Friday, September 09, 2011

Handoffs, Passoffs, and Liftoffs

The image of a team of track stars sprinting a 400-meter relay while carrying a little aluminum tube and passing it, effortlessly, without breaking stride is what I think of when I hear the term "handoff." In medicine, a "handoff" is more like sprinting the same race, or at least trying to, and passing a 100-kilogram boulder: there is simply nothing smooth about it.

In earlier times, doctors worked exclusively at one clinic and usually one hospital. There would classically be a "morning report" where attending, medical residents, interns, and a chief resident would assemble to hear the calamities that occurred the night before, discuss and dissect the most interesting cases, perhaps learn a tidbit from the highly respected "chief resident" - the Grand Pubah of all things medical - who had their whopping 1 year of independent clinical experience but plenty of time to assemble a case discussion to point out things you should have known.

The morning report was well-attended. It was, after all, a requirement for graduate medical education and actually a heck of a lot of fun. There was something strangely bonding that occurs when you see your colleague get embarrassed for their lack of understanding just as you had been the day before. It was never punitive (at least not usually), mind you, but rather constructed to make damn sure you never forgot the lapse in judgement you had made the night before.

Late afternoon "check-out" was a different matter. That meeting was never supervised by attendings and served as a "working" meeting between residents where cases were passed to the night call team. Not uncommonly, there were residents who had been there from the preceding night: they got to go first listing their patients' name, a brief problem list, pressing issues that needed to be checked, and so on. No brag, just fact.

And surprisingly, it usually worked.

But why did it work?

I think it worked because we were given responsibility. It was our butt on the line as you worked mano-a-mano with the patients you had to cover. We all knew were going to have to face the music the next morning if things didn't work out so well. The better the night went, the easier morning report was. The better the night went, the better your credibility with the nurses grew. The better the night went, the better the chances of getting selected for a residency slot. The better the night went, the better you slept the next day knowing the patients did well under your care.

Today, things are different. For resident trainees, there are more change of shifts with more handoffs, fewer patients per resident, and fewer hours in which to see the patients you are given from the group before. More dispersion, less ownership. But this is not always the resident's fault. In fact, when a problem arises on one or two patients during an evening call, it is now not uncommon for residents to have to handoff a handoff, having never seen or touched some of the patients they had heard about at their earlier signout. Fortunately, the dedicated (paid) GME physician-instructors are still consistently there at morning reports, but those with day-to-day clinical experience, the attendings and specialists tasked with making their own rounds each day, are at morning reports much less often. That's because they are seeing their growing inpatient populations no longer "covered" by housestaff and working to maintain productivity standards.

Handoffs for attendings themselves are also a growing problem as credentials for doctors are no longer are issued for one hospital, but a system of hospitals. Rarely do attendings meet face-to-face these days: a phone call will have to do since not uncommonly they're at one hospital and clinic one day and a different hospital and clinic the next. That's right, as challenged as handoffs for GME have become, the handoff issues for attending physicians with the consolidation of health care institutions underway isn't even being discussed.

Increasingly, I see the electronic medical record filling the handoff void between attendings. Lists can be assembled, short notes compiled with the patient's name/room number/institution attached to the particulars, leaving the on-call doctor to forage through the electronic chart for details as needed. Messy, lumbering, but it does work, yet (and this is important) it has nothing to do with the "handoff skills" our single-center residents are learning today.

I dream of the day I can text my colleague my signout list from my cell phone without having to worry about the HIPAA police. I dream of the day I can receive an EKG or a chest-xray without being threatened with the concern of litigation. I dream of the day when we can collaborate and work together again, whether virtually or in person, instead of in silos of responsibility.

Imagine: liftoffs rather than passoffs while making a 100-kilogram boulder as light as an aluminum tube.

Well, at least I can still dream, right?



Dennis said...

Micheal Jackson tried to circumvent the medical maze by hiring a personal physician... did not work as planned.

Like the marine said... kill them all and let god sort it out.

Steve Parker, M.D. said...

Morning report back in Residency WAS a great time. I miss it. Thanks for the reminder.