Sticky Notes Do Not Cost $1.6 Million

I was reading this article in the Clinician Review, April edition on Malpractice. They do these brief series on different malpractice cases and the results and I thought this particular case would be good to share.

Overview of the case:

19 yo patient comes in for a pre-sport physical exam. The physician noted a “slight systolic murmur” and documented it on the college physical exam form. Since this finding may be consistent with a heart condition that causes sudden cardiac death, the doc ordered a EKG and then signed the clearance form for the young man to play basketball. He also noted that the patient was in good condition and that he could participate without restriction. Almost 4 yrs later the patient collapse during a game and later died. The parents of the young man filed suit against the doc claiming neglect for signing the form and for not following up with the EKG. The physician argued that the patient never went for the EKG.

Outcome:

$1.6 million verdict was returned for the plaintiff.

Lesson:

Keep track of patients with potentially life threatening signs/symptoms/illnesses. It doesn’t really matter how you do it. Keep a running list on a sticky note or flag the charts for follow up in your system. The important thing is to find a system that works for you and stick to it. Start as a student so it’s a habit by the time the responsibility is all yours.

PDAs. Are They All the Same?

 I love my iPhone. I used to work at Verizon so I’m a bit of a cell phone nut. I’ve tried most every brand… Blackberry, Windows, Droid, and now the iPhone. If you are looking to get a PDA for school or work, I will give you my 2 cents.

Blackberry (BB): Been around the longest, most secure, BB has its own enterprise server (among other less expensive server options), a good “work horse” phone, not so good for fun games and applications. Because BB’s primary market was business/gov’t, security was of the utmost concern so they do not open their platform for people to freely make apps like Apple and Google did. Hence, less apps.

Windows: I must admit that my last Window’s phone was about 3 years ago and they have gotten much better since then. HTC has put out some great phones, but when it comes to apps Droid and Apple have the market locked.

Droid: I really, really liked my Droid. There are tons of apps (and more everyday). Whenever I searched for an app I was able to find it without a major problem in the Android market… with the exception of one major category, medical apps. There are medical apps for the Droid, but definitely not as many as for the iPhone and since I’m headed into the medical field and I am an avid Mac user… the iPhone was the best fit for me.

APPS, APPS, APPS

**Some of these are available on the Android. If you search the app title and android on Google you should be able to find them if they exist.

My Free or Nearly Free Favorites:

Dragon Dictation: http://itunes.apple.com/us/app/dragon-dictation/id341446764?mt=8

Dictation program that allows you to send texts, emails, notes to yourself. Very accurate

MedCalc: http://itunes.apple.com/us/app/medcalc-medical-calculator/id299470331?mt=8

Used to be free, I think its .99 now (but worth it)

Medscape: http://www.medscape.com/public/iphone?src=ppc_Google&ef_id=o-JNuZaCYzoAAIEN:20110428163202:s

Free

Blackboard: http://itunes.apple.com/us/app/blackboard-mobile-learn-for/id376413870?mt=8

Helpful to check grades and assignments on the go

Amazon: http://itunes.apple.com/app/amazon-mobile/id297606951?mt=8

I use it to scan the bar codes of books. It finds the cheapest price online and if you sign up for Amazon Prime for Students (free for 1 year with student email address) you can get the book in a day with FREE shipping.

MPR: http://itunes.apple.com/us/app/monthly-prescribing-reference/id347073471?mt=8

Free. This is the Monthly Prescribing Reference. I honestly use this 10 times a day while in the hospital to look up medications that I haven’t heard of before.

VisualDx: http://www.visualdx.com/mobile/

One of the few apps that I’ve found that allows you to work backwards from signs and symptoms to diagnosis instead of needing the diagnosis before you can look up the signs and symptoms.

Sound Builder (Littmann): http://itunes.apple.com/us/app/3m-littmann-soundbuilder/id414942730?mt=8

Free. A learning tool designed to help improve the auscultation skills. There are 14 unique lessons - based upon key heart sounds - that combine text, a virtual mannequin, 3D cardiac animation and dynamic waveforms.

NEJM: http://www.nejm.org/page/about-nejm/mobile-applications

Free. Great videos and case studies.

