When patient histories start to blur

I am guilty of neglect.

I’ll admit it. I’ll own it. I’ll embrace it.

When I am doing a consult now for one of many hospital emergency rooms, I am sent a pretty standard package of history, nurses notes, doctor’s assessment, physical exam report, lab results and other information that I review prior to actually seeing the patient on the screen and doing my own assessment. Now, on a day like today, I arrived to find about fifteen consults pending, I completed a handful through my eight hours there in the office, and there were twenty-one in the queue when I went home.

At an hour and a half a piece, average, that’s over thirty hours of work pending, with most of our shifts now being covered by one doctor, rarely by two if we’re lucky indeed. Point being, the volume is overwhelming at times. At others times, it’s dead. That’s the nature of emergency room work. It’s very easy to miss little details if they’re buried, if you’re tired, or if you’re simply too rushed to get done with one patient and move on to the next one. Being overwhelmed sometimes leads to sloppiness or apathy, something none of us would ever want to admit to but all of us have felt at one time or another. Dull routine also leads to indifference, and there is a very real danger of that in a job situation where patients start to blur and histories begin to look alarmingly alike. Sometimes, these problems can lead to missing issues, glossing others over or outright minimization of the issues at hand, something our patients are all too happy to be an active partner in if we let them.

Example? Smoking in psychiatric patients is ubiquitous. Almost everybody smokes, anywhere from five cigarettes per day to the rare person who smokes five PACKS of the sticks a day. Alcohol use is also very, very common in mental health patients. Now, marijuana use is taking on that check it and forget it place on the history form. It seems like every single patient has used or is actively using marijuana. Most urine drug screens are positive for cannabis, and most patients I talk to now feel that marijuana is not a drug anyway and therefore is not anything that should be discussed in the context of a consult. It would be so much easier to just skip over the parts of the forms that ask about smoking, using pot, or drinking alcohol, as “everybody does it” has become the wisdom of the day.

I use a pretty a standard form for recording my information, both pre-consult and during the actual interview, one that I designed for myself thirty years ago and keep tweaking periodically even today as circumstances dictate. It has prompts for me to remind me to ask the big questions about sleep, appetite, mood, psychosis and suicidal and homicidal ideation, things that you just can’t forget to assess. I have dropped some of the small details from time to time, trusting my memory or realizing that each interview is different and will prompt its own set of pertinent questions as we go. The only problem is, if you don’t ask questions, you don’t get answers.

How am I trying to improve on the process and capture all the details and information that I need to make my best assessment of the patient and give my best recommendations for his or her care?

1. I’m remembering to get back to basics when I stray too far away. A standard interview and mental status examination is still pretty standard after all these years. Use of forms, prompts, standard questions, and accepted interview techniques insures that no steps are skipped or questions left unasked.

2. I’m trying to do each assessment the exact same way every time. I don’t skip steps or topics or confrontation that need to happen with every patient.

3. I’m not glossing over or discounting or even ignoring problems that clearly need to be identified and mentioned as possible targets for interventions. If someone is smoking two packs of cigarettes a day, no matter how common that might be among his peers, it still portends future problems for him. There are DSM codes for all of these problems. They need to be used.

4. I’m being more careful to diagnose what’s there, to capture it in the record and to legitimize it as something that deserves a healthcare provider’s time and attention. If someone is thirty-five pounds overweight, it’s way too easy to see that as normal for that person instead of talking turkey about what steps can be taken to increase activity levels, modify diet and start an exercise regimen.

5. Finally, I’m recommending treatment for all active problems, even if the majority of these are not the presenting problems for me and not the focus of my attention. If that means delegating or even referring out, then that’s what needs to happen.

I hope that I can get myself back on track and a little less rough around the edges. If I can pay more attention to detail, then important data will be captured, more realistic and appropriate goals will be set, and patients will get better.

What do you see yourself neglecting day-to-day? What do you need to pay closer attention to? How will you do things differently starting today?

Greg Smith is a psychiatrist who blogs at gregsmithmd.

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