Listen:
Check out all episodes on the My Favorite Mistake main page.
My guest for Episode #261 of the My Favorite Mistake podcast is Dr. Andrew Wilner, a board-certified internist, neurologist, and epilepsy specialist. In 1982, he discovered that locum tenens was the perfect solution for achieving work/life balance as a physician and writer. Dr. Wilner has practiced locum tenens in a variety of inpatient, outpatient, academic, and community settings.
He is a prolific medical journalist and author of several books, including Bullets and Brains. Currently, Dr. Wilner is an Associate Professor of Neurology at the University of Tennessee Health Science Center, Memphis, TN, where he cares for patients, teaches, writes, and lives with his wife and baby boy. He's also host of the podcast “The Art of Medicine.” His latest book is The Locum Life: A Physician's Guide to Locum Tenens.
In this episode, we discuss the concept of “locum tenens”, a staffing solution that is steadily taking root in the world of healthcare. Locum tenens, which means “holding a place,” provides medical professionals the flexibility of temporary placements in clinics or hospitals due to extended leaves or transitions between hires. Our guest for this episode, Dr. Andrew Wilner, a seasoned neurologist and epilepsy specialist, has thrived using the locum tenens approach. He gives insightful revelations about the career growth and personal satisfaction that come with adopting this method of staffing.
In addition, Dr. Wilner gives an account of the human errors that can occur in healthcare settings. Using a personal tale about a mistake made during his training years, he emphasizes the necessity for checks and balances to prevent such occurrences. The discussion encourages healthcare professionals and administrations to approach healthcare provision not as invincible entities, but as humans who are prone to making mistakes. It is through such humility and acknowledgment of weaknesses that better healthcare systems can be fostered where errors are minimized and learning is continuous.
Questions and Topics:
- How could that medication error happen? Sleep deprived
- Did the nurse challenge the order?
- More of an expectation to speak up now?
- A team effort to help you and help the patient?
- EHR risk of errors – wrong chart? New risks
- Human factors — 36 or even 24 hour shifts now?
- Tell us about your Podcast: “The Art of Medicine”
- The Locum Life: A Physician's Guide to Locum Tenens
- Your experiences with writing and self publishing?
Scroll down to find:
- Video version of the episode
- How to subscribe
- Quotes
- Full transcript
Find Dr. Wilner on social media:
Video of the Episode:
Quotes:
Click on an image for a larger view
Subscribe, Follow, Support, Rate, and Review!
Please follow, rate, and review via Apple Podcasts, Podchaser, or your favorite app — that helps others find this content, and you'll be sure to get future episodes as they are released weekly. You can also financially support the show through Spotify.
You can now sign up to get new episodes via email, to make sure you don't miss an episode.
This podcast is part of the Lean Communicators network.
Other Ways to Subscribe or Follow — Apps & Email
Automated Transcript (May Contain Mistakes)
Mark Graban:
Hi, everybody. Welcome back to the podcast. Our guest today is Doctor Andrew Wilner, a board certified internist, neurologist and epilepsy specialist. In 1982, he discovered that, as they call it, locum tenens was the perfect solution to achieve work life balance as a physician and a writer. I'm going to ask him in a minute what that means if you don't know.
Mark Graban:
Doctor Wilner has practiced locum tendons in a variety of inpatient, outpatient, academic, and community settings. He's a prolific medical journalist and author of several books, including Bullets and Brains. Currently, Doctor Wilner is an associate professor of neurology at the University of Tennessee Health Science Center in Memphis, where he cares for patients, teaches, writes, and lives with his wife and baby boy. He's also a podcaster and the host of the Art of Medicine.
Mark Graban:
So, Doctor Wilner, thank you for joining us today. How are you, Mark?
Andrew Wilner:
Thanks for that nice introduction. Well, it's a pleasure to be here.
Mark Graban:
I'm excited about the conversation here today. I don't normally throw a lot of latin at the guests. Medicine loves latin phrases. What is locum tenens first.
Andrew Wilner:
So locums refers to a place, and tenens is kind of like the same root as tenacity to hold on. So it means holding a place. And it's really just a fancy way of saying placeholder or most people are more familiar with the term substitute, like a substitute. You know, we all had substitute teachers along the way because our teacher was sick or went out on maternity leave. Well, for physicians, there are times when an organization, either a clinic or a hospital, needs somebody to fill in today and maybe for a day, maybe a week, a month or six months, maybe they've hired somebody already.
Andrew Wilner:
But that person is finishing out another contract and has to move and get a license and get credentialed. And in the medical world, that process can really drag on. So it turns out that there's a role, and frankly, an increasing role since there's a physician shortage for doctors. And also some nurses will do this as well. You've heard of traveling nurses, so to come and fill in for a specified time.
Mark Graban:
And Doctor Wilner's latest book, I should also mention is on that topic. It's called the Locum a physician's guide to locum tenens. There we go. We got the COVID for those on the video, so we'll come back and talk about that later in the episode. But as we always do here, though, I'm not going to let you off the hook on the key question.
Mark Graban:
I know you're ready for it. But the different things that you've done in your profession, what would you say is your favorite mistake?
Andrew Wilner:
Right. Well, I gave that some thought, and I was looking at your book, and I was really impressed that you really had, I think, hundreds of, you know, pretty prominent people confess what they thought their favorite mistake was. So I was chatting about it last night with my wife. You know, it's like, well, you know, obviously there are many mistakes to choose from. And she said, oh, obviously, you should just tell me it was getting married.
Andrew Wilner:
So I don't know if this show is the best sort of format for that discussion, but I have a more professional example, and it's something I haven't forgotten, even though it happened, probably, at least I'd have to calculate it out. But probably about 40 years ago when I was in medical training, and in those days, we worked all day. And every third night or fourth night, you simply kept working all night long and then work the next day. So you would routinely do 36 hours shifts, and the following day, you would work a normal day and then try and finish, you know, by five or 06:00, you know, go home and shower and sleep, you know, and get as much sleep as you can so that the next day was kind of your easy day, and then the next day you were going to stay up again all night. Well, current medical trainees and young physicians still work pretty rigorous hours, but that particular scenario has been eliminated.