Plastic/Ortho HG: http://www.hyperguide.com/Ortho_Mobile.htm

Interested in Ortho or Plastic surgery? This app is great to pass the time learning about cool things in these 2 fields. Each has its own app.

AO Surgery:

iTalk: http://www.italksync.com/

Lite version is free. This is a recording program. Many of my classmates just used the built-in voice recorder on the iPhone (and it worked well), but I liked this app because it allowed you to name the file on the phone. The built-in one marks it as a date until you get it to iTunes, then you can change the name. This program also requires that you down load something to your computer so that you can wirelessly upload the recording to your computer. May be a bit too much for people but thought I’d throw it out there.

Some others:

http://itunes.apple.com/us/app/annals-of-im/id387375364?mt=8

Annals of Internal Medicine App

http://www.acponline.org/residents_fellows/resources/doctors_dilemma/

Doctor's Dilemma Mobile App

http://www.acponline.org/clinical_information/guidelines/mobile.htm

Clinical Reference/Preventive Medicine App

I am constantly looking for and test-driving new apps. As I find more I’ll post them. Feel free to post some of your own.

The Graceful Gymnast

One of the most important things you will learn… should learn… is how to balance. I dare to say, you won’t survive long without this skill.

Preferably you will do so in a graceful fashion, like a seasoned gymnast on a tight rope, keeping school, significant others, family and friends in perfect equilibrium and happiness. Sigh. The world ain’t perfect. More likely than not, you will look and feel like a waiter/waitress carrying one too many plates, rushing around trying to unload before disaster strikes.

I’m convinced that all of the PA program administrators get together before the first day of classes to plan exams at the least opportune time in each student’s life (or that is just what it feels like). I don’t know how they knew when my car was going to break down or when my hard-to-reschedule dental appointment was, but they did, and they scheduled something at that very moment. I am almost certain that supervisors have this sixth sense as well, so the quicker you transform into that graceful gymnast, the better off you will be.

Figure out what works for you. Some of my classmates kept one day a week as a personal, PA-free day, some did community service, while others hit the gym… or the bar. The point is: Find time for your friends and family. Find time for your studies. Most importantly, find time for YOU.  

Shared Decision Making vs. Informed Consent. What’s the Difference and Who Cares?

I was talking to some PA-Cs a while back and the subject of shared decision-making (SDM) came up and I was surprised by their responses. Most thought it was something that health care providers had been using for decades.

“Just yesterday I sat down with a patient before surgery and told them all of the things that could go wrong if we replaced their joint as well as the benefits. We’ve been doing that forever. It’s all part of informed consent.” - one the the PA-Cs

This provider is right. What was mentioned above IS part of informed consent. But informed consent and SDM are the not same. Hopefully this post will help to clear up some of the confusion.

A.When is the SDM model appropriate?

1.SDM should be used with Preference Sensitive Care decisions, NOT Effective Care decisions.

Effective Care = there is a medically indicated course of action in which benefits have been shown to outweigh risks. In these cases patients will follow their provider’s advice. [Example: Newborn vaccinations]

Preference Sensitive Care = there are multiple (or at least more than 1) medically reasonable options.  [Example: Prostate surgery or watchful waiting after receiving an elevated PSA result]

2.SDM should be used when a patient is not 100% certain about their decision. Perhaps there is no “right” answer, family pressures, or strong emotional ties that make decision making hard.

B.What is the difference between SDM and informed consent/patient education?

In informed consent/patient education, the “education” typically focuses on informing about a specific option and the risks and benefits of that option.  SDM, on the other hand, attempts to present balanced evidence based information about all reasonable options as well as incorporate the patient’s values into the decision making process.  The encouragement of patients to become active in the process is crucial.

C.Who cares?

By treating patients with unresolved conflicts, we as providers open up ourselves to patient dissatisfaction, patients changing their minds, higher rates of delayed decision making, and blame for bad outcomes (aka legal action). If by simply changing our approach to care delivery we could gain better results – Why aren’t more people on board?

I will continue to write on this subject. Consider this a teaser, a toe dip, a trailer. I look forward to comments or experiences that you’ve had with health care providers that have used SDM or just informed consent. I will also include some great resources for SDM in future posts.

