over not prescribing one. We wonder, “Gosh, why do patients always want something done–a blood test, a study, a scan–when often watchful waiting is the better choice for the patient?” Culture is certainly to blame, but perhaps so are doctors. Patients have learned that more (tests, studies, scans) is better because more is better: for physicians’ pocketbooks. There’s a clear incentive in the system for doctors to do more, so perhaps patients have just learned that more is better by watching us to begin with. ( See this NYT article for a perfect example of “more is better.” ) I’m not suggesting doctors do this consciously, or that this is the only reason, just one that should be considered as it has drastic consequences for health care costs and unnecessary procedures that unnecessarily place patients at risk.

Time. Borrowing this point from the Panda Bear : when doctors only get 15 minutes to see a patient, you leave them no choice but to start referring a patient out to specialty care when often the diagnosis just requires a bit more time to sniff out. A few more questions to come to the right one. But instead, in this system where each patient only gets 15 minutes of a doctor’s time per visit, everything is referred to a specialist (who often either gets a bit more time to see each patient, or at least is just dealing with one single issue). Can any adult medicine doctor manage someone’s heart failure leg edema? Sure! But put the heart failure in a 75 year-old with glaucoma, dry skin, lung cancer, diabetes, and peripheral neuropathy, and it’s no wonder someone might say “Hey, go see a cardiologist about your leg swelling, I’ve got enough other problems to fix.” This not only leads to increased health care costs from unnecessary specialist care, but also leads to patient confusion (why am I seeing ANOTHER doctor?). I just read some study (can’t find it) linked somewhere saying that most specialists get referrals from primary care doctors without ANY documentation of why the patient is being refered? Perhaps there’s no time for the primary care doctor to write up the referral?

One can look at concierge medicine, which I discuss here and here , as symptoms of this lack of time and money problem. Thanks to Roy Poses for this analogy.

In typical Over My Med Body style, I think we need to address the root concerns identified above: time and money. Lack of primary care affects us all. ( We Are All Connected. ) I’m probably going to piss off both primary care doctors and specialists with my suggestions here, so please, leave your two cents on how these ideas might be improved.

Money: The simple answer is “pay primary care doctors more.” I believe this should be at the expense of specialists, meaning that the gap between specialists and primary care doctors’ incomes should shrink. Primary care is an incredibly challenging field–one of the most, in fact–and doctors should be better-compensated for practicing it. Perhaps, as well, they should be rewarded for good long-term outcomes for their patients.

Another idea I’d like to float down the river: pay primary care doctors per hour, like lawyers, instead of per patient, with minimums and maximums based on a patient’s comorbidities. So if a patient takes 15 minutes to see and 5 minutes to document, and another 5 minutes to arrange a CT scan for, the doctor gets paid for all 25 minutes (currently they only get paid for the 15 minute visit). All other doctors would still only receive payment for the 15 minutes to see a patient. I’ve suggested this idea before–pay primary care doctors for their paperwork–and I think it would pay primary care doctors better, allow them to provide better care for their patients, and encourage more medical students, residents, and other already-trained doctors to go into the field.

Time: Simply, doctors need to be given more time to see more complex patients. With the 15 minute system we’re in today, I think it has had the effect of trimming the fat from the patient visit, but it leaves little to no room for patient complexity or severity of illness.

I do think also that there are plenty of primary care options that should be open to nurse practioners and physician assistants. There are lots of circumstances where a patient needs to be seen by a doctor, but if the diagnosis is viral upper respiratory infection, why not allow a physician assistant to reassure a patient? I have trouble seeing the other side of this argument.

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Medical students spend an average of $139,000 on medical school in the United States , while other nations provide either fully-funded medical school education or at least greatly subsidized medical education. When you add in the costs of an undergradate degree (which is often either not necessary for other countries’ medical school admission or again tax payer-funded), it’s not uncommon to have medical students starting residency in $200,000 of educational debt.

Often medical students also need to purchase or own a car in order to work at the multiple hospitals which will comprise their clinical training. This adds significantly to their expenses (as they have to take out separate car loans at higher interest rates than most of their student loans, and any car loan debts they have get subtracted from their eligible financial aid amount as well). In order to match in certain specialties, students may have to apply to 50 or more programs and interview at a huge number of them. This enormous amount spent applying, booking flights and hotel rooms and meals on the road can easily add up to $10,000 — and unless the student has $10,000 sitting around, it all goes on the credit card, at an even higher interest rate.

