Thursday, August 7, 2014

How to solve a new problem, when the problem is only new to you

I often find that one place I am able to add the most value in life--whether personally, at work or otherwise is to solve a "new" problem.  When approaching something that you or your colleagues do not know how to do, you are facing a new problem.  The key first distinction is whether the problem is new to you, or truly new, as in no one has a really good solution.

The bevy of technology between Google and nearly all of the apps out there has made it far more trivial to determine if the problem is truly new, or just new to you.  If others have an answer but you cannot find it, you might as well consider it a new problem.  You may find collaborators later, but there will be a good deal up front.

The reason to distinguish between newness and new-to-youness is that there are drastically different solutions to the different problems.  New-to-you problems have answers, and your job is to find them as quickly and cheaply as possible.  Remember that anything built by humans (I am looking at you, software) has an answer.  Someone, somewhere, made a choice that led to your problem.  They may have also built a solution.  They may have also disclaimed that they don't have a solution yet, but at least you will have your answer.

When facing a problem that is new to you, the first thing to do is look for someone else's answer.  remember if you believe there is answer, you are very likely to find it. Do not exert effort trying to solve a solved problem.  You are generally wasting your time an others.  In the pre-Google days, this meant asking someone.  It also usually meant asking the person who gave you the problem assignment in the first place.  When someone assigns you work, it is because they do not want to do it.  Asking them for help is fine (a later step), but gauge if they are in a teaching mood before asking for help.  If so, ask away and learn it, and you better get it right after the teaching.  If they are busy/stressed/distracted, Google it.

Step 1: Google it.
Start with the humble assumption that there is nothing special about your particular problem.  Of the billions of people that have ever lived, assume many people have had this problem.  A subset have solved the problem, and a truly blessed subset have written down an answer in the form of an article, blog post, software application, product or business service.  Most new problems can be solved with step 1 alone.  Most searches yield something worthwhile in the first 10 minutes.  Be clever in your searches and learn Advanced Google Searching to speed things up and cut down on crap.

For proprietary business software, look through any help files, documentation and/or internal wikis for guidance.  Respect your colleagues time-- if they spent time writing it down, respect them enough to read what they have written.  This may seem to take longer than asking for help, but you can learn much more and no one else need be available so you can proceed with your work.  Besides, once you get reading you never know what else you can find, or even how you can contribute to great documentation and save other's time.

Once you have found answer, find a way to remember it--either with memory, practice, bookmarking, notes, etc.  Searching for old solutions may feel like a time waster, but not even remembering that there was a solution is an even bigger waste of time.

If you have not found an answer, proceed to Step 2.

Step 2: Ask someone for help
After you have done a reasonable amount of Google diligence (again, nothing in 10 minutes of clever searching and/or someone asking you for money are good signs you have done your diligence), it is ok to ask for help.  There are two types of people you can ask-- Mavens and Connectors.

Mavens are people who know things.  If you know them, they can get you the answer.  They are usually the final common pathways.  They are usually harder to find and/or reach.  Do not be frustrated when they do not have the answer and do not know who does-- you just picked the wrong Maven, find another one.

Connectors are people who know people.  If you know them, they know who you need to talk to.  They are rarely the final common pathway, but can save you hours of time in finding the right person, and usually a tip on how to reach said person, what they like, the best way to reach them, etc.  Respect the connector for their connections, and do not be frustrated when they don't answer your question directly.  They almost never will.  That is not why you called them.  They provide value in saving you time in getting the people or resources with the answers you need.

Having a method to get to the people with the answer quickly, and obtaining their help is a valuable skill. In some ways, being worth teaching is the most worthy thing you can be.   Being worth teaching includes humility, politeness, responsiveness to feedback, curiosity, acceptance of widely varying solutions, and respect.  If you are worth teaching, you will find that you are continually learning.  If you fail any of these-- arrogance, rudeness, discarding of different ideas, excessive expertise, disrespect--you will find yourself adrift without oars.

Choosing your method of communication is also important.  For urgent and important matters, synchronous communication is required-- in person or phone.  As you go down the urgency/importance, text message and "chat" (semi-synchronous modes) are appropriate.  Email is next, real mail after that, and asking for help via Facebook message is just peculiar.  Pick the least intrusive method that you can tolerate and still get your answer in the time that you need.

Distributed networks, fora, social networks, message boards, etc. are the intersection of Steps 1 and 2.  When you cannot find an answer in Step 1, and do not know who to ask in Step 2, consider asking the internet.  Be prepared for some gold and some garbage.

Finally, never fear asking for favors.  It may actually be of great benefit.

Step 2 is often the end of your journey.  If not, head to step 3.

Step 3. Consider spending a little money
Free solutions are always more attractive that solutions for money, but remember that your time is valuable.  Spending small amounts of money to speed up a solution often far outweighs the cost. Don't spend a LOT of money yet, but spending $5.99 for an app that might work or $10 for an article, or $100 for an hour of someone's time may be incredibly valuable.  If spending your own money, make sure it is with your budget (and yes, You Need a Budget, it will change your life).  If someone else's money, keep within whatever guidelines they have spent.