Andrew Wilner:
So now there's a new doctor that comes in for the night time. But what happened was I worked in a very busy hospital, and we weren't just sitting waiting for things to happen. When you were up all night, you were moving and seeing patients and writing orders and doing all those things. It was very rare, actually, that where I worked, you would sleep, and then you just start rounding the next day. And one day somebody came up to me in the morning after a long night and said, doctor Wilner, you wrote this order for Misses Jones to get insulin.
Andrew Wilner:
And, well, it turned out I was working on a diabetes ward where everybody got insulin, unless there was a wrinkle to that. But basically, you could be there for a heart attack. If you had diabetes, could be there because you had wound infection, but you had diabetes. And when you're sick and you have diabetes, sugars are harder to control. You know, if anyone listening has diabetes, they know they got to look after their sugar.
Andrew Wilner:
But when you get sick, even if you get the flu, it throws things out of whack. So if you're critically ill, in the hospital, this becomes a big job. And consequently we had a diabetes ward. It all made sense, with one exception is we had a young woman who was there because of a suicide attempt and she had injected herself with handy an overdose of her insulin. And so her glucose has gone very, very low.
Andrew Wilner:
And of course our job was to get her sugar higher, whereas the usual job is to get it lower. And we were doing that by giving her intravenous glucose. And what we would do, our routine was at eleven at night, we check blood sugars on everybody. And then depending on what their sugar was and what the goal was, you would write insulin orders. And I did that.
Andrew Wilner:
They showed me my order. They said, well, you wrote for insulin on Misses Jones, but she's here for an insulin overdose. I said, well, I didn't do that. I'm smart enough to know that I shouldn't do that. That wasn't our goal.
Andrew Wilner:
I said I didn't do that. And I was 100% convinced that I didn't do it. And these were in the days of paper charts.
Mark Graban:
Yeah.
Andrew Wilner:
And we wrote, literally wrote your orders and signed them. And there was a time and they showed me the chart and sure enough, it was, it was my signature. And my signature is fairly unique. It would take some practice to, you know, to, to fake it, for somebody to sign my name that way. So the truth of the matter was that not only had I made an error, which was pretty egregious, but I didn't remember doing it.
Mark Graban:
Yeah.
Andrew Wilner:
So there are like two mistakes. And when I thought about it, well, how could this happen? And it turned out when I thought about it, there were a lot of reasons that it happened. You know, the obvious one is that I was sleep deprived.
Mark Graban:
Right.
Andrew Wilner:
And that's why I didn't remember what happened. If you've ever, you know, stayed up all night because you were traveling or partying, you know, things get a little blurry and that's not really the best way to practice medicine. So I thought about it and there was like a whole bunch of things, some of which I thought, you know, didn't have to happen. You know, sometimes you make a mistake because that's just the way it is and you have no choice. But things didn't have to kind of set me up.
Andrew Wilner:
So should we talk about that?
Mark Graban:
Yeah, it would be great to talk about that, but I just wanted to dig in a little bit more into the nurse speaking up to say, hey, Doctor Wilner, did you realize it sounds like a situation where instead of just, if you will, blindly following the medical order. She said, wait a minute, this doesn't seem right. I should say something, right?
Andrew Wilner:
Oh, I should clarify. No, no. The patient got the order. This was only hours later when somebody figured out that this was probably not the right thing. Because I think the lady's glucose had tanked again.
Mark Graban:
Yeah.
Andrew Wilner:
Because of me. And. No. So the mistake was made. There was.
Andrew Wilner:
I think that's a good point. There was no check and balance in the system. You know, he just wrote the orders and off they went.
Mark Graban:
Yeah. So maybe let's explore that a little bit, too. And thank you for sharing the story there. Well, maybe it's just to close the loop on the story. We can come back to some of these elements about human factors and speaking up when an order seems to not make sense.
Mark Graban:
But I feel like maybe I should let you finish the story in terms of kind of your reaction to kind of fully coming to that realization that you had written the order. You know, even if you didn't remember it, it was undeniably yours. How did that feel? What did that lead to both short term and long term, for you as a professional?
Andrew Wilner:
Right. So, long term, it was very impactful because as a young, studious physician and very compulsive, it was my contention that I did not make mistakes, and I certainly wouldn't make a mistake of that amplitude. Everybody makes little mistakes, but I would never make a mistake like that. And I did. So my first response was, I didn't do that because I would never do that.
Andrew Wilner:
That's incompatible with my self concept. And when I realized that it was true, I had to reevaluate. I mean, this sounds maybe arrogant, but I had to reevaluate my self concept that indeed I was fallible. And that one of my. The kryptonite for me was staying up all night.
Andrew Wilner:
That that really messed me up. And I needed to know that because I was going to need to stay up all night for many, many times during my future career. So I needed to know that when I am in that situation, I need to be doubly careful. So that was lesson one, is that I am susceptible to making a grave error, that staying up all night is a risk factor, and I need to take care of that risk factor as best I can. And I still do that.
Andrew Wilner:
I still make sure that if I'm going to have a big day and I've got hospital patients in the morning and clinic patients in the afternoon, and I'm writing a paper that I have adequate sleep so that I'm working on, you know, all four or eight cylinders, you know, so that everything goes the way I want it to. So it was very humbling and pragmatic. Right. I mean, it led to a intentional change in the way I did things.
Mark Graban:
Yeah. And, I mean, being careful, I always describe, like, being cognizant of risk of a mistake is helpful but not fully sufficient because of, you know, human factors. And nobody's super human in terms of being able to be fully fresh after a bad night's sleep or after no sleep. But let's talk a little bit more about the human factors there. I've heard, and I could be wrong on some of this.
