Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes
“From a charting standpoint, the sins of commission easily outnumber the sins of omission. Our group’s progress note template begins with a summary that eventually becomes the narrative for the discharge summary. Most of the time, most of the important stuff is in there. It’s just obscured by what data scientists technically describe as ‘oodles’ of no-longer-relevant details. Like a package of cheap ramen, the single cube of chicken meat is in there. Your job is to find it.
Why do we do this to ourselves? Why do we keep simply adding details to a note rather than subtracting the no-longer relevant ones?”
Craig Bowron is an internal medicine physician and can be reached at his self-titled site, Craig Bowron, MD.
He shares his story and discusses his KevinMD article, “Bloated notes are a huge problem and a time suck.”
Did you enjoy today’s episode?
Please click here to leave a review for The Podcast by KevinMD. Subscribe on your favorite podcast app to get notified when a new episode comes out!
Do you know someone who might enjoy this episode? Share this episode to anyone who wants to hear health care stories filled with information, insight, and inspiration.
Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.
Transcript
Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Craig Bowron. He is a hospitalist, and he wrote the KevinMD article “Bloated notes are a huge problem and a time suck.” Craig, welcome to the show.
Craig Bowron: Thanks, it’s good to be here. It’s an honor to be part of your media empire. You’ve really built something.
Kevin Pho: Well, thank you so much for writing, reading, and listening. We’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?
Craig Bowron: Yeah, so it’s interesting. When I was growing up, I grew up in a smaller town in northern Illinois, and I really had the vision of becoming a small-town doctor. I basically spent my career as a hospitalist in a tertiary care center in downtown Minneapolis. So sometimes life is just living you, you know, rather than the other way around.
I refer to myself as a silverback hospitalist, because I started as a hospitalist in 1995, ’96, and at the time there were just two people, three people in our group. We certainly didn’t use the term hospitalist or know what that was, and now there are 80. So, again, going from having these aspirations of being a small-town doctor to ending up being a hospitalist in a tertiary care center has been quite a journey.
I was also an English major in undergrad. I was writing all along, but shortly after I finished my residency, I started writing, so I’ve kind of had a dual career. Mostly I’m not writing to physicians; I think your site is kind of unusual for me. Mostly I’m writing to the public, and I really enjoy that part of it. Because, you know, as physicians, what do we end up doing? We spend a lot of our time explaining to people why they’re sick, what’s going on, what we’re going to try to do to figure it out, and what we’re going to do about it. So those are those two things: a hospitalist and a writer.
Kevin Pho: So you’ve been a hospitalist for 15-plus years now. What would you say are some of the biggest challenges facing the hospitalist profession, and where do you envision the hospitalist profession going in the near future?
Craig Bowron: Well, they predicted the future quite accurately. People were going to come into the hospital and spend a shorter time in the hospital, they were going to be more sick, and they’d be medically more complicated. And, you know, it has followed that script. It’s just so interesting to see. Like everyone, you kind of think, can people get any more complicated? Can the pace move any faster? Asking this question: The minute they roll in, we’re already planning how we can facilitate their discharge. Obviously, we’re not trying to rush anybody out.
And just the sheer complexity of the people who we’re keeping alive is stunning to me. I trained just as the HIV pandemic, the AIDS pandemic, was really rolling in, in ’91, ’92, and we saw that miraculously change in a couple of years with the protease inhibitors. But now, some of the things that we’re doing in advanced cardiology, the people who we’re placing valves on, it’s really quite amazing. And I think those challenges will only intensify in the future, which is part of why I got involved in our group and working on notes.
Kevin Pho: All right, so let’s talk about that article where you share that experience. It’s titled “Bloated notes are a huge problem and a time suck,” and that certainly applies to the primary care world that I’m in. But for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?
Craig Bowron: Yeah, what’s interesting about it is it’s not a medical article. It comes out of a study done at the University of Virginia, and I think it’s out of their engineering and psychology departments, so it doesn’t have a medical background. But the interesting thing is that they did the experiment. They did eight separate experiments, and they asked people to do some simple solving of a problem. The problem, as they put them together, had a simple subtractive solution, or it had a more complicated additive solution. For instance, they developed this Lego device and said, “Can you fix this so we can carry a brick on top of it?” The subtractive answer was to remove one Lego brick. The additive answer was to add three additional ones. And what they found through all of these eight separate experiments was that people’s, our, natural proclivity is to add things and not subtract.
I head this notes committee for our group, and when I read that, I was like, “I’ve got to, this is absolutely talking to us.” You know, as a primary caregiver, for instance, I have 80 people in my group. Most of those people I hardly ever interact with directly, maybe at one of our social gatherings or maybe at a group meeting. But the way I interact with them regularly is through our notes. Again, referencing our earlier conversation, the more complicated people get and the shorter they stay, the more we need to get this right. We need to have a summary that’s concise and specific and detailed and not cluttered. We really need subtractive solutions, not additive.