Because interest accrues immediately following graduation, even a low interest loan at 2-3% grows quickly when the principal is $100,000 or $200,000.

While these are just numbers on a piece of paper for most of us medical students (translation: I can’t really fathom owing $200,000, so I just pretend it doesn’t exist), we understand it well deep in our financial souls. Most medical students would be lying if they said this doesn’t at all cross their minds when they consider a specialty and future salary. Being in the hole $200,000 is a gigantic Sword of Damacles that scares the crap out of me.

As I’ve said before, i would much rather have medical school be free (read: tax-payer financed) and either have an expectation of:

1. making less money after residency or
2. required service time to the taxpayers who financed my education

Maybe we make it a choice. You can choose to pay full price, or pay no price, with either a guarantee that you make less money for life or have required service time for the country.*

I know the government has made unsuccessful attempts to do this in the past by essentially providing too little of a sudsidy for physicians; I would recommend improving this strategy by altering tuition reimbursement based on specialty need and location served. (For example, a primary care physician working in a rural area might be reimbursed 75% of tuition per year, while a pediatrician in the Bronx might be reimbursed 60%.) Perhaps physicians who continue to practice in these settings might receive bonuses for 5 years served, 10 years served, etc. (Yes, I realize the military does offer some programs like this for tuition reimbursement, however it is not available to some physicians *ahem, me* because of don’t ask, don’t tell.)

* Many medical training programs in other countries already require their trainees to essentially complete a medical internship in a rural or underserved area of their country where they are the doctor for the entire community; only then can they go on to specialize in surgery, radiology, obstetrics and gynecology, etc.

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HIPAA is like the Transportation Safety Administration’s requirements that everyone take off their shoes and only carry a quart of liquids and creams: it apparently makes us feel safe and protected, but really just it’s all a big pony show that wastes everyone’s time.

The idea of HIPAA’s privacy rules is this: health information is private. It’s nobody’s beeswax besides yours, your doctor’s, and whoever’s agreed to pay for your care (insure you). And I agree. It is nobody’s beeswax. But it’s so bogusly enforced that it just creates headaches. As I’ve said before, I could easily walk into any hospital in the United States, and dressed appropriately, start reading anyone’s paper chart. Guaranteed. So, see, your health information isn’t private. It should be, but it isn’t.

HIPAA also prevents information from being shared between physician and patient easily electronically. HIPAA lists 18 items that must be protected and cannot be included unless the information is transmitted securely. (Note to bloggers: this is why I change everything about my patients if I write about them: saying anything more specific than what state you’re in is Protected Health Information!) Patients clearly want the ability to electronically talk to their physicians; my generation of physicians would certainly want this as well. Quick question, or side effects of a medication becoming a problem? Want a list of your medications? Want lab results emailed to you? Want your physician to email you an appointment reminder? No no no no no. Instead, we have systems where your doctor sends a message to you in a system with ANOTHER username and ANOTHER password, and it’s a big headache. Even if it’s not that bad of a system, you don’t have access to the messages on your own computer. It’s not like an email that you can just go back and find the message.

What’s even more ridiculous is that HIPAA doesn’t apply to anyone that’s not providing health care or paying for it. So neither Google nor Microsoft even have to comply with any of these requirements, so they’re more free to make information exchange happen than your own physicians!

Make HIPAA opt-outable easily. Maybe this is already common thing, but I haven’t really seen it anywhere. A simple form: I hereby authorize Dr. Walker to unsecurely email me with my: ___ Medications ___ Lab Results ___ Diagnoses to [email protected], and waive my right to HIPAA security protections.

Also: pay doctors for email consults. When in doubt, the physician should always bring the patient in, but it’s a waste of both the physician’s time and the patient’s for questions like, “I feel better, do I need to finish my antibiotics?”

Be consistent with privacy rules. Either require all hospitals to go electronic so that data is behind a password (although one could certainly argue that it’s even easier to steal more data more quickly electronically) or don’t be so damn ridiculous about privacy standards. Also in exchange, provide a more standard protocol to streamline the reporting of stolen identities and stolen health records.

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These terms are often thrown around as synonymous, when they clearly are not. Someone’s, or some society’s health takes into consideration the freedom from illness, disease, or injury (actually from the Germanic meaning “wholeness”). Health is impacted by genetics, stress, violence, diet, laws, living standards, and health care, to name a few.

