Hi group.
I know it has been a busy semester for me... how are you guys doing?
How far have you read? who is done? who is on Chapter 2?
What do you think of the format so far?
Please freely post questions and comments as you are reading this
book. You do not need to wait for me to lead the discussion. Take
some initiative to post questions, comments, challenges of your own!
-nk
As I've been reading this book (I'm currently on Chapter 6) I've noticed a similar pattern in the cases discussed. It seems as though these doctors tend to get into a pattern, much like most people when faced with the same task day in and day out. When they get into this "groove" they tend to make these errors in judgement. I know that this can occur in any field, but it reminds me to take the time to ask questions of our patients and physicians even if we are having a busy day.
ReplyDeleteI guess I liked the format Groopman used for the book (I finished reading it). As was mentioned in class today, it does follow a lot of the case learning we are taught at school. This book is largely a large case collection. I agree with Laura's comment, the book provides a lot of examples where errors are made by not looking outside of familiar patterns. The example from chapter two is an incredible example. A healthy, active park ranger that ended up with an MI. This was an almost fatal missed diagnosis, and a good reminder that people don't always "look" like a diagnosis. If Mr. McKinley was 15 years older, 50 lbs heavier, heavy smoker, or heavy drinker, would the heart condition have been missed?
ReplyDeleteMost likely, the patient would have been treated differently. According to the book, commonly, doctors make attribution errors when patients fit a certain stereotype. For example, Mr. McKinley did not fit the stereotype of someone at risk for an MI, which is why it was overlooked. As healthcare professionals, we should do our best to not stereotype our patients. Unfortunately, in class we are often presented cases with evidence where it is obvious what the condition or drug therapy problem is. Although we should not completely ignore the stereotypes, we should be able to "think outside the box..."
ReplyDeleteI haven't read the entire book yet, but I am enjoying it in parts. I like how the book is done through case presentations. If the entire book was done as a review of studies that have been done on how doctors think, I don't think I would find it as interesting. Case studies are a great way to learn information on a medical topic because it puts into perspective what you are learning. The fact there is a real outcome of an actual person in a case makes the ideas Groopman is presenting more meaningful.
ReplyDeleteI have not finished the book, and I am also enjoying certain parts. I find some of the cases helpful and interesting, but honestly, I feel like there are too many cases. Many of them are similar and when there are so many, it is difficult to related names to cases. When Groopman refers to a name from a previous case, I have to flip back to find the name and remember which case that was. On the other hand, if there were less cases, they may stand out to me more and be more memorable.
ReplyDeleteDo you guys feel the same way? Just playing devils advocate...
Marjan, I agree. I wish the author would have organized the chapters by each case in the beginning, so even if you needed to flip back, it would be easy to find the case in question. Happy Thanksgiving everyone!
ReplyDeleteMarjan, I also agree with you. While some cases really stand out to me, like Anne's case in the introduction of the book, I feel like most of them are just starting to blend together. I'm only halfway through the book but it's starting to feel like the same meaning just a slightly different story, I'm not sure if anyone else feels this way but the book is starting to feel as though it is dragging on whereas when I first started it I enjoyed the cases. Maybe the book takes a different turn during the second half!
ReplyDeleteGood to hear you guys feel the same way! I am reaching the half-way mark, I hope it takes a different turn as well!
ReplyDeleteI am a little over half way and I am starting to lose the point of the book. There are so many cases that they are now blending together. The book almost worries me a little bit about physicians. I never thought of second-guessing a physician, but almost every case is about an error that could have been prevented. Was Groopman's point in writing this book to expose the fallibility physicians? I hope that it turns in a more positive direction before the end of the book.
