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Life In The Hospital

Lose Your Job By Using Email In 11 Easy Steps

If you are like many Americans, you probably wake up each morning thinking “I’d really like to screw up my life and lose my job today”. Well, some good news for you – I can help. I’m going to show you how you can destroy your career and lose you job simply by getting on your computer in the morning, before you even go into work. All you have to do is use email. After decades of observing physicians and hospital employees use email to mess up their lives and make people really dislike them, I now know the secrets and I’m going to pass them on to you today.

  1. When replying to an email, always use the “reply to all” button. This is such an easy way to infuriate people that I don’t understand why so few people use it. Sometimes, the use of “rely to all” is only just a minor annoyance, for example, when the department chairman sends out an email to all of the faculty announcing that a member of the faculty received a prestigious award or research grant – there is always a few people that will use “reply to all” to echo the congratulations. After the 15th or 20th time that your email alert goes off with these, you feel like you are in a pinball machine with the little metal ball bouncing endlessly back and forth between two mechanical flippers. But there are some people who have perfected the art of “reply to all” and use it to thank the administrative assistant who sends out the weekly grand rounds lecture announcement with the philosophy that no email is to small to reply to all. You can use this strategy to clog up dozens of people’s email accounts with your inane comments.
  2. If you can communicate something to someone with a 1-minute phone call or an email that takes you 20 minutes to type, always use email. Everyone will realize that you are wasting time inefficiently and it is a great way to make your boss pass you over for promotion or raises.
  3. Email while intoxicated. There is no law against it like there is with driving and it is a great way to sound like an idiot. This is particularly effective when coupled with off-color jokes since as that joke gets forwarded to more and more people, it is bound to eventually end up forwarded to someone in human resources. Not only is this a great way to get fired but it is also a great way to be sure that no other hospital in the area will hire you.
  4. Attach liberally. One of the best ways to become disliked using email is to send an email out with nothing but the message “see attached” and then attach a 20 or 30 page document, or better yet, several documents. Since there is nothing else in the body of your email message, the recipient will have to open the attachment and read it to figure out what you are trying to communicate. This is a guaranteed way to infuriate.
  5. When you are angry or if you get a particularly unpleasant email, always respond immediately. If you wait 10 minutes, you might have calmed down and actually responded in a rational and restrained way but if you respond right away, you’re far more likely to type in a message that you will later regret. It is much better to come across as an irrational hothead which is a far easier way to lose your job. Remember, a temper tantrum only lasts 5 minutes but an email lasts forever.
  6. If you have something critical to say about someone, always use email rather than a phone call or a face-to-face conversation. An email is a contagious thing and you should say anything by email that you would want taped to the front door of the hospital. So if you want to communicate that a manager made a really stupid purchasing decision, or a newly hired physician’s wife is really ugly, or one of the senior physicians is incompetent, be sure to put it in an email since there is a good chance that it will be forwarded repeatedly until it finds its way back to the manager/new physician/senior physician. This is a fantastic and highly effective way to screw up your life.
  7. Use unsecured email to communicate patient information. Unfortunately, the hospital’s email system is maintained on a secure server so you won’t get fired by sending another hospital employee patient-related information by email. Fortunately, any email address that ends in “gmail.com”, “yahoo.com”, or “hotmail.com” is not secure and so a political candidate who is trying to dig up information about his adversary (who is your patient) can easily pose as your patient by email to get information about his recent hemorrhoid operation. Since this is also a violation of federal HIPAA laws, it is not only a sure-fire why to lose your job but as an extra bonus, you can also end up in federal court!
  8. Use sarcasm liberally. You can wear your emotions on your sleeve but your email has no emotion. With facial gestures and voice intonation, everyone will realize that you are making a sarcastic response or a joke. But in email, it can become threatening or just make you look stupid. Unfortunately, doing this once or twice is not enough to get you fired but if you make this a regular part of your day, then eventually you’ll irritate enough people to at least make everyone hate you.
  9. If you have an argument with someone, it is always better to do it by email. Email arguments are great – you always eventually say something that you later regret and the person you are arguing with is far more likely to forward your email to the person who will be in the best position to terminate your job.
  10. Whenever you are on vacation, always use the automatic reply function on your email account and be sure to indicate exactly how long you’ll be gone and where you are traveling to. That way, the guy who is sending you spam or a phishing email will know that it is open season on all of your belongings in your house. If you want to be even more sure of messing up your life, indicate in the automatic reply that you keep a spare key under your front doormat and include your house alarm code in the email.
  11. If you get an email from someone that you don’t know that asks you to open the attachment, always open it, particularly if it looks like the email comes from some place in Eastern Europe, Russia, or an island in the Pacific Ocean that you’ve never heard of. There is a great chance that this is a phishing attempt and a great way to get malware loaded into your computer. If you’ve been trying to get your monthly direct-deposit paycheck diverted to someone’s bank account in Costa Rica, this may be your best opportunity.