“Health care” is the interventions we perform on individuals to try to keep them healthy . Economically, “health care” is resources spent on health: not just monetary resources, but time, energy, workforce, etc.

Health insurance is a way to pay for health care . The theory behind insurance is this: big, bad, expensive things can happen to you at any time. Your house can catch fire. You can get into a car accident. You can get cancer. We pay for insurance to decrease this risk–that we pay into the system now so that it will bail us out later . The more people in this system, the better. If there’s only two people, and one gets robbed, there goes a lot of the other guy’s money! But if 100 people are in the system, there’s 99 people’s money left to even out the risk.

The goal of health policy is to make the population as healthy as possible.

The goal of health care policy is to make the health care system — only one part of the determinants of health — as “good” at divvying up limited health care resources as possible. (Lots of ways to define good. I define it as going to those who most need them.)

I would love to see a population whose health is so darn good that we wouldn’t have to worry as much about health care. Health alone could be its own blog, so I’ll simply suggest a few ways that we might be healthier, without even messing with health care :

• Reverse the subsidies for vegetables versus meat. Wonder why a salad costs more than a Big Mac? It’s not that cows are cheap. It’s that government subsidizes.
• Walking instead of driving. Afraid as Americans we screwed the pooch on this one during white flight and suburban sprawl of the mid-20th century. One of many reasons I prefer the city.
• Create a more equal society. It should be no surprise to anyone that the poor are the earliest to die and are the most obese. When your food options are canned foods or McDonald’s, the game’s already against you.

I illustrate these points only to remind you that if your goal is to make people healthier, there’s many, many more avenues that might be far more effective (and far far cheaper) than optimizing or fixing the health care system. (We just like to argue about it because it’s the most accessible and well-understood by us.)

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(No, I’m not going to get all Kumbaya on you.) Listen:

We’re all in this thing together, whatever it is. That “limited resources” bit you remember from Econ 101? It applies to health care, too.

Look, the lesser argument has been made many times over, by the likes of Paul Farmer and other radicals who have fought battles in Infectious Disease: that if we don’t control infections in one population, they spread to other populations and make us all sicker. That if we don’t treat multi-drug resistant TB in Haiti, Peru, or the prisons of Russia, then we Americans will be fighting the MDR-TB here at home. (Similarly in the infectious disease world is the fact that vaccine “herd immunity” is becoming less useful, as our international lifestyles put us into contact with people who were born outside the US and never got measles vaccines, for example, and may be contagious.)

But the greater argument for our interconnectedness is this: that by allowing whole swarms of people (often but not always the un- or under-insured) to go without necessary chronic care and necessary follow-up, they eventually become sicker and more complex. And this, my friends, creates problems for all of us. Because sicker and more complex patients require more doctors and more time and more hospitalizations. And more hospitalizations that take more time, because sicker and more complex patients have more things that will go wrong with them.

How does this get back to you, oh-self-concerned one? Because when there’s more sick patients, there’s less time for you , when you’re sick. Some say that patients will get worse care and will be seen slower in the Emergency Department. While this may be true to some extent, triage — the sickest people to the front of the line — often takes care of much of this. But because there’s simple more people (quantity, not necessarily quality), your mom with the broken hip is seen slower, and fewer minutes are spent on her since there’s more patients total. It’s no wonder hospitals are stuffed to capacity.

So take a system with sick people, discourage them from seeking primary care by:

1. having them pay for primary care when they themselves often don’t see any benefit from it and
2. discourage doctors from going into primary care by making it a nightmare of:
   • paperwork
   • referrals
   • tons of complex, sick patients to be seen in 15 minutes and
   • little pay compared to other doctors

And you’ve got what we have today: any number of people who are sick, complex, and take up tons of time, energy and resources. And no matter how you spin it, it ends up creating worse care for us all.

We as doctors tell our patients to do certain things to stay healthy — and often pay more money to buy these pills – when often patients don’t see one lick of good from our recommendations. All they see is a lower blood pressure number, and money out of their pockets for expensive pills. (That is, until they stop taking their pills, or have a really bad consequence of their disease, then they see it.) Throw in any number of health care and physician scandals in the past decade, and it’s no wonder they’re skeptical.

In order for us to receive better care and to fight the constant ambulance diversions and hospital overflows, we’ve got to ensure that people take care of themselves. And that starts by removing the barriers to self-care.