Mark Graban:
Are there still 24 hours shifts in residency, even if it's not 36? Or has that really been kind of curtailed or eliminated?
Andrew Wilner:
You know, I'd have to go look at the fine print. But there was, you know, I'm not the only physician who's made a mistake due to sleep deprivation. And finally, there was the Libby Zion case in New York, I'm sure you're familiar, where somebody died because an over sort of committed resident who hadn't slept enough made a very serious error. And so now I think it's an 80 hours a week, and there are rules that it can't be too many, you know, hours sequentially, you know, and that does limit, you know, at 05:00 my residents go home, and the night float comes, and if there's a, you know, we're in the middle of something, the resident leaves, and, you know, that kind of goes against a lot of years of that's your patient. You know, you stay with that patient.
Andrew Wilner:
But it is kind of a concession that people, you know, have limits, including physicians. In the old days, physicians didn't have limits. So, you know, but now we work in these big corporate structures. But I wanted to get at something else that you hinted at, and that is the system. Why wasn't there someone who looked at my order and said, hey, that doesn't make sense?
Andrew Wilner:
In other words, why wasn't there a pharmacist who was informed? Or the nurse, maybe, you know, the nurse could have picked it up, but it might have been a new nurse, or maybe she was, you know, it's the middle of the night. She's just trying to get all her work done. Doctor Wilner knows what he's doing, and she gave the order. But, yeah, there needed to be a formal structure to sort of weed out.
Andrew Wilner:
You know, I made a similar order, one around that time where I had. Someone told me to order goots which I'd never ordered Gou, you know, instead of milliliters. And I thought it was the same thing, and it turned out it wasn't the same thing at all. And the pharmacist never picked it up. So the patient got, like, ten times what they were supposed to get because of my ignorance, doing something that somebody told me to do.
Andrew Wilner:
I was sort of in the chain, and then again, nobody sort of double checking. So that's something where the system, and of course, there are the computers now, will get flagged things, incompatibilities, and so on, but unfortunately, those tend to be more useless than useful. Yeah, it's an attempt. It's an attempt to fix this problem, but it's created a whole lot of other problems. It's not a good fix.
Andrew Wilner:
We can leave it at that. And so fixing it as, number one, limit the hours. Number two, there should be a double check. And number three is how our unit was set up. That woman never should have been in our unit because she didn't need insulin in the first place.
Andrew Wilner:
She should have been in a psych unit, but instead, because of her diagnosis of diabetes, she got thrown in with everybody else. So, again, it was an attempt to simplify and be efficient by putting everybody with diabetes in the same place. But it was too crude. And it's what I'm talking about is situations setting you up for an error. And I'm interested in general aviation, and, you know, when you always read about a, you know, one of these little piper cubs goes down or something, it was usually not a simple mistake.
Andrew Wilner:
Right? This guy, you know, it's bad weather, and he was in a hurry, and he thought somebody else had checked the plane, but that person didn't do it for some reason. And, you know, there's this whole series of things that lead to the crash. It's not just, oh, I turned the wrong dial, and I was. And I made a mistake.
Andrew Wilner:
It's not. It's not like that.
Mark Graban:
Well, that's what James reason and others refer to as the swiss cheese model, that different factors have to line up or conspire against you for something to happen. When you think of all the things that might not have happened, the things that might have been caught. So, to be clear, I'm not faulting you for being fatigued in that system. There were a lot of human factors and systemic causes where I would think, you probably know the phrase just culture. I would say it wouldn't have been fair.
Mark Graban:
And just to punish you or end your career over having made a mistake.
Andrew Wilner:
Well, luckily, the lady did fine, ultimately. But it was very sobering for me to realize that I could make such a dumb error and that, and then analyze the factors that kind of led to it and, you know, try and avoid them, and we're all human. And that's the other thing I heard just the other day, I think it was a tv show where they said, there's apparently, there's a japanese saying, fall seven times, get up eight.
Mark Graban:
Right.
Andrew Wilner:
So the first time that went by me, I said, well, you know, that really shows that, you know, you need to persevere, you need to restart. But, you know, the other thing that's hidden in there, it's like, why did you fall seven times in the first place? So I think that's an acknowledgement of human behavior, is that, well, if you're moving forward, you are going to fall, you know, over and over again as you get through the world, and you just need to keep getting up. But avoiding the fall is my point. Might should somehow enter into there, too.
Mark Graban:
Well, I mean, I'll give you credit. And, you know, like you said, the patient recovered. The patient was okay. That's great. It was still a great learning opportunity.
Mark Graban:
Right. So you don't have to fall seven times. You fall once and learn from it instead of waiting until the third or the fourth or the fifth. Similar fall now is, let's say, an incorrect order or an incorrect dose that does, let's say, kill somebody. We can learn.
Mark Graban:
You know, that's why I think whether it's sports decisions or other business decision making, we can't just judge the outcome. Sometimes a bad decision that leads to an okay outcome is still a learning opportunity.
Andrew Wilner:
Oh, yeah. Sometimes you get lucky and, you know, there's a very famous case here in Tennessee where a nurse administered the wrong medication because it started with the same letter, and they use a special dispensing machine, and it didn't want to dispense that medicine. It knew better. But she did an override to the machine because apparently the machine doesn't dispense what you need on a regular basis. So the fact that it wasn't dispensing wasn't that unusual.
Andrew Wilner:
And she gave the patient what she thought was a sedative, and it turned out to be a paralytic. And the patient did die. And that's been. She was prosecuted, actually, as a criminal, which is why it's made national news.
Mark Graban:
She was convicted.
Andrew Wilner:
Yes, as a criminal, when it was really kind of a. It was a dumb mistake that had major implications, you know, ramifications in the death of the patient. But it was actually a very simple error of just substituting one drug, you know, for another drug.
Mark Graban:
But when you look at these complicating factors, whether it's the medication cabinet giving all these alerts, the EHR electronic health record system giving all of these alerts, like alarm fatigue, is a very real human factor and dynamic, and that seems to at least have been a contributor. That nurse was redonda Vaught, and I think that still.