Because we’ve all seen it. If you do primary care, you probably get a hospital discharge summary, and you see that it is essentially a diary, a diary of every day: “Well, this is what happened today, and this is what happened today, and this is what happened today.” And you’ve got 20 minutes to do a post-hospital follow-up on a summary that’s like this long. This is not smart, and it takes a lot of extra time. So that was the gist of my take on this thing. It was, listen, we’re fighting our natural tendency to want to add stuff, when really we’ve got to work on subtracting stuff and giving people clarity.
Kevin Pho: Now, for those who aren’t involved in the medical world, especially in the hospital, paint us a picture of a typical note that gets bloated over time. And how does that affect patient care?
Craig Bowron: The way we do our notes is it starts with a summary. And we kind of feel like, as the primary care doc in the hospital, if there’s someone who knows really everything that’s happened, it ought to be us. Then we have the middle of the note, which kind of talks about the exam and what they’re doing today, and then at the end, the assessment and plan. That daily summary that we have is the way that we communicate doctor to doctor. There’s no way that I can talk with the person who’s coming on overnight about every one of my patients, but they ought to be able to see that note quickly. If they get called, they can quickly read it, know where that patient’s at, and be able to make decisions. So that’s kind of how we do our notes.
I don’t know how you feel about this, but to me, gathering the information on a patient is like 80 to 90 percent of the work. The last 10 percent is once you have everything in front of you, you can say, “OK, I’ve got all the pieces of the puzzle.” You know, the actual decision that we need a CT scan, or you need a bone marrow biopsy, or whatever, that’s the last 10 percent. But when the important details are scattered, it’s an intense amount of work to actually know where we’re at and get to that decision point where you can actually start making orders or making changes.
So it’s really critical. I think sometimes there’s a push in medicine that we ought to be better storytellers, and sometimes that can be pooh-poohed as, “Oh, you want us all to be the next John Updike.” But it’s really about communicating clearly what’s going on with our patients and where we’re at right now, and getting rid of the junk. Whether it’s me or someone who’s picking up this patient, for us, the busiest days are Mondays and Saturdays, because that’s when we’re coming on and we’re seeing patients who are new to us and we don’t know. When you have an excellent summary, you read it, bing, bang, bang, and you are ready to work for that patient. And if it’s not there, it’s just a lot more extra time.
It kind of reminds me of one of these grocery stores, if you’ve ever gone to one, that’s like the size of an aviation hangar. The good news is everything you want is in there. The bad news is you’ve got to find it, and you may not find it. And that’s the way it is. So typically, when we talk about what I mean to lay people by a bloated note, it’s that people are just adding stuff. They’re not getting rid of old stuff that’s no longer of any importance; they’re just adding stuff. So it gets longer and longer and longer. And again, everything you need to know is in there. It’s just not easy to find.
Kevin Pho: Now, who’s ultimately responsible for the solution? Is it the maker of the EHRs? Is it hospital administration? Is it physicians themselves? Who’s ultimately responsible for solving this problem?
Craig Bowron: Well, I was just talking with a partner and friend of mine who is in oncology, and he happened to be looking back at older notes from his partners, you know, a generation ago, and how short and concise they were, and what they are now. So some of note bloat is for billing purposes. I mean, let’s be honest about that. It has to hit a certain number of points in order to justify billing. And maybe it’s a nihilistic sort of view, but I sort of think that’s out of my purview. That’s not something I’m going to change.
So the things that are in my purview are things like the summary, which the EHR can never just automatically generate. That’s my issue, and those are the things that we can fix. Within my group, I love my group. I think we work at a really high level, so I don’t want to pretend that somehow we’re doing bad notes, but we can do better. So we’ve started this initiative to try to improve that. The problem is this stuff isn’t like dot phrases that can be fixed. We’ve done some stuff with automation, the way the EHR has helped us, but most of this is really just, can you tell this story concisely and to the point?
When I saw that research article, it was very curious to me. I would love to see if they got a group of writers and editors to take those same eight tests and see if they would come up with the same results. Because writing and editing really is one profession where, from the beginning, you know that you are overwriting and then you will edit back. Whatever famous book you can think of, it was a lot larger when they started, and then they edit it back to make it the best that it can be. And I think that’s challenging for people. They’re like, “Should I get rid of that?”
And they showed in that research that when people got stressed, or when they made the people they were experimenting with busier, they were even more likely to just add something, add something, add something. “Just add something, because I’m busy,” rather than subtract. So part of it is giving ourselves more time to do that. And the other thing within my group is that I hope that once we start to see these shorter, more concise summaries come around, it will become a movement. When you inherit my patient on Monday and you say, “Boy, Craig’s note, that’s really tight,” you get the idea that, you know, my summaries can be tighter. And maybe through that alone, we’ll be able to kind of ratchet things down.
Kevin Pho: We’re talking to Craig Bowron. He is a hospitalist, and he wrote the KevinMD article “Bloated notes are a huge problem and a time suck.” Craig, what are some actionable tips you could share with fellow hospitalists listening to this podcast on how they can pare down their notes and make their notes sharper and more concise?
