Dr Felicity Sinclair-Ford reflects on her recent time working clinically and how it illustrates potential challenges with clinician engagement.
I have a great job.
As a Medical Projects Consultant with Clinical Documentation Improvement Australia, I feel privileged to empower clinicians and CDSs to improve patient safety, one correctly documented diagnosis at a time.
Every now and then, however, I dust off my stethoscope, retrieve my scrubs from the back of my wardrobe, and head back to the wards. This allows me to preserve my clinical skills, update my clinical knowledge, and maintain my general registration.
While there’s always a slight nervousness when you return to an environment you haven’t experienced for a while, and especially one where people’s lives are at stake, there was one thing I didn’t doubt: my ability to clinically document.
I’d thought that surely (surely!) having a CDI Medical Projects Consultant on the team would mean that documentation, for that week at least, would be practically perfect in every way. You know, the kind that makes clinical coders weep cathartic tears and finance departments pop bottles of champagne.
I was in for a rude shock.
Despite my in depth and expert knowledge in CDI, there were still multiple roadblocks preventing me from accurately documenting in the patient record.
The realisation that knowledge alone is not enough startled me. I tried to ascertain why this had taken me by surprise. Had I forgotten these elements when looking at clinical medicine with rose tinted glasses? Had I not realised how significant they were before my knowledge of CDI was developed? Or were these particular issues I was only identifying because I was trying to document in the way that I now know supports safety, data, and finance?
To answer these questions, I’d like to consider some of the situations I found myself in (in just a week!) that demonstrate the stark reality that changing clinical documentation culture is an uphill battle and requires more than change on an individual level.
Offside
My CDI brain couldn’t help itself.
It was the public holiday and I was rounding with the urology fellow. We only had four patients to see, and the round would be brief.
I knew I had a doctor in front of me that, in their long career ahead, would have countless patients with sepsis due to UTI. And the recent 12th edition changes have made it crystal clear that “urosepsis” is coded as “UTI” and nothing else.
Trying to remain casual, and unable to give my full spiel on a public holiday ward round, I offhandedly mentioned that urosepsis needs to be documented as “sepsis due to UTI”.
And I was floored by the response.
“It’s stupid, isn’t it?”
I was in shock. All I could think was “No, it’s not stupid at all!”
I wanted to explain about potential ambiguity and the need for consistency and discuss the difference between how terms such as “abdominal sepsis” and “chest sepsis” are used clinically, and how this can cause confusion.
But we had to keep going, and I wasn’t there in a CDI capacity. I was a resident, and I had to keep up with the round.
So despite my knowledge, identification of someone to whom it would be relevant, and opportunistic education, all I had succeeded in doing was making someone dismiss clinical coding. How the heck did that happen?
The Holy Grail
I was writing a discharge summary for a surgical patient who had been admitted and had their operation before I was on the team.
And I saw the holy grail of potential CDI interventions in surgical patients: a patient with “division of adhesions” documented, with a long list of previous surgeries. However, I’m not the surgeon, nor am I a surgical registrar with the authority to make the call that the adhesions were “due to” previous surgeries. So despite the likelihood that these adhesions were, in fact, due to previous surgery, I didn’t feel I could ethically document that without a more senior member of the team confirming it.
But I knew (in my bones! And I wasn’t on orthopaedics) that if I contacted the surgical registrar about an esoteric link, on a discharged patient, that did not directly impact patient care at that time, they would be incredulous and, let’s face it, annoyed.
Maybe I was wrong; maybe I should have.
But the culture of hierarchy is deeply engrained, and this was even knowing I was working with particularly nice registrars.
So despite my excellent knowledge as a junior doctor, without senior education it was (in this instance) all for naught.
Not a Job for Ward Call
My Sunday ward cover co-resident was annoyed, and, in fairness, he had every right to be.
“That is just not a job for ward cover.”
The job in question?
Writing a discharge summary.
The hospital I was at had a very high discharge summary rate. However, these could be completed on a Monday if the patient discharged over the weekend. But for a patient transferring to another hospital, the paperwork had to be with them before they left.
“The doctor that discharged them should do it. It’s not our job.”
Only later did we realise that the doctor who had discharged the patient, a consultant, had been sitting behind us as he said this. Awkward.
Given my day job, I was quite happy to be the one to do the discharge summary. However, once again I found myself in a situation where identifying the diagnoses to be included was difficult. They were a complex oncology patient and the summary, while as good as I could make it with the documentation I had, potentially had missing diagnoses.
Once again, my expert knowledge was not enough.
Know thy Place
As a locum, in this case there for only a week, it’s important to be flexible and adapt to the team you’re integrating into. No need to take control, or step on anyone’s toes. You’re there to help, so I personally allow other members of the team, including those more junior than me, to allocate jobs and roles, if they would like to.
What can I say? I’m chill like that.
However, there are people who live by the maxim “if you want something done right, do it yourself.” This can, unfortunately, lead to unequal division of labour, when people are doing a lot of work because they don’t trust others. This never offends me, as I know it usually stems from anxiety.
So, despite explaining my job in depth, the intern on the team said he would prefer to write the notes. I would never dream of insisting that I “must” write the notes, as this is his regular place of work, and he has every right to write the notes if he would like to.
And while the notes were of good quality, and it’s possible it wouldn’t have made any difference if I wrote them, my skills weren’t being put to the best use.
Poor human resource allocation at its finest. So even if there are doctors who are especially interested in CDI, or CDI champions, they might not have the opportunity to use that knowledge.
I Still Don’t Know
Now, I have always suspected that I do not have the ability to read minds, but this week confirmed it once and for all.
Despite being many more years out of med school than the average resident medical officer (I won’t say how many!) and having done most of my work on surgical wards, I still couldn’t always deduce the condition that the registrar was treating with the plan they gave.
In the past I would say that this can be overcome by educating junior doctors and empowering them to ask for clarification. However, there were several instances in which I didn’t realise a diagnosis was missing until I came to enact the plan. And by this time the registrar was off the ward. I didn’t always have the time (or the energy!) to chase the diagnosis through the “Holiday Surg Team” WhatsApp chat.
I don’t exactly remember examples of these conditions, probably because it’s somewhat difficult to remember something when you don’t know what it is. I just remember going “oh shucks” when completing jobs from the plan.
So, despite all the will in the world, if the registrars didn’t tell me the diagnosis, I didn’t know. And, more to the point, sometimes I didn’t even realise a diagnosis was missing. While I’d picked some of these up later, how many had I not noticed at all?
So Why Hadn’t I Considered These?
If we go back to my original question, why had these problems taken me by surprise? Where had my belief come from that my expert knowledge would be enough?
Perhaps in the fervour of my CDI zeal, I believed that the one great truth of CDI could blitz all these barriers away.
Maybe I hadn’t encountered them since I had learned about CDI. Now I think about it, in my previous locum stint, I was the only resident on team and had a registrar who was accessible to answer questions. So lots of these problems weren’t applicable.
But in the end, I don’t think it matters why.
Medicine, CDI, and any complex field, is all about learning, growing, trying new things and assessing their results, and integrating new and old information.
If I use this experience to target my education to clinicians and inform CDSs of the potential barriers in clinician engagement, then it’s all been worth it.
The Take Home
So if you’re struggling as a CDS, or HIM, or anyone committed to improving clinical documentation, know that what you’re doing is really hard, and you’re not alone.
Medical culture has a long history, from butchers with blood-soaked rags out the front of their shops, to a learned (and male dominated) community of scholars, to the frenetic, diverse, and hierarchical system we know today. Changing something with this much history is going to take a huge effort and, no matter how hard we push, time.
It’s difficult, but then, so is everything in life worth doing.
And together, we can do this.
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