Andrew Wilner:
I don't know. I don't remember all the details, but I think it's still ongoing. And, of course, the nurses, if you're a physician and you're going to get criminally prosecuted for making a human error, well, first of all, that's pretty daunting. And second of all, you're pretty unlikely to admit you made him an error so that, you know, the whole culture of error avoidance, and I'm sure you'll agree with me, requires admitting the error in the first place so you can figure out, you know, how not to do it again. If people are hiding their mistakes because of fear of prosecution, well, that's gonna.
Andrew Wilner:
That's totally counterproductive.
Mark Graban:
Right.
Andrew Wilner:
I agree.
Mark Graban:
But let's talk a little bit more about maybe some changes that you've seen, because, you know, your favorite mistake story, you said, was roughly 40 years ago. Is there more of a team effort or an expectation that it's okay to question a physician or a surgeon or to raise a concern as a double check? Do you encourage others to speak up if they might have been conditioned not to do so with other physicians?
Andrew Wilner:
Well, first of all, I'd say that that culture has certainly changed. It used to be, and I trained in Europe and for two years, and there you would just never question, you know, the doctor in charge. Whatever he said, it didn't matter if he said, you know, the sky is, you know, polka dot. It was like, yes, sir. I mean, you just went with whatever the chief of service said.
Andrew Wilner:
And in the US, it might have been that way 75 years ago, but it's certainly not that way now. People are not shy to question to the point where many physicians are irritated that they're always being second guessed when they shouldn't be. But I would say that nobody is shy to question the doctor these days.
Mark Graban:
And you're saying they get annoyed because they think they shouldn't be second guessed, as opposed to they shouldn't be annoyed.
Andrew Wilner:
Yeah, they shouldn't be second guessed because they're right. 99% of the time, and it wastes a lot of time and it's insulting. So, you know, and then you have to go into this long explanation why you were right. And, you know, I mean, you gotta so all to pick up that one mistake that you might make someday. So I would say that personally, I would say that the, what do they call it, the seesaw here is sort of off on the wrong side these days, where physicians are over questions and second guessed way too often.
Andrew Wilner:
And so there's no fear of questioning physicians, I would say, or very, very minimal these days. So it kind of slows things down. And the other thing that's happened is teams have grown. It used to be the doctor and the nurse, and now there's more doctors and more nurses and physicians assistants and pharmacists and pharmacists assistants. And so think you're, you're not working in a vacuum.
Andrew Wilner:
So that people, a lot more people involved. And then, of course, electronic medical record can be accessed by, you know, the whole team. So a lot of people are kind of looking over each other's shoulders, which I think is generally helpful, you know, the more people that kind of know what's going on. And of course, I always tell the residents, call the other doctor, you know, don't just assume he's going to read what you said. You know, there's still a big place for one on one talking, you know, for communication because some, a lot of errors are communication gaps.
Mark Graban:
Right.
Andrew Wilner:
You order something, you thought it was done, two days later you find out, oh, I didn't see that, or, I don't know, someone canceled that order, or, you know, it just never got done and you don't know. So communication is, that's a big challenge. And there's a lot of work there, you know, because of HIPAA. Right. You can't share details.
Andrew Wilner:
That's even been interpreted where a doctor can't share the details with another doctor. Really obviously counterproductive. Well, that's wrong. But there have been where people have thought that, oh, I can't send your records over there, you know, because, you know, we got to protect your privacy. It's like, well, I'd rather get better care than worry about, personally, my privacy.
Mark Graban:
I agree. And I've seen in the healthcare consulting work I've done there, there are often misperceptions of what people think HIPAA says and what the regulations actually say. But yeah, there's a big difference between sharing information with another physician or another caregiver versus leaking it to the media. That's a huge difference.
Andrew Wilner:
That is a big difference. And one should not leak in personal information to the media, but one should share so that the patient gets the best of care. Care with all of the caregivers.
Mark Graban:
Yeah. Then you mentioned electronic health records. When I first started working as a consultant to healthcare in 2005, paper charts were still the norm, and there were different ways where a slip of paper could get lost. Handwriting. It's the old joke that's maybe there for a reason about physicians and their handwriting, but that was a real human factor.
Mark Graban:
And it seems like electronic health records and computer systems might help prevent some other. Some errors, but it introduces other errors where somebody accidentally scrolls on the mouse wheel and it changes something in a dropdown or somebody's logged into the wrong patient chart. I mean, there are still.
Andrew Wilner:
That happens a lot because of the layering of windows. I can't tell you how often a resident's been. I said, okay, let's look at their, you know, their brain scan. And they pull up the scan. You know, it doesn't really look right, and it turns out it's the last patient that we were talking about, not the new one.
Andrew Wilner:
And there's no sort of double check on the EMR to prevent it from doing that. You know, it doesn't. It'll just give you whatever, you know, whatever button you press. That's what it does. So there's a lot of room.
Andrew Wilner:
You know, I think it's a good opportunity. I want to tell you about a system fix that I'm personally familiar with. That was like a stroke of genius and didn't cost anything.
Mark Graban:
What's that?
Andrew Wilner:
So, when I was in practice, I remember that my colleague across the hall had been treating a patient that severe headache, and he's had a CAT scan, and the CAT scan was red as negative, and everything was fine. Until one day, he was shuffling through the big paper chart, and he saw that, in fact, there was an addendum to the CAT scan report because it was over read by somebody else on page two. But that page two had gotten separated from page one, which said it was normal. And the addendum said that there was a brain tumor. And about two months had passed from the time the doctor had spoken to the patient and told them that their scan was negative until the time he was probably looking, you know, for some other thing and stumbled on this buried report.
Andrew Wilner:
That was the addendum that showed he had a brain tumor, which obviously changes things significantly. So it turns out that this was a common problem, because the addendum is at the bottom.
Mark Graban:
Yeah.