The internet has made our lives easier in so many ways and email has brought us lots of great opportunities to wreck our careers and lives. So, next time you wake up trying to decide what you can do today that will be really stupid and maybe even that you can regret for the rest of your life, you don’t need to go any further than your email account.

September 19, 2016

Categories
Inpatient Practice Life In The Hospital

The JCAHO Site Survey

We just went through our Joint Commission site survey and I have a few thoughts after doing this as a medical director. The Joint Commission for the Accreditation of Healthcare Organization (JCAHO or just “Joint Commission”) is the largest of several organizations that review and accredit hospitals in the United States. Hospitals pay the Joint Commission to do a top to bottom review of the hospital every 3 years and they look at everything from medical records, to equipment, to policies, and to the plumbing. The stakes are high: if you lose your accreditation, you can lose your ability to see Medicare and Medicaid patients. I’ve participated in about 2 dozen Joint Commission surveys between Ohio State and Select Specialty Hospitals in various medical director roles. This year’s survey was the first that I have gone through as a medical director for the whole hospital.

Each hospital will have an open “window” of time every 3 years that the Joint Commission can show up. The surveyors will show up unannounced at the hospital administration offices, typically on a Monday at 7:30 AM. The hospital then gives them access to all patient care areas, medical records, policies, etc. and the surveyors inspect… everything.

The number of surveyors can vary in number depending on the size of the hospital and other factors. This year, we had 8 surveyors: a social worker/counselor, a pediatric critical care nurse, a women’s health nurse practitioner, a former hospital chief nursing officer, an OR nurse, an infectious disease physician, a pediatric oncology nurse, and a former fire marshal. The social worker and the fire marshal were only here 1-2 days but the nurses and physician were here daily from Monday through Friday.

The survey consists of informal inspections and relatively formal sessions where one of the surveyors will sit down with a group of hospital leaders to discuss things like medication safety or credentialing. The real detailed part of the survey is when one of the surveyors goes to inspect a specific practice location. They may do this by deciding to go to the respiratory therapy department in the morning and the physical therapy department in the afternoon. They can also do this using a “tracer” method where they randomly pick a patient chart and then retrospectively follow that patient’s hospital course from when they first arrived in the emergency department to the operating room to the ICU to the nursing unit. They will inspect each location and interview staff at each location.

At our hospital, we have an accreditation specialist whose primary job is to ensure that we are always meeting accreditation standards for a variety of organizations that inspect us periodically. Each person who works in a hospital has a role to play during a Joint Commission site survey. As the hospital medical director, I found my role was a bit different than it was when I was a chief of internal medicine, MICU medical director, or PFT lab medical director. Here are some pointers:

  1. Read your bylaws and know what is in them.
  2. Know what is in your medical staff rules and regulations. I printed out a list of the titles and carried it with me.
  3. Know what your various hospital policies are. Again, I printed out a list of the titles to carried it with me.
  4. Have the policies and rules/regulations at hand. Ours are on our internal hospital internet site so I carried an iPad with me so I could pull them up if needed.
  5. Seek out the surveyors and introduce yourself. Accompany them when possible so you can answer questions.
  6. There is a penalty for guessing. You’ve spent your entire life taking multiple choice questions and knowing that if you don’t know the answer, you still have a 20% chance of getting the question right if you guess. With a Joint Commission survey, a wrong guess about something can be lethal. It is better to say that you don’t know and would have to check the files than it is to guess and be wrong.
  7. Get the medical staff involved. Too often, when they know that the JCAHO is in the hospital, the doctors will hide out in their offices or the doctor’s lounge. The surveyors really like to see the physicians engaged in the process so take time to introduce them.
  8. Walk through the hospital. The best way to keep your backyard tidy is to poop-scoop weekly all year round. But if you are hosting the annual office cook-out at your house, you still want to do a quick walk through the grass an hour before the party starts just to be sure. Same goes with a survey. Look for stuff stored in the hallways, unsecured medication drawers, dust on the sprinkler heads, and water stains on the ceiling tiles.
  9. Timing is everything. The surveyors are likely not going to be judging you on your choice of a statin in hyperlipidemia. It is just too subjective and hard to do in a short survey. What they can and will judge you on is whether you adhered to your policies. So, if your policy says you need an H&P on the chart less than 30 days before a surgery, that H&P better be dated < 30 days earlier. If your policy says that the anesthesia assessment needs to be done immediately before surgery, it better be timed before the start of the surgery.  If your policy says that a preliminary op note needs to be in the chart before the patient leaves the OR area, it better be timed before the time the patient is transported to the floor.
  10. It’s your policy, stick to it. Don’t make policies that the doctors can’t adhere to. A policy is what your doctors have to do every time, not what they should aspire to eventually do. If you put in your policy that your doctors need to assess the Mallampati class prior to doing procedural sedation, it has to be done and documented every single time.
  11. Everything expires. This is low-hanging fruit for a site surveyor, every bottle and package in your hospital has an expiration date whether it is a medication, a test strip, or a cleaning agent. Be sure that someone is checking them regularly. After our recent Joint Commission survey, I went through my refrigerator at home… there was salad dressing from 2011 in the back. Good thing they were inspecting the hospital and not my kitchen.

But the good news: we passed our survey. Next week, we have to start preparing for the next one.

September 9, 2016

 

Categories
Life In The Hospital

Screening Physicians For Drug Use

cannabis-sativa-plant-1404978607aklJune and July are busy months for our medical center’s credentialing department. Every year, we have more than a hundred new residents, fellows, and attending physicians who apply for privileges. Part of the application process is a mandatory urine drug screen. Positive drug tests for marijuana are becoming more and more common in physicians coming to Ohio from Colorado and other states where recreational marijuana is legal. We are now in a quandary about how we handle these physicians.

Most hospitals have adopted a zero tolerance policy for drug and alcohol abuse. Not only do we do urine drug screens for all new physicians but any physician can be required to undergo on-the-spot drug testing if anyone (colleague, patient, nurse, etc.) reports them as possibly being impaired at work. This is an incredibly powerful tool to prevent impaired physicians from harming patients but the testing does have the potential for abuse. For example, a couple of years ago, an inpatient who was seeking opioid medications threatened one of our hospitalists with reporting her as being under the influence of alcohol unless she prescribed oxycodone for him. She refused to prescribe it, he called the medical staff office reporting her, she underwent immediate testing for drugs and alcohol, and she passed her testing with flying colors.

Until recently, the drug policies were pretty straight forward, if your urine test was positive, you were determined to be abusing drugs or under the influence of alcohol at work. All that has changed with legalization of marijuana in some states. The issue is that cannabinoids (the main chemical in marijuana) are detectable in the urine for days and in some cases, as long as a month, after marijuana use. Let me give 2 examples of where this can be a problem for physicians.

  1. A medical student in Colorado might legally smoke marijuana for recreational purposes on an occasional basis. If that medical student then goes to another state to do his or her residency and undergoes mandatory drug testing, cannabinoids will be detectable days or even weeks later.
  2. A physician goes to Colorado for a ski trip and while on vacation, smokes marijuana. He or she then returns to their own state the following week and is accused of being under the influence of drugs at work. That physician provides a urine sample and it tests positive for cannabinoids.