Preparation is a Poor Prophylaxis for 1st Day Butterflies

Perhaps this picture won’t be appreciated until your first hospital session during which you practice the history and physical (H&P), but it made me laugh because this was most of our class. During my first session I felt like my white coat didn’t have enough pockets (it had 6) and that if I had just had 1 more day to prepare I would have been less nervous. Preparation is a poor prophylaxis for 1st day butterflies... because no amount of prep will help. Study, by all means, study! But realize that no matter how much you study, you're gonna make some mistakes. There are questions that you won't know the answer to... Relax. You are a student. Your preceptor and fellow students will be supportive and you will do the same when you see one of your classmates struggle. PA school is hard, but focus on making it a comfortable environment to make mistakes and learn from them and you'll be much happier when your time rolls around to screw up. Below are some quick hit resources to help you study the important stuff without the fluff. Trust me. You won't have much time for fluff.

I’m not sure how other programs are run as far as recommended texts, but at Northeastern, there are few required texts. Most of the information that we need is given to us in supplemental packets or powerpoints. Although I like to consider myself a digital maven, I also like to collect books. So I thought I’d throw out some books that I have referenced many times as well as a non-exhaustive list of websites to aid you on your quests for knowledge.

Books:

1.Step Up to Medicine 2^nd Ed. By Agabegi and Agabegi

This is by far my most referenced book. It covers almost every disorder and disease talked about in PA school in a nice straight to the point fashion. Each disorder is broken down in bullet point style (definition, clinical presentation, tests to run, treatment options, and pearls of wisdom). No fluff.

2.Some anatomy and physiology book

It doesn’t really matter which one- I like the Netter books personally.

3.Rapid Interpretation of EKG by Dubin

A must have if you have never read EKGs before.

4.Blueprints (Pediatrics, Surgery, and Emergency Medicine) are all good.

5. Bates Physical Diagnosis (both the reg size and the Baby Bates)

Websites:

General
1. Awesome General Website (you need to sign up but its free): http://emedicine.medscape.com/
2. Normal #s Reference: http://pathcuric1.swmed.edu/pathdemo/nrrt.htm
3. More references than you'll know what to do with but some great resources: http://www.medicalstudent.com/
4. Stay up to date and there are some good videos (like how to do a lumbar puncture or central line, available app for phone too) http://www.nejm.org/
5. If you are interested in community service- check out The Albert Schweitzer Fellowship: http://www.schweitzerfellowship.org/
6. If you are interested in Surgery: http://www.aaspa.com 

7. UpToDate: www.uptodate.com (Several of my classmates got a subscription in lieu of buying any books. Its not cheap: $195/year for students. $495/year after you graduate.

EKG
1. http://ecg.bidmc.harvard.edu/maven/mavenmain.asp

Anatomy
1. Just subscribe to this person's channel because when you have cadaver lab all of their videos will be invaluable: http://www.youtube.com/watch?v=hxNV2Tfuiy8

Neurology
1. Online Neuroscience textbook: http://www.ncbi.nlm.nih.gov/books/NBK10799/

I have a ton more resources and could go on forever -- but these were the most used for me personally. Feel free to post any helpful links that you’ve found. I love checking out new sites!

Let's Get This Party Started

I'm 10 days into my vacation from PA school, thus my sanity is just returning to normal. Coming off a 7 day, 8 exam, 2 paper stint... my brain took its time with the recovery phase. I'm currently at Northeastern heading into my final semester of 1st year status. Eight classes on the summer schedule and I'm excited... I'm pretty sure that the excitement and anticipation of clinical rotations will float me through the summer semester.

I decided to start up a blog for a couple of reasons:
1) When I first decided that I was interested in becoming a PA, I scoured the internet for everything and anything I could find on what it was going to be like... the schooling, the job opportunities, the trials and tribulations... truly anything. As I've discovered... many of my classmates were the same way (Type-Aers on a mission). So I hope this blog can serve as a source of information for the information seekers and that I can help answer any questions you, my future colleague, may have.
2) I am very interested in the integration of social media into the delivery of health care. I believe that social media and blogs can serve as an integral part in the distribution of medical knowledge to patients as well as propel the shared decision making model (no, not informed consent).

This blog will be a combination of "Life as a PA student" and "FYIs for the Aspiring/Practicing PA". Feel free to contact me with any info requests or just to say hi.

All that we are is the result of what we have thought. -Buddha