By Rob Lamberts, MD

This, apparently, is a map of my mind.  It’s a little shocking to find out that my mind looks like a sea creature, a bug, or perhaps a vegetable.  Actually, “Rob’s mind” and “vegetable” are often used in the same sentence.

Someone suggested to me that I may benefit from mind mapping.  I don’t know how to describe it, but I think spatially; I see things abstractly as if I am pulling up from the ground and getting an aerial view of things.  I write that way, I solve problems that way, I even play music that way.  Maybe it’s tapping on the right side of the brain that is about nuances or about how things relate to other things in proximity or direction.  Like I said: it’s hard to describe.

Anyhow, I was thinking about task-management with my patients, wondering what’s the best way to think about it and what is the best design for a system helping with this.  Task management is perhaps the most important thing in health care that’s never talked about.  Maybe that’s because it makes doctors feel less special, reducing our “magical” knowledge and “miracle” cures to algorithms and checklists.  Personally, I take great comfort in systems because they assure me I am not going to forget important things (like setting a reminder to take the trash out on Sunday and Wednesday nights).

The problem is that there are many, many tasks to consider when thinking about patient care.  For example, when test is ordered it need to be:

1. Sent to the lab
2. Sent back to us
3. Reviewed, with the information used appropriately
4. Filed into the patient chart
5. Decided if/when the test needs to be repeated
6. Decided if more testing or treatment is needed
7. Sent to the patient with explanation of my interpretation and plan.
8. Document that I communicated this
9. Schedule any follow-up

You can see how this would quickly lead to overload, with a simple lab test resulting in 9 steps.  It is a bureaucrat’s dream, but a busy doctor’s nightmare.

Another problem is the complexity of the care of a patient.  There are lots of different aspects to patient care that can’t be ignored.  This brought me back to the idea of story telling, and how it relates to patient care.

• What is the back story?  Who is this person and what are the various things in the past that have made them who they are?
• What is the current scene?  What’s going on with the person right now?  What are they feeling, what medications are they taking, and what is their emotional state?
• What is lurking in the future?  What are their risk factors?  What will need to be done and when?

Furthermore, in making a list that will work, we need to know:

• The timing of the task.  Is it immediate or is the time flexible?
• The importance of the task.  How critical is it to the patient’s health?
• What is gained by doing the task?
• What is lost by not doing it?
• Who is responsible for the task.  Is this something I must do, does it go to my nurse, or is it something for the patient to do?
• Who is responsible for checking to see it’s been done?

Heavy stuff.  How do I wrap my brain around building a task management system without making my brain turn to mush?  It was getting a little depressing.  I was tempted to shut down my brain and play Bejeweled for a few hours, but then I remembered the suggestion of mind mapping.  Why not?  Let’s step back and get a bird’s-eye view of the patient and what things we need to consider.  It couldn’t hurt.

What I got was a big spider-looking thing that could probably fill the pages of a book in explanation, but it’s the big picture that will hopefully help me decide on how to handle my patients.  Here’s what I included:

1.  Their Situation – What is going on right now?  What things are happening of significance?  Are they going through a divorce?  How old are they? Are they in a job they hate?   Do they have insurance?

2.  Their Lifestyle – While a situation happens to the person, lifestyle is a choice (by my definition, at least).  How does a person want to live?  What choices do they make?  Do they smoke?  Do they buy expensive cars?  Do they spend their days playing the lute and drinking mulled wine?  Obviously, these choices have a huge impact on a person and our approach to their health.

3.  Their state of well-being – This is their perception of their lifestyle and their situation.  It depends on a lot of things, but is predominately a function of perception.  It’s how they measure up to the “should” of life.  People with terrible disease can have a good state of being, while healthy people can be living in fear.

4.  Level of Understanding – How well do they understand their situation in regard to medical issues and others as well?  How open are they to learning new things?  Do they actually understand things, or have they convinced themselves that they do?  I value education and communication very highly, and yet there are some people who are not open to teaching at all (dogmatists) while others will devour eduction when given a chance to get it.

5.  Risk – This takes the overall situation of the patient and looks into the future.  Much of medicine is about anticipating risk and reducing it.  High blood pressure isn’t a problem in itself, it’s the higher risk of heart disease, stroke, and kidney damage that we are actually addressing.  In considering risk, the question always should turn to the severity of the risk (how bad of a problem), the immediacy of the risk (how soon it could happen), and the risk/benefits of intervention.

6.  New Problems – these usually drive the most items in a care plan, as assessing each of the above come into play with a new problem.  The key is to understanding overall impact of the problem on both length and quality of life, as well as the benefit of investigation and treatment.  First off, we need to understand the nature of the problem.  Is high blood pressure a problem needing treatment, or is it simply that they are totally stressed out about the weight we just checked? Please note that, as opposed to our beloved health care system’s view, the patient is the focus, not the problem.  Everything has a context on which it exists, and problems happen in relation to a patient.  Do always treat diabetes in a patient?  What about in my Mickey, who turns 100 today?  How big of a problem is a sugar of 200?

7.  Intervention (labeled as “treatment”)  – We don’t think of problems for the mental exercise, we do so to intervene where appropriate or to understand future risk.  Interventions are often the things next to the check boxes on the task list.  Sometimes we choose to observe.   Intervention always comes with a cost, but non-intervention may cost more.  All intervention must be weighed, considering all the factors listed above.

8.  Chronic Problems – This is the “management” portion of medicine that plays well to a task list, and the one that folks measuring the “quality” of care don’t get beyond.  All medical care is not boiled down to meeting metrics, but the metrics are not unimportant.  The key is, like with the rest of this exercise, to consider the situation, risk, understanding, well-being, lifestyle, priorities, and other problems the patient has.  This doesn’t play well with the bean-counters of medicine, but it’s the reality that docs and patients face.

So, does this help?  It sure looks fancy, and sounds all TED talk-ish.  It scares me that I may be advocating something “holistic.”  I may just get a call from Oprah because of it.  Scary.

The benefit to me is that it pulls me away from the seductive simplicity of cookbook medicine.  In the end, medical care is a human interaction that is designed to result in health gain of the patient.  This is far more complex than a set of checkboxes or a bunch of criteria to assign meaning; in it’s best form medicine is very much right-brained.

And that, my friends, proves that I my just be in my right mind.

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind),where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.