In both situations, the physician legally used marijuana but because cannabinoids are so lipophilic, the urine drug test was positive long after the effects of the marijuana have worn off. However, as a medical director, I cannot tell from the urine test whether the physician smoked marijuana 4 days earlier in Colorado or 30 minutes earlier in a hospital bathroom. In order to protect patient safety, I am going to have to assume the worst, that the physician is illegally using marijuana in Ohio and may be practicing medicine under the influence. That means that the physician will likely need to be enrolled in a drug treatment program and undergo regular drug testing for the foreseeable future.

As a general rule, cannabinoids will remain in the urine for 2-5 days for the infrequent uses, 1-2 weeks for the frequent user, and up to 4 weeks for the habitual uses. However, because cannabinoids are so lipophilic, marijuana users who are obese will have positive urine tests for much longer than non-obese users and even relatively brief marijuana use in obese people can result in positive drug tests for up to a month.

It is also easy to see how the long detection period for cannabinoids could be used to intentionally cause harm to a physician. For example, if a vindictive former partner, a former spouse, or a patient who is suing a physician wanted to damage a physician’s career and knew that the physician had recently vacationed in a state where marijuana is legal, all they would have to do is to anonymously report them to their hospital as being under the influence.

So my advice for senior medical students at medical schools in Colorado, Oregon, and Washington: the marijuana smoke you inhaled in June might have been legal but your urine won’t be legal in July. And for the physician vacationing in Alaska, Colorado, Oregon, or Washington, stick with the local craft beer and pass on the marijuana.

July 12, 2016

Categories
Life In The Hospital

The Yin And Yang Of Yelling At Doctors

Yin_yang.svgAs a medical director (or any kind of leader or supervisor), it is your responsibility to call out physicians who are behaving badly. It is one of the things that medical directors like least about their jobs but if you don’t do it, then you become an enabler of bad behavior.

There are two ways to yell at a physician. First, it can be done at the spur of the moment when you see something, hear something, or someone tells you something that a physician did that breaks a policy, deviates from normal civil behavior, or violates international law. The advantage of this method is that you can invoke discipline as close to the time that the behavior was performed, kind of like yelling at your dog if you catch it peeing on the carpet. The disadvantage is that your temper is usually up pretty high and this can result in your emotional intelligence quotient falling by a couple of branches on the human evolutionary tree to about the level of Australopithecus. This method is highly reflexive and although it can get you the results you need, there can sometimes be significant collateral damage.

One of my former chairmen was a great guy but when he’d get angry, there were these two veins on his forehead just above his nose that would stick out. We all knew that if you were walking down the hall and you saw those two veins walking toward you that you should put your head down, look at your feet, and hurry past as fast as possible, hoping that you were not the subject of the excessive cutaneous venous engorgement.

The second way to yell at a physician is the planned ambush.  This requires forethought and careful rehearsal of what you are going to say. The advantage is that your temper has usually cooled and your emotional intelligence quotient is back in the usual Homo sapiens range. The disadvantage is that the longer you wait after the bad behavior, the less effective your yelling will be, a lot like yelling at your dog on Thursday for peeing on the carpet on the previous Monday.

Regardless of which method of yelling you do, yelling at a physician will suck the joy out of your day so it is important to have emotional balance. That is where the yin and yang comes in. Whenever you yell at a physician, you have to find someone else to pay a compliment of equal intensity to. If you are standing at a nursing station and hear a physician loudly complaining about the quality of the donuts in the physician lounge and have to tell him or her to knock it off, then you have to go find another physician to thank for coming into the hospital in the middle of the night to operate on the patient with a perforated bowel. There are a lot of ways to pay compliments and in order of effectiveness:

  1. A text to their phone
  2. An email
  3. A phone call
  4. Seeking them out and telling them in person
  5. A hand-written note
  6. A hand-written note with flowers
  7. A hand-written note with use of the medical director’s prime parking spot for a week

Disciplining a physician is almost always going to leave you feeling bad. So it is important to find something to make you feel good to maintain your personal psychic symmetry. Furthermore, if everyone knows you for your responses to physician badness, they will never know you for promoting physician goodness.

August 6, 2016