Andrew Wilner:
Well, somebody at the Mayo clinic figured out, why don't we put the addendum on the top. Good, because that's really the most recent latest version. You know, if it's a book, the ending should be at the end. But, you know, when you're a physician, usually you want to know what's. What's the latest news, and then I'll work my way back.
Andrew Wilner:
So instead of putting addendums at the bottom of the report, they instructed all of the people that make these reports to put the addendum on the top.
Mark Graban:
Well, I mean, that's like journalism, where they say, don't bury the lead, bury the lead. Traditional newspaper reporting, or is the most important thing, is in the first paragraph, and then you kind of build supporting information. And that way, if an article has to be cut for space, you're not losing the most important.
Andrew Wilner:
But I bet that's not universal. I mean, somebody had to think about it and do it. And I know they do that at Mayo because I used to work there, but I don't think everyone does that. But it's an example of a systemic change. We say, oh, we can't do that, it's going to cost too much.
Andrew Wilner:
Blah, blah, blah. Doesn't cost anything. It's the same typing. You just put it here instead of there, and it could change people's lives. So I thought that was a great example of that.
Andrew Wilner:
There is room for cost neutral improvement just by doing things differently.
Mark Graban:
Yeah, and I would much rather see a systemic fix than a bunch of reminders to be careful. Don't miss that last page. You get this annoying email or memo once a month, like, hey, remember, people tune that out, too. That doesn't help. So let's.
Mark Graban:
Dr. Wilner, our guest again today, is Dr. Andrew Wilner. Let's talk about your podcast. Before we talk a little bit about the book, the art of medicine. I've heard people describe medicine as both an art and a science. Right.
Mark Graban:
Tell us about that. And about the podcast.
Andrew Wilner:
Right. So, you know, I think for centuries people have realized that when you're a physician dealing with a patient, everyone is different, right? They have different spiritual beliefs, different religious beliefs, different physiology, different bodies, different levels of education, different social standing. And when you're communicating about a health issue, which all of us, I would say, pretty much rises to the top of our priorities. When you're in the, it's like sitting with your accountant, you know, when you're with the doctor, something, something important is going to happen here.
Andrew Wilner:
You need to be able to communicate with that particular patient. And that has a lot to do with the art of medicine, which is not to underestimate the importance, of course, of the science of medicine. You know, we have medications, we have vaccines, we have surgeries, we have new technologies. That's critical. But I think the interesting thing is if you go back 200 years or even 100 years back to 5000 years, didn't really have much, and yet physicians were still very, very important in society because of the art of medicine, the laying on of hands.
Andrew Wilner:
They could make people feel better by understanding what was happening and saying the right thing. And I think the art of medicine in medical school, you know, is kind of neglected because the burden of science. And many, in fact, I just introduced for, interviewed for my podcast a retired physician named Doctor Alan Sussman, who's an endocrinologist who just wrote a book called saving the Art of Medicine. And so he sought me out because he felt he ought to be on the podcast. And he was right.
Andrew Wilner:
And what we talked about was that when I was a medical student, there was this much biochemistry to learn, and now there's this much biochemistry to learn. And genomics was Mendel and the beans. And now you can do PhD after PhD and trying to understand what we know about gene therapy. And so the science of medicine has really exploded. And so if you're a medical student, what you need to learn has the four years of school are stayed the same.
Andrew Wilner:
There's a lot more science. And of course, what gets lost is the art of medicine. What is my response to the patient? Do I like this guy? Does he irritate me?
Andrew Wilner:
Am I feeling bad for him? Is he wasting my time? You know, I'm a human being, so I have these responses. But these responses can be very helpful for me, figuring out what's wrong with that particular patient, by the way, you know, I respond, and, you know, that's really, most of that's not really taught, you know, and then how does the, you know, you see bad things every, you know, a lot of. Sometimes resident will introduce the patient, you know, this unlucky 49 year old, this unfortunate, you know, 52 year old.
Andrew Wilner:
It's like, well, you know, it's a little redundant, right? They're already here. How fortunate could they be? You know, they might be particularly unfortunate, you know, got hit by a car and then run over by a truck. You know, I mean, things can, can keep getting worse, but, you know, our job is to help in any way that we can, given whatever we're presented but that takes a toll.
Andrew Wilner:
You know, there's a lot of bad stories. How do you deal with that? So I'm interested on my podcast on featuring physicians and other people involved with healthcare who are trying to find ways to understand things better to defeat burnout, for example, trying to be better at what they do, often by writing books. You know, like, you've written a book. You know, when you write a book, it's like this whole thing, right, where you got, you focus on a topic and you invest a lot of time and you neglect, you know, a lot of other priorities in your life.
Andrew Wilner:
Your wife will tell you, right, that, you know, how come you're doing that instead of doing this? But it's a big investment. And so I like to interview physicians who've written fiction books, and I have several on the podcast or nonfiction books and people who have written about leadership and then financial issues. Everybody has to deal with those. We don't learn those in medical school.
Andrew Wilner:
And you just kind of have to pick it up sort of the hard way. But that's not really the way it ought to be. But I like to feature people who have done sort of thoughtful things above and beyond what they had to do every day, and I think it shed a little light. You know, I've had artists and poets about the art of medicine, so it's fun, and I always enjoy the interviews.
Mark Graban:
Yeah, I hope people will check that out. The Art of Medicine and the most recent book seem clearly targeted toward physicians who are maybe considering going the locum tendons route or those who are doing it and trying to navigate all of that. The book is the locum a physician's guide to locum Tenens. What's your pitch for, let's say, a physician listening to this about your book?
Andrew Wilner:
There's this whole industry now of people trying to help physicians who are suffering burnout. There's a lot of problems in medicine, systemic problems, that are making physicians and other healthcare providers, particularly nurses, very unhappy in work that they selected because they were giving helpful people, and they feel betrayed by the system because they're miserable. So one of the sort of industries for that is finding non clinical careers for physicians. Oh, you can work in the farm industry. You could work at NIH, you could work at CDC.