Craig Bowron: So one of the things is we kind of use an opening sentence, and, as you know, oftentimes those have been almost like sedimentary rock. They’re from 12 notes ago, and they keep getting bigger and bigger and bigger. And yes, they’ll have something like heart failure, but no description. So was it heart failure like they had severe heart failure and they’re being seen by the advanced heart failure team? Or does heart failure mean that one time they went into the clinic, there was a chest X-ray that suggested a little bit of pulmonary edema, and now they have heart failure?
So we’re asking our members, when you write, here are 10 or 15 critical diagnoses. For heart failure, put behind it “ejection fraction of 35 percent,” or “heart failure with reduced EF.” And if you say COPD, tell me, is it moderate or severe? Are they on home O2? Just in a very short parenthesis, so that in that opening sentence, we hear the most critical information about the most critical diagnoses. And then the other side of that is I don’t really care that they’re status post bunions, that they have occasional gout, or that they have GERD, unless they’re coming in with epigastric pain. So keep that opening sentence to the really critical things. Trim that down.
One of the things about excess language is if you look, oftentimes it says, “This is a 33-year-old gentleman with a past medical history pertinent for.” I know it’s past medical history; I can infer that. I know that it’s pertinent, because I assume it’s pertinent, because you’re telling me that it’s pertinent. So just say, “This is a 72-year-old with heart failure.” Don’t tell me “with a past medical history that’s pertinent for.”
And then very commonly, what you see next is basically a reprise of the HPI: that they were sick for three weeks, and they did this and that, and then they came into the emergency room, and in the emergency room this and this. And that is just left there. That was from postop day one. Get rid of that. If they came in and felt poorly for two weeks and were found to have urosepsis with an obstructive kidney stone in the emergency room, just say that. Get rid of all that extra stuff.
We often pick up patients from the ICU, and of course, ICU stays are very complicated, and you can go deep in the weeds. But it’s enough to say that they were on multiple pressors and were weaned off pressors on this date. It’s enough to tell me that they were intubated, then reintubated, and permanently extubated on this date. So just get rid of, for instance, “Neurology was consulted and recommended a CT scan. CT showed,” and just say, “CT showed.” There’s just a lot.
And the challenge is, if you think it’s as short as it can get, try again. Once I was the head of this notes committee, I felt an extra burden to make sure my notes were good, and I’ve spent the whole last year with them getting shorter. And in my view, and I think in my partners’ view, they’ve not suffered for it. They’re better. So if you think it’s short, it can get shorter. And I say that both as a hospitalist and as a writer: It can get shorter, and it’ll almost certainly be better.
Kevin Pho: So the concept of concise notes in internal medicine is almost the antithesis of what medical students are taught in medical school, right? Because traditionally, in internal medicine rotations, it’s always the student who has the most comprehensive notes, who writes pages and pages, who gets the honors. Now, how do you reconcile that with your thoughts on notes needing to be more concise?
Craig Bowron: So it’s almost like, if you think of medical school, let’s say medical school is learning medicalese. You are there to learn a language, and in that language, yeah, you write much more than you need, because you don’t know what’s important. You have to include everything; you cast a wide net. I work with medical students, and of course, on a busy day, they’re presenting, and you’re kind of like, “Hurry up, get to the important stuff.” I don’t care that their temperature was 97.3, or was it 97.4? “I can’t, let me look at it. It’s 97 point.” You don’t care. The difference is you know what’s important, and that’s called wisdom.
So I totally understand, and I think it’s necessary. You need to know. I tell first-year med students, “I don’t suggest memorizing a lot, but you need to memorize a review of systems, so that when someone comes into your office and says, ‘I think I might be depressed,’ you have some words to use and some symptoms to check.” The way med students do it now is necessary. They’re learning this language; it has to explode. But then, when you get experience and wisdom, now it’s time to implode and get shorter and more concise.
So I don’t see the two ways as necessarily at odds, although I think part of my role is educating med students, saying, “Today, why don’t you give me the briefest? You don’t have to give me the full one. Just tell me what you think is important.” So I do challenge them: “You don’t have to give me the whole spiel. Give me this. Saturday, we’re all short on time. I need to know what I need to know.” And so, yeah, I don’t think they’re particularly at odds.
Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?
Craig Bowron: So there’s a companion article to the Nature magazine one in Scientific American, and it has like a six-minute video. It’s very good. It’s really, really well done, and Scientific American had comments on that. But in that video, one of the engineers from the University of Virginia quotes the philosopher Lao Tzu, who said that to gain knowledge, you need to add information every day, and to gain wisdom, you have to subtract. He was paraphrasing, and now I’m paraphrasing him, but I think that’s really smart.
And maybe that gets back to medical students. They’re adding, they’re adding. They want to develop knowledge; they want to get smarter, and so they’re adding stuff every day. But as we get more experienced as physicians, really, we want to be wise, and that allows us to get to what’s really wrong and what we need to do about it.
Kevin Pho: Craig, thank you so much for sharing your time and insight, and thanks again for being on the show.
Craig Bowron: Thanks, Kevin. I really appreciate it.
Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes
