Monday, May 29, 2017

The Broken File Effect


The three most important pieces of equipment that I have to improve neurological outcomes and perhaps even save lives in Zambia are my stapler, staple remover, and hole punch. Most people would wonder how this is possible. These three simple tools help me address what I call "The Broken File Effect".

This term is adapted from "The Broken Window Effect" which was felt by some to be responsible for the high crime rate in New York City in the early 1990's. When it was addressed, the result was a dramatic, almost unfathomable drop in the city's crime rate. "The Broken Window Effect" is elegantly described in Malcom Gladwell's book "Tipping Point". In its most simplified form, "The Broken Window Effect" describes how the environment such as broken windows, abandoned cars, and graffiti on subway cars contributes to crime because of the behavior it "permits". The book goes on to describe how cleaning up the environment and addressing smaller crimes like targeting turnstile jumpers on the subways helped police to prevent larger crimes in the long run. It turns out that turnstile jumpers were often perpetrators of larger crimes and arresting them prior to getting on the subway was an effective tool for prevention.

I think the same principles can apply to health care in Zambia particularly as it relates to patient files. A patient's medical file is essentially the only record that exists related to a patient's medical history. The same medical file is used to document clinic visits as well as notes during an admission. Most patients take these files home. It is a valuable source of information.

The main problem is that these files are often in horrendous condition. Notes, laboratory studies, and radiology reports of varying sizes are thrown together, most commonly attached by a swarm of staples in the upper left-hand corner. Often, there are no blank pages at the end of the file for further documentation. Instead, random pages, that are blank on one side, are stapled to the last page adding chaos and instability to the file.

I have become obsessed in my outpatient clinic with cleaning patient files. The first thing that I do after recording a patient's biographical information is to go through their file and remove excess staples, reorder the papers in chronological order, save vulnerable laboratory results or radiology reports that are loosely placed in the file, punch holes in all the papers, add continuation sheets, and finally ask the clerks to bind the papers into a new file if necessary. They have become accustomed to my emerging from the clinic room with a dilapidated file stating, "This file needs love!".

I am convinced that addressing "The Broken File Effect" saves patient's money, reduces unnecessary testing, and improves outcomes. There is no greater waste than performing a test and not having the result. It is worse than not performing the test at all because a resource has been used for no reason. A CT scan in Zambia costs US $120. This makes up a substantial portion of a family's income for the year. Yet, patients often find a way to raise some or all of the money to have the test done. Often, the only record of the test is the radiology report and/or a CD that is placed in an envelope and attached to their file. I frequently have seen these envelopes fall out of files or hanging on to the file for dear life by half a staple.


If this radiology envelope is lost, there may be no record of the study if it has been erased from the CT scanner. This happens frequently. As an example, a patient may develop chronic headaches after losing their spouse to HIV infection. During the course of their initial evaluation, they had a normal CT scan but lost the radiology envelope. So, what happens? Instead of getting what they need which is grief counseling they may see a new provider who orders another CT scan.  This waste of resources, unnecessary financial cost, and delay in the initiation of proper care could be avoided simply by addressing "The Broken File Effect".

Tuesday, July 26, 2016

A Drop in the Ocean

Upon waking up on Wednesday mornings, I try not to press the snooze button. It is my neurology outpatient clinic day at the University Teaching Hospital and the first patients start arriving at 5 AM. Most patients live in the greater Lusaka area but there are always a few who have traveled hours by bus, sometimes overnight. If I can see my first patient by 6:45 AM then I can keep up with the flow. However, if I begin some time after 7 AM then the patient files start to build up and I feel like I am sprinting.

As I walk through the doors of Clinic 4, there is already a group of patients seated at the benches. I always try to acknowledge the crowd with the standard Nyanja morning greeting, “Mwa-uka bwanj?”. Its literal translation is “How did you wake?”. Without fail, the tired faces turn to smiles as they appreciate my attempt to use the local language. I get the standard reply “Bwino” (Good) from the crowd. The hour-long Nyanja lessons that my wife and I take on Sunday afternoons with a Peace Corps language instructor has to be one of the best investments that we have made. The nurse, Sister Gloria, who is the matriarch of the clinic, always gives me a knowing smile when she hears my Nyanja as it was upon her insistence that I formally greet all the patients.

I am always at battle with the pink colored patient files. If I have some visiting neurologists, usually from the States or Europe, then I don’t get too upset with the height of the pile. If I am alone, then a large pile can mean that patients at the bottom will be waiting for hours. I try to see the follow-ups first as they are usually more straightforward: a well controlled epileptic in need of a medication refill or a recovering stroke patient requiring a physical therapy referral. However, the clinic is first come first serve so it never quite works out as planned. Inevitably, I will have new patient evaluation that will require as much time as I can provide. A typical example might be a newly diagnosed HIV-infected patient with the inability to walk. In the States this patient would get an hour-long evaluation, subspecialist referral, and perhaps even a presentation in a multidisciplinary conference. I am still grateful that I can give 30 minutes.

Normally, I have finished seeing the last patient by noon. I diligently record every patient I see in an excel file. I am always amazed at how predictable the numbers are in terms of new patients, no shows, and drop ins. As a result, I have learned what I can handle in terms of efficiency. On my average clinic day, there will be 11 follow-ups, 7 news, 6 no shows, and 2 drop ins.  The prevalence of HIV-infected patients is equally predictable. No matter if I audit my files over 3, 6, or 9 months, it is always 18%. Scheduling appointments in time blocks has essentially been proven not to work in this setting as it would require a complete shift in the Zambian concept of time. As my language instructor once told me, “Americans think time can be lost, Zambians think time can be recovered”.

I could see patients every single day and it would still not make a dent in the overall neurological disease burden. I have two other colleagues, also expats, who make up our small neurological community. There are limits to what three providers can do when you are talking about a population of 13,000,000 people.  Hopefully, we make a difference for the patients we see. Our most effective role is training frontiline providers on common neurological conditions.  The holy grail is to train a cadre of Zambian neurologists to take our place and build a meaningful and vibrant neurological community. Until then, our clinical contributions are just a drop in the ocean.

“Do you ever get frustrated?” I received this question recently at a fundraiser in New York City. It was such a simple question but a great one.  I had never formally thought about it and I really had to think hard about the answer. Yes, I get frustrated all the time: power outages, medication non-adherence, bureaucracy, and theft. However, most people working in resource-limited settings are aware of these challenges going in. Also, when something works out despite all these challenges it is incredibly rewardng.  Our EEG laboratory in Clinic 4 is a huge source of pride. It was the first lab of its kind in Zambia, provides a valuable resource to epilepsy patients, resulted in the training of two Zambian EEG technicians, and until a recent economic downturn in Zambia, had been self-sustaining.  I often equate my situation to a coach who has taken over an athletic team full of talent but has never had a winning season. If I can work within the system, motivate the players in the right way, then the wins will start to come.