Useless charts and fresh eyes in handoffs

The medical record is not all that helpful when you don't know a patient and have to make a quick, on-the-spot decision.

Last month, I was a speaker for the American Medical Student Association on their patient safety webinar. This was the brainchild of Aliye Runyan, a fourth-year medical student at the University of Miami, and her colleagues, to expand the patient safety taught to medical students. They are not alone. The Institute for Healthcare Improvement Open School also virally spreads patient safety training where traditional med schools have failed.

Photo courtesy of Vineet Arora
Photo courtesy of Vineet Arora.

My topic was handoffs. I wondered what I could tell mostly preclinical medical students, some of whom may not have even entered the clinical arena, about the issue. Would what I said be over their heads and irrelevant if they had no clinical context? I was also hoping there were some fourth years on the call who could talk about their experiences doing handoffs as sub-interns.

But I forgot about the importance of “fresh eyes,” a concept that is sometimes used to describe the one positive aspect of a handoff—that sometimes the best insights come from someone who is not well acquainted with the case. I had a lot of fresh eyes (and mostly ears) on the call. In the vibrant Q&A session that followed (and continued via email), one thing the medical students asked me about is something bad in signouts: “TMI” or “too much information.” This often happens when the signout is used to help the primary team track the patient, but it loses its function for the receiver. In hospitals with electronic health records, TMI is often a symptom of “CoPaGA syndrome” or “copy-and-paste-gone-amok syndrome.”

This led to the most interesting debate of the night: Why has the medical chart become so useless that people feel they need to use the signout this way? I was asked to think about this question again later in a meeting with our Epic staff, who are working to create an automatic signout system for our residents. They really wanted to know why we needed a separate system. Since our residents have iPads, why couldn't they just look at the record?

I had to think about that one. I said that the chart is an archive that is most helpful for people who know the patient. It is also one large medical bill. The truth of the matter is that the medical record is not all that helpful when you don't know a patient and you have to make a quick, on-the-spot decision. This is why we can't ask a busy resident who doesn't know a given patient to pause to look in an electronic health record to answer the clinical question of the moment. The information there is overwhelming.

Our chief resident had a better answer than me. The night resident needs the CliffsNotes version to answer the question since he or she wasn't assigned (and doesn't have time at that moment) to read the full text.

Of course, handoffs are more than just written information; they also have to include a verbal, interactive component. Just as the implementation of shorter duty hours is still new, so is a requirement that all residency programs make sure their residents are “competent in handoff communications,” both verbal and written. Because programs are looking for a way to meet this requirement, I have racked up quite a few frequent flyer miles visiting residency programs to teach residents about how to perform handoffs better.

After I give a talk, attendees may talk about it for a bit, if I'm lucky. Once, I actually witnessed residents putting some of the principles I taught them into action shortly after I spoke at their resident report. However, these moments are isolated and, as you can guess, education by itself will not translate into practice change (We could talk to the handwashing people all day about that!). So, like handwashing, a monitoring plan for handoffs is also needed. And yes, that is also part of the new requirement—that programs actively monitor resident handoffs.