{"id":43892,"date":"2019-01-17T15:24:48","date_gmt":"2019-01-17T14:24:48","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=43892"},"modified":"2019-01-28T13:05:55","modified_gmt":"2019-01-28T12:05:55","slug":"abraar-karan-doing-things-for-no-reason-in-the-hospital","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2019\/01\/17\/abraar-karan-doing-things-for-no-reason-in-the-hospital\/","title":{"rendered":"Abraar Karan: Doing things for no reason in the hospital"},"content":{"rendered":"

Many of the things we do as doctors continue simply because \u201cthat\u2019s the way we\u2019ve always done it,\u201d says Abraar Karan<\/p>\n

\"abraar\"\u201cAnyone who tells you that you can get any rest in the hospital is full of sh*t.\u201d Not the usual way I expect to start off my morning rounds, but the patient<\/span> had a point. Between having his vital signs checked every four hours (the tight squeeze of the blood pressure cuff, the unapologetic beep of the thermometer), a tangle of wires restricting any reasonable movement (one was his oxygenation probe, the other his cardiac telemetry), and the incessant commotion of the night team admitting a new patient behind his curtains, I couldn\u2019t blame him. <\/span><\/p>\n

That day on rounds, our team discussed whether he truly needed to have his vital signs checked overnight\u2014they had been relatively stable for a few days. Similarly, his oxygenation levels had never really been a concern. He did initially require telemetry, but his heart rate had been relatively well controlled. We ultimately discontinued these monitoring measures\u2014both to give him more comfort, but also because he no longer really needed any of them from a clinical perspective. <\/span><\/p>\n

The reality of medicine is that there are many things we as doctors do for absolutely no reason. That is to say, there is no evidence (randomised controlled trial or otherwise) for doing them, other than \u201cthat\u2019s the way we\u2019ve always done it.\u201d <\/span><\/p>\n

Some of this unnecessary medicine is propagated by what behavioural economics call the \u201cdefault effect\u201d\u2014which essentially says that a user will pick the default option unless the cost of switching to a different option is less than the cost associated with keeping the default. <\/span><\/p>\n

In this case, the electronic medical record order set at my hospital has \u201cQ4 hour vitals,\u201d \u201cEKG monitoring,\u201d and \u201ccontinuous O2 monitoring\u201d set as default options when a patient is admitted. The same is true for daily laboratory values, such as \u201ccomplete blood counts,\u201d \u201cbasic metabolic panels,\u201d and \u201cliver function tests.\u201d For most admissions, it is common for these options to never be unclicked or changed to \u201conce\u201d so as to establish a baseline set of lab values. <\/span><\/p>\n

I think much of this comes down to the fact that doctors are not the ones paying for the labs, are not the ones actually drawing them, and are not the ones being stuck by needles to have them taken. Consequently, doctors experience little to no cost associated with keeping daily monitoring going. This is true as well for overnight vitals, which the patient care assistant (PCA) or nurse has to physically measure. If doctors had to actually act on many of the orders they place, I guarantee that most, if not all, of the unnecessary ones would quickly disappear. <\/span><\/p>\n

Over the past few years, we\u2019ve seen a growing awareness that these trends are problematic and <\/span>the Choosing Wisely Campaign<\/span><\/a>, which aims to cut down on unnecessary tests, treatments, and procedures, has taken off internationally. As part of this initiative, the <\/span>Journal of Hospital Medicine <\/span><\/i>started a series of articles on<\/span><\/a> \u201cThings We Do for No Reason.\u201d Some of their most recent examples on common practices that have no robust data behind them include overtreatment of hypertensive urgency and the hospitalisation of patients presenting with low risk chest pain.<\/span><\/p>\n

So how do we change this? One operational shift would be to start a daily \u201cUnnecessary Checklist,\u201d which could incorporate questions including, \u201cDoes my patient still need: Daily labs? Overnight vitals? Telemetry or pulse oximetry? Finger stick glucose checks? Deep venous thrombosis prophylaxis? Dietary restrictions? Bed restrictions?\u201d among many other regularly ordered items. <\/span><\/p>\n

Secondly, physicians should recognise the need to question practices that have otherwise become reflexive. Are there data behind why we are doing this? If there are not, why are we doing it, and what unnecessary discomfort and work does it impose upon patients, nurses, PCAs, phlebotomists, pharmacists, and others on the team, not to mention the increased financial costs to the system and, ultimately, the patient? <\/span><\/p>\n

In medicine, there is a cultural deference to tradition and seniority, but that doesn\u2019t always translate into the best clinical care. Lastly, while this is certainly not the responsibility of patients in any way, I would encourage all patients to question why something is being done if they are unsure. No question is a bad question, and ultimately you have every right to have any intervention, no matter how simple, explained and justified to you. <\/span><\/p>\n