ReplyDeleteHey Julie, I didn't think that Groopman intended to make physicians look error-prone, maybe just more human. I think sometimes people go to the physician and believe their decisions shouldn't be questioned, especially by patients that wouldn't be there if they didn't need help. Groopman shows that doctors go through a process based on science and experience, and sometimes they make mistakes. The example in this chapter with the park ranger, the doctor probably dismissed a more serious heart issue because the patient didn't look like someone that should have MI. The physician had unlikely seen anyone this "healthy" with such a severe heart condition.
ReplyDeleteAlso, I tend to agree, the cases are hard to follow after a while. I finished the book a while back, and outside of the opening case, only a couple I can recall without looking through the book.
After thinking about the questions having to do with clinical trials in the last Therapy exam, I thought of this book. Where do we get the information to make clinical decisions in practice? From the evidence of clinical trials in many cases. Danger comes from just taking someone's word for it as seen in the "fluid around the heart" case p136-138. At the same time, I feel like we are just taking someone's word for it in many of the classes we are in. Although many professors do site their information in slides, sometimes it is not, or we accept their interpretation of the documents. Is it okay for us to accept what we hear from our professors? When is it not? Do you accept many of the practices of the pharmacists at your work without question?
ReplyDeleteI couldn't figure out how to start a new question thread, so I will just ask another question...Chapter 8, The discussion starts about radiologists and the volumes of cases/images they see. (pg 178) Groopman reports a radiologist may see up to 25,000 cases each year, some with hundreds to thousands of images. The chapter goes on to summarize accuracy studies ranging from over-diagnosis (to avoid missing cancers, esp breast cancer) to completely missing items, like a missing clavicle.
ReplyDeleteI can't help but be reminded of days at work, like any Monday, where everyone is flying around. Any negative outcome for a patient isn't ok, but I always worry these situations are when an avoidable mistake could be made. It's hard to slow down when you have a hundred things to do. According to a study by Dr. Potchen, the top radiologists have 95% accuracy, the bottom are 75% (pg 180)... Its not apples to oranges, but would a pharmacist catching 75-95% of drug therapy issue be ok?
Jason, your question reminded me of a situation that arose while I was on my IPPE this summer. I was at a location that wasn't terribly busy, but their business was growing and they were quite understaffed. As an intern they let me perform double checks on their prescriptions, and I was surprised at how many errors I found. Many of them were small, such as an incorrect quantity dispensed, but a few of them required calling the patient to have them return the prescription and pick up a new one. One patient even had a fall as a result of one of these errors. In this instance, the pharmacists probably did catch 90-95% of the errors made, but this rate is still unacceptable in my opinion, because one patient getting hurt is too many. My IPPE was at a chain pharmacy, and while I understand that is is expensive for them to pay an extra pharmacist, I question how much they value their customers when they allow pharmacies to operate with such short staffing that errors like these easily slip through the cracks.
ReplyDeleteI wish there was a way to reply directly to comments, since this is in response to some of the first comments and the example in chapter 2. A very similar situation happened with my CT, who was experiencing severe, intermittent pain in her shoulder that worsened with exercise. She went to her primary care physician multiple times with the same complaint, and he consistently kept trying to prescribe amitriptyline because he insisted that it was a physical manifestation of depression! Because my CT is female, or was younger at the time, or lacked some classical symptoms, her complaint was not only misdiagnosed, but it was as if the physician refused to consider any other possiblities. My CT was adamant that she was not depressed, and she was familiar with the signs of depression, but her doctor wouldn't listen. She ended up having a MI very shortly after her last visit. The examples of Mr. McKinley and my CT show how harmful stereotyping can be, and I think it is really important to keep in mind that risk factors are not mandatory for a diagnosis, and that patients without risk factors for a condition can still have that condition.
ReplyDeleteShelly, as for your first post, I know exactly what you mean, I interned at the same location as you. I have the same concern more so with my paid internship. My home store is a pretty slow location, very well-trained staff, and great pharmacy manager. I feel very comfortable in this environment. However, I also work for a large chain, and eventually when push comes to shove, I ended up working high volume, short-handed store, and that makes me very nervous. As an intern they like to have you there, it takes a lot of heat off of pharmacist, especially if they are the only one on duty. But these were the types of days that came to mind when I heard about the radiologists looking at thousands of slides a day. Nobody can work like that and not make mistakes, but at the same time, pharmacists cranking out 400+ scripts working alone for 12 hours...that scares me and I see it.