If Step 3 fails, you may not be dealing with a problem that is that new.  You may be dealing with a hard problem, possibly even a new problem.  Stay tuned for Part 2...

Tuesday, July 15, 2014

What "I Wouldn't Worry About That" really means when it comes from your doctor

Nearly all the patients that come to one of our practices have done so after leaving another primary care physician with whom they were unsatisfied.  Among the many complaints fairly or unfairly directed at their former physician, one that I hear frequently after explaining some lab or result is: "My last doctor just told me not to worry about that.  They didn't care about me."

Not to worry... is there a more dismissive, potentially condescending way to explain something to a person who is in fear for their health?  What a terrible, uncaring and hurried physician.  But here is the kicker, contained within that phrase is the essence of what primary care, and all honest medicine is all about--balancing risk.

What their quite astute doctor thought, and meant to say was probably something like, "Based on what we know about the uncertainties of diagnostic testing, and the differential diagnosis of that particular abnormality, and the risk associated with further exploring and/or treating those possible abnormalities, the risks of harm, misery, cost, side effects and complications by proceeding on this issue far outweigh any potential benefit."

That is a much longer sentence, and worth breaking down a bit:

1.  Uncertainties of diagnostic testing: Every test is imperfect with possibilities for human, chemical or interpreter error anywhere along the way.  Even performed perfectly (which is the norm), there are still built in margins of error in every test (think presidential election results).  No test is perfect, and even though it looks like a beautiful, meaningful, significant number, it is not.  It is one of a range of numbers, some of which imply doom, some of which imply nothing.

2. Differential diagnosis:  Medical speak for all of the things this could be.  This is the essence of practicing medicine.  Patients come in with symptoms and want to know what they are.  It turns out that our bodies have a limited vocabulary and lots of things look similar.  It is why googling your cough on WebMD is so dangerous.  Colds cause cough, cancer causes cough--so which is it?  The differential diagnosis is a method we use to determine all of the likely diagnoses that explain your symptoms or lab results.  The more a physician creates but whittles that list down quickly by probability, the more blood (and parts) you get to keep.  Here is a hint-- some type of cancer is always on the differential, but its persistence & rarity only make it a major player in special circumstances.

3. Risks associated with further exploring and/or treating: Everything doctors do can be dangerous.  That is why we go to school.  If it isn't dangerous (or if not doing it isn't dangerous), you don't need doctors.  You need parents, friends, family, herbalists, physical trainers, coaches, yoga instructors, health coaches, smoothie makers, cooks, grocers, etc. etc.  It is why we are bad at recommending diet and exercise.  We are trained on judicious use on the dangerous stuff, and that is what you want us doing.  You don't want doctors rigorously evaluating what you should eat, because self experimentation is really useful and really safe--until you start to add in multiple medical conditions and medicines (which are dangerous) and then our input matters. Therein lies the key.  Our work is dangerous, and we work hard to minimize the danger and maximize the benefit.  It is why we don't want to give narcotics and antibiotics for everything, because it is dangerous.

And remember, our promise is to first do no harm.

So now you see why your doctor said not to worry-- it was an unfortunate attempt at time savings.  When I take patients through the above, I find that we are better connected, I can understand their values and preferences, and they see how (and that) I think.  To the docs out there, next time you tell someone not to worry, think about taking them through the above and see the magic that happens.

Wednesday, July 9, 2014

Maker's Schedule, Manager's Schedule: What does that mean for Physicians?

Before you read what I am about to write, go read the inspiration for this piece, Paul Graham's 2009 "Maker's Schedule, Manager's Schedule."  Then read everything else Paul Graham has written.  Then, please, come back.

Briefly summarized-- if you must do something that is hard, takes creativity, thought and solves uncertain problems by combining lots and lots of information, then you need uninterrupted time to do so.  You are making, and making is hard. If you must manage people, communicate, socialize, learn, obtain new information, present, etc. then by all means fill up your day with a series of 30 and 60 minute meetings with enough time to get to each.  You are managing, and managing is incredibly time consuming.

Reading Graham's piece was incredibly enlightening as it calls to some of my frustration about not being able to think, being "too busy to get anything done," having days full of meetings and then endless leftover work at night.  Long ago I saw Jason Fried's fantastic Ted Talk on a similar topic: Why Work Doesn't Happen at Work.  (I am writing this entry on a plane....).  If it were not for airlines with Internet I am unsure how I would ever keep up.

So what if your job is to meet with people, obtain new information, socialize ideas, present and teach AND THEN to synthesize large amounts of multi channel information to begin solve a poorly defined problem. Over, and over, and over again.  Are you a maker? Are you a manager?  No, you are a physician.

Such has become of the life of the modern physician, especially the primary care physician.  In our clinical work alone, we are forever switching back and forth between meetings and really big thoughts.  It is challenging, often impossible, and the work really matters.  Add to just our clinical work the numerous interruptions in the day from other team members, scheduled meetings, etc. and it is a wonder anything gets done at all.

What we have developed as physicians is a honed sense of anxiety that something is not finished.  We remember using check lists, to do lists, fear, emotion, sticky notes, anything that we have to go back to where we were.  When given long blocks of time, I find that I work at a furious pace, assuming that some interruption is coming somewhere, so I better finish before it happens.