Andrew Wilner:
You can go work at an insurance company. And those are all sort of legitimate, fine careers. But for physicians who enjoy, at least in theory, clinical medicine, I think it's a tragedy because clinical medicine requires a lot of training, a lot of dedication. It's very hard to do well and for a doctor to bail, you know, and check insurance forms. Oh, yeah, you really should have this CT.
Andrew Wilner:
No, you really don't need it. I mean, to me, that's an abomination. And so what locum tenens offers is kind of, is flexibility to work as much or as little as you want without the overhead of, you know, staffing and hospital administration. And a lot of the things that I do when I'm not seeing patients, you don't have to do, all you have to do in a locums assignment is show up, see your patient, write your note, and go home. And you can do that one week a year.
Andrew Wilner:
You can do it 52 weeks a year. You can do it as much or as little as you want. And I've talked to many locum doctors who have, who have talked with me, and they say, you know, doctor Miller, I was kind of burned out, saying I started doing locums and I cut back and I just do it, you know, when I want to. And I love it. I love medicine so much more now that, you know, it's not overwhelming.
Andrew Wilner:
It makes sense, right? I mean, anything you do to excess, you know, you know, one cup of coffee is great, but ten, you know, you get upset stomach. So, you know, I mean, it's really not rocket science. And because physicians are so dissatisfied and because there's a physician shortage and because the system is so kind of disjointed from what it's trying to accomplish, which is take care of patients, there's an increasing shortage of physicians, which means there's an increasing opportunity for locomotive physicians. There's approximately 50,000 physicians that work locum tenens in the United States.
Andrew Wilner:
And it's growing because it's not ideal, right. You don't have continuity of care the way, you know, Marcus Welby did. And, you know, but on the other hand, if you can come home from a day's work and say, oh, that was so much fun, and I helped so many people and I earned the amount of money I should have earned for my effort. And I'm a happy person and I want to go back, I think it's a great solution. So my pitch is that any physician who is burned out and thinking of leaving medicine, and as I say, unfortunately, there are many, that they should look at locum tenens first and cut back.
Andrew Wilner:
Try locums a little bit, and you can do locums and something else also. It can be a bridge to another career. It can be a bridge to retirement. There's a lot of ways it can be used, but a lot of doctors never even heard of it. So I think the, and the book tells a lot of stories and gives a lot of very pragmatic advice about credentialing and licensing.
Andrew Wilner:
And every now and then, somebody reaches out to me, you know, through my website and says, hey, doctor Miller, I was thinking of doing this. What do you think? And it's nice to be able to be helpful and save someone from a life of becoming a bureaucrat instead of a clinician.
Mark Graban:
Yeah. And, you know, to each their own. And, I mean, it sounds like for one, that's a great outcome if it helps spark Respark somebody's love of medicine, if it keeps them from leaving the profession altogether. And I know people who've done this and, you know, they can do locum tendons, work in some fairly exotic locations or go, go to underserved communities, you know, somebody who loves being out in the middle of nowhere or somebody who loves being in a beach community or whatever point in between. So seems like there's a lot of interesting options out there.
Andrew Wilner:
Yes. And I'll say that through my website, Andrew Woolner.com. if people have questions about locums, I answer them for free because I'm always interested in helping physicians who want to stay in practice patients. There's a lot of patients out there that need care and can't get it, and locums can provide that. So if I can provide some guidance in 15 minutes, I'm more than happy to do that.
Andrew Wilner:
And I do do that on a fairly regular basis.
Mark Graban:
Well, great. So again, our guest today has been doctor Andrew Wilner. I'll make sure the show notes have links to his website, his podcast, the Art of Medicine, the books. Hope people will all come check that out. So thank you for telling your story.
Mark Graban:
I appreciate your willingness to share that story, to have kind of a broader conversation about those systemic factors and in some cases, systemic fixes. So I really appreciate you being here with us today.
Andrew Wilner:
Well, I think the statute of limitations had run out, so I felt safe in telling the story. But it was a pleasure being here. Thanks very much, Mark.
Mark Graban:
Yeah, thanks.
Episode Summary and More
Embracing Locum Tenens: The Pathway to Work-Life Balance for Physicians
The Rising Demand for Locum Tenens in Healthcare
The concept of locum tenens, which translates to “holding a place,” has become a fundamental solution for many healthcare providers facing the challenges of physician shortages and the need for flexible staffing solutions. Locum tenens positions offer a means for medical professionals to step in on a temporary basis, filling in gaps created by various factors such as extended leaves, transitions between permanent hires, or spikes in patient volumes. This practice has not only provided healthcare facilities with the agility to maintain a high level of patient care but has also opened up a world of opportunities for medical professionals seeking work-life balance, diverse experiences, and career flexibility.
In recent years, the demand for locum tenens positions has seen a significant increase, driven by both the evolving landscape of healthcare needs and the growing desire among physicians for more flexible career options. The ability to work in different settings—from outpatient clinics to academic centers and community hospitals—offers invaluable experiences that contribute to a physician’s professional growth and personal satisfaction. Moreover, locum tenens roles can be found across a variety of specialties, including internal medicine, neurology, and even more niche fields like epilepsy care, demonstrating the wide-ranging opportunities available for physicians.
The Art of Medicine and Personal Growth Through Locum Tenens
One notable advocate for the locum tenens lifestyle is Dr. Andrew Wilner, a seasoned neurologist and epilepsy specialist, who has embraced this career path to achieve a commendable balance between his professional and personal life. Dr. Wilner discovered early in his career the benefits that locum tenens roles could offer, allowing him to pursue his passions both in medicine and in writing. His journey through various locum tenens positions has not only enabled him to care for patients across different settings but also to hone his skills as a medical journalist and author, thus fulfilling his diverse interests.