As doctors, we have come to forget the consequences of our clicks. Multiple daily blood draws can lead to iatrogenic anemia; overnight vitals disrupt sleep, which is a major risk factor for hospital-induced delirium; continuous pulse oximetry and telemetry can contribute to alarm fatigue, and over-reaction to otherwise normal variations in heart rate and oxygenation; overly restrictive diets for patients who are having trouble eating can lengthen hospitalisations and worsen nutrition (<\/span>a recent <\/span>JAMA<\/span><\/i> study<\/span><\/a> actually highlights a lack of data for sodium restriction even in heart failure patients). <\/span><\/p>\n

Ultimately, doing things for no reason can unintentionally harm patients. I think we can all agree that there is no reason for that. <\/span><\/p>\n

Abraar Karan<\/i><\/b>\u00a0is an internal medicine resident at the Brigham and Women\u2019s Hospital\/ Harvard Medical School.\u00a0Twitter\u00a0<\/span><\/i>@AbraarKaran<\/span><\/i><\/a><\/p>\n

Competing interests<\/b>: None declared.<\/span><\/p>\n

The opinions expressed in this article are solely those of the author and do not reflect the views and opinions of Brigham and Women\u2019s Hospital.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"

Many of the things we do as doctors continue simply because \u201cthat\u2019s the way we\u2019ve always done it,\u201d says Abraar Karan […]<\/p>\n

More…<\/a><\/p>\n","protected":false},"author":1,"featured_media":43900,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[18906,1357],"tags":[],"class_list":["post-43892","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-abraar-karan","category-us-health-care"],"yoast_head":"\nAbraar Karan: Doing things for no reason in the hospital - The BMJ<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/bmj\/2019\/01\/17\/abraar-karan-doing-things-for-no-reason-in-the-hospital\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Abraar Karan: Doing things for no reason in the hospital - The BMJ\" \/>\n<meta property=\"og:description\" content=\"Many of the things we do as doctors continue simply because \u201cthat\u2019s the way we\u2019ve always done it,\u201d says Abraar Karan [...]More...\" \/>\n<meta property=\"og:url\" content=\"https:\/\/blogs.bmj.com\/bmj\/2019\/01\/17\/abraar-karan-doing-things-for-no-reason-in-the-hospital\/\" \/>\n<meta property=\"og:site_name\" content=\"The BMJ\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/bmjdotcom\/\" \/>\n<meta property=\"article:published_time\" content=\"2019-01-17T14:24:48+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2019-01-28T12:05:55+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/blogs.bmj.com\/bmj\/files\/2019\/01\/willett_diagnostic_tests.jpg\" \/>\n\t<meta property=\"og:image:width\" content=\"540\" \/>\n\t<meta property=\"og:image:height\" content=\"350\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/jpeg\" \/>\n<meta name=\"author\" content=\"BMJ\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:creator\" content=\"@bmj_latest\" \/>\n<meta name=\"twitter:site\" content=\"@bmj_latest\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"BMJ\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"5 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2019\\\/01\\\/17\\\/abraar-karan-doing-things-for-no-reason-in-the-hospital\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2019\\\/01\\\/17\\\/abraar-karan-doing-things-for-no-reason-in-the-hospital\\\/\"},\"author\":{\"name\":\"BMJ\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/#\\\/schema\\\/person\\\/ba3da426ed20e8f1d933ca367d8216fe\"},\"headline\":\"Abraar Karan: Doing things for no reason in the hospital\",\"datePublished\":\"2019-01-17T14:24:48+00:00\",\"dateModified\":\"2019-01-28T12:05:55+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2019\\\/01\\\/17\\\/abraar-karan-doing-things-for-no-reason-in-the-hospital\\\/\"},\"wordCount\":922,\"commentCount\":0,\"publisher\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/#organization\"},\"image\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2019\\\/01\\\/17\\\/abraar-karan-doing-things-for-no-reason-in-the-hospital\\\/#primaryimage\"},\"thumbnailUrl\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/files\\\/2019\\\/01\\\/willett_diagnostic_tests.jpg\",\"articleSection\":[\"Abraar Karan\",\"US healthcare\"],\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"CommentAction\",\"name\":\"Comment\",\"target\":[\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2019\\\/01\\\/17\\\/abraar-karan-doing-things-for-no-reason-in-the-hospital\\\/#respond\"]}]},{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2019\\\/01\\\/17\\\/abraar-karan-doing-things-for-no-reason-in-the-hospital\\\/\",\"url\":\"https:\\\/\\\/blogs.bmj.com\\\/bmj\\\/2019\\\/01\\\/17\\\/abraar-karan-doing-things-for-no-reason-in-the-hospital\\\/\",\"name\":\"Abraar Karan: Doing things for no reason in the hospital - 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