The toll it has taken on our profession (and therefore our patients, you know, everyone) is staggering.  Some physicians abdicate the "maker" portion of their job.  They simply meet with patients all day and do the bare minimum cognitive work necessary to bill.  If you have pain in your chest, you get sent to a cardiologist.  If you have pain in your back, you get a prescription for naproxen.  Patient and provider satisfaction is low, quality is abysmal, and patients end up ping-ponged around the medical system racking up risky tests, procedures, therapies and costs.

So what about the physicians who focus on minimizing interruptions and doing the cognitive work necessary to be successful and useful to their patients?  Enter the stereotype of the asshole physician.  The inverse response to interruptions is to block them out at all costs.  Don't answer calls, put up elaborate triage systems to keep people away.  Yell at people that interrupt you so they don't do it again.  Others do not have the temperament for this so they limit access and thereby interruptions in other ways.  Concierge physicians charge a lot to keep most people away.  Other arrangements see panel sizes get reduced (to arguably reasonable levels) so as to minimize the baseline interruption rate.

There has to be a better way.  We are physicians--we listen, examine, teach and interact.  We also think, deduce, reflect, review, synthesize disparate data and write all of this down to our future selves and colleagues.  There are two, related ways forward to preserve this vital role we provide to society.

First, we need to do less as physicians.  Not worse, but less.  Fewer forms, fewer check boxes.  We need to stop satisfying our vague managers, who generally do not recall their days in this role if they ever had them.  The mounting tide of regulation and billing related documentation is frankly terrifying.  It was made by managers and it will destroy us as makers.

Second, we need to find ways to minimize interruptions.  Perhaps it is time to recognize that a series of scheduled visits is not the optimal way to care for patients.  Rather, let us use time to our advantage to proactively manage our patients using data and evidence, and teams to carry out our plans.  We have been doing this for some time and watch as our in person visit rate declines as every metric we have improves-- patient willingness to recommend, clinical indicators, cost and utilization metrics, etc.

With fewer visits, we can use makers time to advantage and make something special for our patients.  It is time to get off the visit hamster wheel-- it benefits no one and is merely the status quo.  We need to organize our work to protect both the meeting and the thinking.  We need to organize ourselves and our teams to minimize the impact of the documentation insanity, and perhaps organize ourselves to fight it all together.

With every interruption we lose something we can regain-- our focus, our thoughts, our time.  We do not benefit, our patients do not benefit.  We must be mindful and fuse our inner manager with our inner maker.

Thursday, June 5, 2014

Thoughts on VIP Medicine

The concept of VIP medicine came up in a discussion today and someone liked how I phrased my thoughts, so I figured it was time to kick off the Schutzblog once again!

I like to think of VIP medicine as how a clinician would deviate from his or her usual style of care for a given patient who is of some special status-- wealthy, famous, connected, in some supervisory position over the patient, etc.  The general teaching is that VIP medicine is generally disastrous for the patient, and can even be lethal; but why?  Why would thinking of a patient more frequently, wishing to spare them discomfort, unpleasant examinations, embarrassing diagnoses, waiting, or the performance of clinical tasks by anyone but the physician be dangerous?

Fundamentally, our job as physicians is to balance risk and benefits for our patients.  All of our tests and therapies are potentially harmful, or at least uncomfortable and expensive and carry the risk of false or true positives and negatives of uncertain significance.  If this were not the case, we would not need physicians to make the decisions-- a reasonable safe therapy or test in all situations would not need to be protected.  

Now, we are able to balance risk and benefit for our patients because we train like crazy, read a ton, have seen good and bad outcomes from our own clinical work over time, and understand what our patients will value based on our relationship with them.  In short, we bring our experience to bear for someone we know well, think only of them, and guide them to a decision.  Whatever happens, they bear the consequences, good or bad, not us.  

Enter the VIP Patient.  VIPs are VIPs only because they can do one of two things:
  1. Help you in some significant way above and beyond a typical patient with financial reward, positive commendation, donations, recognition, etc.
  2. Hurt you in some way if the outcome of your guidance is not beneficial-- get you fired, sued, defamed, executed, etc.
So why is this a problem? Because the VIP Patient, usually through no fault of their own, has you thinking about YOU. Now all of your calculations are askew.  You need a good outcome for the patient so that YOU avoid pain or obtain reward.  

You risk choosing tests and therapies that are pleasant, flattering, and mild and avoid diagnoses that are embarrassing, tests that are painful or therapies that are hard to tolerate.  

Once you have started thinking about yourself, you have terminally endangered your patient.  Perhaps not this one, but some future VIP will seek care from you and will lose.  And remember, VIPs are generally always VIPs, so they always run this risk?

So what to do?
  1. Be honest with yourself: Acknowledge, at least to yourself, that this person has you thinking about you and not them.
  2. Stop that: Focus on your patient, not their money/power/fame-- even if they flaunt it.  Presume they are delirious/demented and making wild unsubstantiated claims if it helps. 
  3. Get help: Talk the case over with colleagues leaving out the VIP part and see if they come to the same conclusions.