Dr. Wilner's experiences underscore the profound impact that locum tenens work can have on a physician's career trajectory and personal development. By adopting this flexible approach to medical practice, physicians like Dr. Wilner can explore different facets of medicine and healthcare, engage in continuous learning, and importantly, maintain control over their work schedules to ensure time for other pursuits and family life. This balance is pivotal in promoting not just professional but also personal well-being among medical practitioners.
The Human Factors: Learning from Mistakes
Another critical aspect that Dr. Wilner sheds light on, reflecting on his extensive career, is the importance of acknowledging and learning from mistakes—a natural part of the medical profession's growth and development. The story of a sleep-deprived error made during his training years is a powerful reminder of the human factors that can influence medical practice. It emphasizes the need for a healthcare system that acknowledges human limits and implements checks and balances to prevent avoidable errors. Dr. Wilner’s takeaway from his experience—is to approach medical practice with humility and a recognition of one’s vulnerability to error, especially under challenging conditions like sleep deprivation. This lesson is invaluable not only for individual practitioners but also for the healthcare system at large, as it navigates the complexities of providing care in a high-stakes environment.
Moreover, Dr. Wilner’s story brings to the forefront the crucial role of systemic support in ensuring patient safety and physician well-being. The shift towards structured work hours, exemplified by the changes in residency shift lengths, reflects a growing acknowledgment within the medical community of the need to balance the demands of medical training and practice with considerations for health and rest.
Locum Tenens: A Path Forward
The journey of Dr. Wilner and his advocacy for locum tenens work highlight a transformative path in medicine. Locum tenens roles not only offer a solution to the pressing need for flexible and competent staffing in healthcare but also provide physicians with an avenue to explore varied interests, achieve work-life balance, and continuously grow as professionals and individuals. The reflections on human factors and the lessons learned from mistakes further enrich this narrative, offering deep insights into the ongoing evolution of medical practice.
As the healthcare landscape continues to change, the role of locum tenens positions and the stories of physicians like Dr. Wilner will undoubtedly inspire current and future generations of medical professionals to explore diverse career paths. These opportunities not only promise personal fulfillment and professional development but also ensure that healthcare systems remain vibrant, adaptive, and responsive to the needs of their communities.
Enhancing Physician-Patient Safety with System Improvements
The narrative shared by Dr. Wilner brings to the forefront critical gaps in the healthcare system that can set the stage for potentially fatal errors. These anecdotes serve as a stark reminder of the repercussions when system checks and balances fail. This story underscores the need for holistic system improvements that reinforce patient safety and protect healthcare professionals from the risk of making grave errors.
Strengthening System Checks and Balances
The healthcare system's efficacy in preventing errors hinges on multiple layers of checks and balances. Implementing robust mechanisms for verification and validation at every step of the medication prescription and administration process is pivotal. This involves leveraging technology to strengthen these processes without overwhelming healthcare professionals with numerous but ineffective alerts.
- Streamlining Alert Systems: Electronic Health Record (EHR) systems must evolve to provide meaningful, actionable alerts that genuinely assist rather than hinder medical practice. Reducing “alert fatigue” can help ensure that critical warnings are heeded rather than dismissed as part of a routine barrage of notifications.
- Encouraging a Culture of Double-Checking: Instituting a policy where it is not just encouraged but expected to question and verify orders can create a safer healthcare environment. This includes empowering nurses and pharmacists to seek clarifications without fear of reprisal or undermining their professional judgment.
- Interprofessional Collaboration: Fostering a culture of teamwork and mutual respect among physicians, nurses, pharmacists, and other healthcare professionals is essential. Every member of the healthcare team should feel empowered to voice concerns and contribute to a patient’s care plan, recognizing that diverse perspectives can enhance patient safety.
Learning from Errors: Moving Towards a Just Culture
Dr. Wilner’s reflections resonate with the principles of a Just Culture, where the focus is not on penalizing individuals for mistakes but on learning from these incidents to prevent future occurrences. This culture shift is critical in encouraging healthcare professionals to report errors and near misses.
- From Blame to Understanding: Transitioning from a blame-based approach to one that seeks to understand the root causes of errors can significantly enhance system safety. Recognizing that errors are often the result of systemic issues rather than individual negligence is a step forward in this direction.
- Error Reporting Mechanisms: Establishing secure and confidential reporting channels for healthcare professionals to report errors without fear of undue punishment is essential. Learning from these reports can lead to critical system modifications that prevent recurrence.
- Education and Continuous Improvement: Regular training sessions that include case studies of past errors and their system-based resolutions can help embed a culture of safety. These sessions can also serve as reminders of the importance of vigilance and the role of each team member in ensuring patient safety.
Incorporating Technological Solutions Responsibly
While technology, such as EHR systems, plays a vital role in modern healthcare, it is crucial to address its limitations and the new challenges it introduces. Ensuring that technology serves as a helpful tool rather than an additional source of error involves continuous evaluation and customization to fit the workflows of healthcare settings.
- Customization of EHR Systems: Tailoring EHR systems to better fit the specific needs and workflows of different healthcare settings can minimize errors related to system design. Involving frontline healthcare professionals in the design and customization process can ensure that these systems are more intuitive and user-friendly.
- Training on Technological Tools: Adequate training on the proper use of EHR systems and other technological tools is crucial. This training should not only cover basic functionalities but also include best practices on avoiding common pitfalls such as accidental entries or overlooking critical alerts.
As the healthcare landscape continues to evolve, the insights shared by Dr. Wilner and others who have navigated these challenges illuminate the path toward a safer, more efficient system. By addressing the systemic issues that contribute to errors and fostering a culture that prioritizes learning and improvement, the healthcare community can better safeguard the well-being of both patients and professionals.
Emphasizing the Importance of Effective Communication
One of the profound insights shared by Dr. Andrew Wilner emphasizes the art of medicine, which is deeply intertwined with effective communication. In a realm as complex and diverse as healthcare, where every patient presents a unique matrix of cultural, physiological, and psychological dimensions, the quality of communication can significantly influence outcomes. This aspect extends beyond mere dialogue, encompassing the entire sphere of patient interaction, from the nuances of understanding patient histories to the clarity of explaining diagnoses and treatment plans. Developing these communication skills is pivotal, not only for enhancing patient care but also for mitigating the potential for misunderstandings that could lead to errors.
- Tailored Patient Communication: Customizing communication strategies to align with each patient’s needs and comprehension levels is vital. This approach not only fosters a stronger patient-physician relationship but also ensures that patients are more engaged and informed about their health and healthcare decisions.
- Interdisciplinary Communication: Enhancing communication across various healthcare disciplines is equally critical. As specialists, general practitioners, nurses, and pharmacists collaborate on patient care, seamless and transparent communication can markedly improve the coordination and effectiveness of care delivery.
Strategic Implementation of Systemic Fixes
Dr. Wilner’s recount of a simple yet impactful systemic fix, such as placing addendums at the top of reports, sheds light on the broader subject of how minor changes can have profound effects on healthcare quality and patient safety. This example is a testament to the potential that lies in rethinking and re-engineering processes for better efficacy and safety. It encourages a mindset of continuous improvement where all members of the healthcare system are vigilant and proactive in identifying and implementing such beneficial tweaks.
- Process Re-engineering for Enhanced Safety: Encouraging healthcare settings to regularly review and reassess existing processes for potential improvements is key. This not only involves administrative and clinical procedures but also extends to how information is documented, transmitted, and accessed within electronic systems.
- Cost-Effective Innovations: The fact that significant improvements do not always require substantial financial investments cannot be overstated. As illustrated by the addendum rearrangement, solutions that are virtually cost-neutral can still yield significant benefits in terms of patient outcomes and the prevention of oversights.
Nurturing the Art and Science of Medicine through Continuous Learning
Reflecting on the discussion about the evolution of medicine, it’s evident that while the scientific aspect has grown exponentially, the art of practicing medicine—understanding and connecting with patients on a human level—remains fundamental. This balance between science and art is crucial for the development of well-rounded healthcare professionals who are not only technically proficient but also empathetic and compassionate caregivers.
- Integrating the Art of Medicine in Education: Medical education programs should strive to maintain a balance between teaching the ever-expanding body of scientific knowledge and nurturing the softer skills related to the art of medicine. This includes incorporating more humanities and ethics into the curriculum, as well as training in communication and empathy.
- Professional Development and Well-being: Addressing physician burnout and promoting career satisfaction through opportunities like locum tenens positions can have a significant impact on the healthcare system. These roles not only provide flexibility and a change of pace but also rekindle the passion for clinical medicine by reducing the administrative burdens that often contribute to burnout.
Incorporating technological advances responsibly, promoting a culture that values continuous improvement, and recognizing the intrinsic value of both the art and science of medicine are essential steps toward a healthcare system that delivers the highest standards of care. Through such endeavors, healthcare professionals can ensure a safer, more effective, and compassionate environment for both themselves and the patients they serve.
Expanding the Horizons through Locum Tenens
The concept of locum tenens, a practice where doctors fill temporary positions in hospitals or practices, often in rural or underserved areas, is gaining traction as a viable solution to healthcare disparities. Beyond offering care where it's most needed, locum tenens roles provide physicians with unique opportunities to rediscover their passion for medicine, explore new locations, and experience diverse clinical settings without the long-term commitment of a permanent position. This adaptability in the medical field not only helps to alleviate physician burnout but also plays a crucial role in addressing the uneven distribution of healthcare services.
- Diverse Clinical Experiences: Locum tenens positions allow healthcare professionals to experience different healthcare systems and patient populations. This diversity can enrich a physician's practice by exposing them to a wide range of clinical cases and operational methodologies.
- Flexibility and Work-Life Balance: One of the most appealing aspects of locum tenens work is the flexibility it offers. Physicians can choose when and where they work, allowing for a better work-life balance. This flexibility is essential for maintaining enthusiasm and vitality in a profession known for its demanding schedules.
The Role of Technology in Enhancing Healthcare Delivery
In the era of digital transformation, technology plays a pivotal role in enhancing healthcare delivery and patient care. From telemedicine services that extend the reach of healthcare providers to underprivileged areas, to advanced data analytics for improved patient outcomes, the integration of technology in medicine continues to expand. These advancements not only streamline operations but also facilitate a more personalized and effective approach to patient care.
- Telemedicine: Telemedicine has emerged as a critical component in bridging the gap between underserved communities and quality healthcare services. By enabling consultations and follow-ups through digital platforms, telemedicine enhances accessibility and convenience for both patients and providers.
- Electronic Health Records (EHRs): The adoption of EHR systems has revolutionized the way healthcare information is stored, retrieved, and analyzed. These systems not only improve the efficiency of healthcare delivery but also enhance patient safety by facilitating more accurate and timely diagnoses.
Fostering a Culture of Innovation and Inclusivity
The continuous evolution of the healthcare industry necessitates a culture that values innovation, inclusivity, and adaptability. By fostering an environment where new ideas and diverse perspectives are welcomed, the healthcare sector can not only address current challenges but also anticipate and prepare for future demands.
- Encouraging Cross-disciplinary Collaboration: Innovation often stems from the convergence of different fields and expertise. Encouraging collaboration between medical professionals, technologists, and other stakeholders can lead to groundbreaking solutions in healthcare delivery and patient care.
- Inclusivity in Patient Care: Embracing diversity and inclusivity in patient care ensures that all demographics receive compassionate and competent healthcare. Tailoring communication and care strategies to meet the unique needs of diverse populations is essential in building trust and improving health outcomes.
Through initiatives like locum tenens and the strategic integration of technology, the healthcare industry can navigate the complexities of modern medicine while staying rooted in the principles of care and compassion. It is through continuous learning, adaptation, and a commitment to innovation that healthcare professionals can make substantial strides in improving the quality and accessibility of care for all.