ReplyDeleteJason, I hate to say it, but if a retail pharmacist catches 75-95% of drug therapy problems when the pharmacist is not allowed to see the patient's full medical record, that would be a great pharmacist. Plus add the variables of not having a record of OTC products the patient is taking makes developing professional relationships with your patient very important so you can get the needed information.
ReplyDeleteShelly and Jason, both of your posts reminded me of something that happened to me last night at work. I was working a HP location I had never worked at. When things slowed down, I asked to do some double-checks and I found 5 bins stuffed with prescriptions. I grabbed a stack to start double checking and they were from early November!!! As I was checking them, I found some minor mistakes. I thought, what if I found a significant error?? Although the patient needs to be aware of any mistakes, doesn't is sound ridiculous to call a patient a month later about an error found in their prescription? I feel like it shows a lack of patient care and responsibility on our end.
ReplyDeleteLike the radiologist, pharmacists can "risk missing something significant in the blur." Fortunately, the flow of a pharmacy is set up with many checks and balances. Unlike radiologists, we are not trained to examine and analyze images quickly. However, the fast paced environment of a busy pharmacy, where we sometimes pride ourselves on our wait-time, can force us to review prescriptions quickly and become error-prone.
I did my EPPE at a slower pharmacy this summer and am working at a much faster paced store currently. The slower store seemed to be properly staffed and the two pharmacists were able to double check and counsel patients when they would like. The faster paced pharmacy seems to be in chaos and patient issues are not resolved for days. They cut many tech hours, so it seems that some patients get lost in the shuffle. Especially on busy nights, I don't believe patients get the attention they deserve. The pharmacists do however need to be able to check prescriptions quickly or they run the risk of losing patients. Also, there are company statistics being kept on each individual pharmacist, so they have to be both accurate and fast to keep the company happy. Although they are concerned about patient safety and few errors occur, sometimes I feel that pressure from large companies prevents pharmacists from being able to give excellent patient care.
ReplyDeleteI agree that slower pharmacies have the opportunity to provide better patient care, but it doesn't always translate into results. I truly believe that the PIC and other pharmacists set the pharmacy's culture on patient care is valued regardless of scripts run in a day. Also with a slower pharmacy, I believe errors are made more easily. I did my EPPE at an extremely slow pharmacy; it was so slow that I never really got in a rhythm during the day. I felt that I was losing engagement during the day; I felt that I could possibly miss something at that pace.
ReplyDeleteI don't think it matters how busy the store is, mistakes happen in both types of environments. The point is, mistakes happen. As pharmacists, we should be able to adapt to the environment we are in and come up with strategies to ensure our mistakes are taken care of immediately. I agree with Will, in that my fast paced job keeps me on my toes and forces me to focus. On the other hand, at my slower IPPE, I lost focus and was prone to more errors.
ReplyDeleteReading through everyone's post about their work experiences reminds me that this is why pharmacy is such a diverse field. Some of us do better with the fast paced pharmacy perhaps making more mistakes because when it is slow you tend to be distracted by other things and then others need the slower pace to feel that they are doing their job appropriately and when it becomes too busy they feel overwhelmed. I think I prefer the busy pace but at the same time, I currently work for Fairview and pharmacists always get their breaks and rarely is someone working OT. When I used to work at Walgreens or at my rotation at CVS I used to wonder how they could do it. Working 14 hours straight without one break... as my preceptor put it "that's why I have malpractice insurance. It's not a matter of if I make a mistake, it's when." Scary thought that this could be the future of pharmacy.
ReplyDelete