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US and NZ sittin’ in a tree, K-I-S-S-I-N-G.

New Zealand is the only other country in the world that allows direct-to-consumer marketing. Those Lipitor ads, the Mucinex boogers — they don’t exist outside of those two countries. The pharmaceutical companies claim that their advertisements provide important educational value to patients. “They can learn about diseases they might have!” the companies say. I say humbug.

Patients learn nothing from these ads, besides seeing ridiculously attractive, healthy-looking, active people pretend to have any number of diseases. I’ve said it before–if the companies were truly interested in educating patients, they would teach them about any number of topics that many patients do not understand. Instead, they hawk products half the time and quickly ramble a list of side effects with the other half left.

Remember–the Pharma corporations are responsible to their shareholders, not the public. Their goal is to make more money, by selling more pills. They do not “educate patients” because it’s good for patients. They “educate patients” because it’s better for their bottom line. Do we not trust physicians to make accurate diagnoses that we need patients to ask for Lipitor?

Ban direct-to-consumer advertising.

If not that, make the field “direct-to-consumer educatisng.” 95% of your advertising time teaches the public how scientific studies work, or what a cardiac stress test does, or why antibiotic resistance is a problem and why doctors don’t like to give out antibiotics liberally, or why CT scans aren’t always a good idea, or why vaccines are safe. There’s an almost limitless number of topics physicians are repeating over and over to patients. In the last 5 seconds, you get to flash your drug logo. “Brought to you by Pfizer.” Put out or get out.

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Even before the 80-hour work week, shift work was part of a physician’s and resident’s training. Now, it’s just more prominent. Residency programs have adapted, introducing night teams for their patients, various types of “floats” (night, day, root beer) who take over for a resident–or often an entire team of residents–when one set must go home because of hour restrictions.

In some ways, this is a good adaptation — and even if it’s not, it seems to be staying. I don’t care how tough and hardcore you are, you wouldn’t want a sleep-deprived resident ( equivalent to an intoxicated resident ) making health care decisions about your mother, let alone operating on her. (Having alcohol while on call or in the hospital would be a major violation, but sleep deprivation is inherently part of the system. Funny.)

In other ways, shift work is bad for patients: I know Mrs. Jones much better than the colleague I’m signing her out to, because she’s told me her whole story, her emergency contact, and how to reach her daughter’s cell phone if the first three numbers don’t work. Thoroughly complicating this issue is hospital overcrowding, especially in the ED when patients can be waiting for beds for days, and end up being handed off to a new physician every 8 hours. This knowledge differential between my colleague and I — he coming on shift, me going off shift — somehow must change, because the shift work world isn’t going to. Younger physicians are wanting shift work.

We know that most errors come about through errors of communication and often during shift changes. We KNOW that.

We owe it to our patients that we safely and correctly do hand-offs. We should be relying on a system that is designed to minimize communication errors, prioritize information and patients, and eliminate ambiguity while being as efficient as possible.

I’m not exactly sure what this system looks like. Maybe it means that we have some computer system that somehow collects important information about the patient and puts together a summary based on the electronic medical record.

I certainly know when I come across a piece of information that I know will be vital to sign-out, but sometimes I struggle at signout to remember it. Maybe it means that we carry around voice recorders and make memos to ourselves.

Maybe it means that we follow a cue from the nursing playbook and devote an hour to “shift change” in the name of patient safety. We review the patients in order of severity or likelihood something will come up, and in an order of importance: Patient Name, Age, Admission Diagnosis, Code Status, Active Problems, Active Plan, Anticipatory Guidance.

Maybe it means we teach physicians about conditional orders, and allow them to be carried out even if the physician is signed out. Things like:

IF 
	(Troponin #3 = Normal AND
	Social Work Note AND 
	Dispo = Complete AND
	Patient Has Outpatient Medications Ready AND 
	IV is out) 
THEN 
	(discharge home)

I’m not a communications expert, and I’ve fallen too far down the rabbit hole to probably even see where my own communication errors are. Perhaps that’s the problem right there — we don’t even know when or how we failed. Maybe the first step is to discuss it happening: along with M&M, how about a communication version? W&W? Words and Warnings?

As I’ll repeat throughout this series: if we as physicians don’t step up to the plate and do something about it ourselves, someone else will. And often that “someone else” isn’t caring for patients and doesn’t know what they’re doing. Being proactive about this stuff will help us in the long run.

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