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Deep Dive #1: How do you decide when lung nodules should be worked up inpatient vs. outpatient?
- According to a JAMA review, lung nodules appear in 30% of chest CTs.
- About 80-90% of nodules are less than 8mm, at which point imaging surveillance is reasonable given the risk of cancer of 1% or less. Also, if the nodule is <6mm and the patient is low risk they do not need follow up at all per Fleischner Guidelines
- Management of nodules greater than 8mm is more of a gray area
- Prediction tools such as the Mayo Clinic Risk Model can help assess pretest probability of cancer.
- Pretest probability, patient performance status, and nodule characteristics may determine management with either surveillance CT imaging, PET scan, or biopsy.
- Should larger nodules be managed as outpatient or inpatient?
- Fast Forward Rounds can guide the decision by determining how logistically challenging follow up will be as an outpatient.
- Benefits of outpatient management
- Availability of multidisciplinary conversations at tumor boards (with pulmonary, thoracic surgery, radiology, oncology, radiation oncology,…)
- Risk of biopsy complications, such as pneumothorax or hemorrhage, are lower as outpatient since patients are generally in better health.
- Benefits of inpatient management
- Prevent loss to follow-up and ensuring the biopsy gets done, especially in patients with barriers to care such as non-English speaking, poor social support, or being house-bound
Deep Dive #2: How can outpatient follow-up for lung nodules be optimized?
- Discharge summary
- Only 23% of patients requiring follow up had the lung nodule listed on their discharge summary
- Lung nodule more likely to be included on discharge summary if there is specific mention of the nodule in the summary headings of the radiology report, radiologist recommendation for explicit follow up, and use of medical discharging services
- Where the nodule is listedon the discharge summary is also important to call attention to it for primary care physicians
- Only 23% of patients requiring follow up had the lung nodule listed on their discharge summary
- Closed loop communication
- Phone calls to primary care physicians is ideal but time intensive
- Emails are an alternative but are not always read
- Creating redundancy in the system
- Making multiples appointments for imaging or with different specialists can create a safety net by ensuring at least one of these appointments happens for follow up
- Patient education
- Using a visual aid, such as drawing a nodule, may help educate patients and their loved ones.
- Advocating for systems level approaches to create a safety net
- Overall, a risk adapted approach for each patient is necessary to optimize outpatient management
A: Welcome to Gray Matters, where we unpack how medical management is rarely black or white
J: and we go on deep dives along the way! I’m Jason Freed and I’m a hematologist at Beth Israel Deaconess Medical Center.
A: I’m Ali Trainor and I’m a pulmonary and critical care fellow at the Harvard combined program at MGH and Beth Israel Deaconess.
J: You know Ali, ever since our first episode where you talked about how you found out your patient had died only because of an EHR alert, I’ve been thinking about how spotty the feedback I get is.
A: Yeah totally, I mean if I hadn’t had that alert, I would have had no idea.
J: There’s this case from a bunch of years back where I only found out what happened through random chance and I’ve never been able to get it out of my mind.
A: What happened?
J: This goes waaaaay back to when I was a resident actually.
A: I’m guessing your age but I don’t think you’re even 40, that really wasn’t that long ago.
J: I mean I didn’t have kids then, so it feels like a different life, anyways … This was a 72-year-old vietnamese-speaking woman who gets admitted initially by one of my co-residents for severe gallstone pancreatitis. Long complicated hospital stay lasting several weeks in the ICU for large parts of it. During one of the many points where she had a fever she has a chest CXR and there’s an incidental finding of a lung nodule. That of course leads to a chest CT
A: Of course
J: So the chest CT confirms a single 2.5cm nodule. ID was consulted and recommends 3 AFB smears since she’s from a TB endemic area. Those turn out negative. So we basically stopped the work up on that at that point. Lots of other stuff happens, including getting a DVT and being started on anticoagulation for that. But eventually after like 60 days she’s well enough that she’s gonna be discharged to rehab.. and I’m the discharging resident.
Ali: 60 days?? Oof I do not envy you prepping that d/c summary
J: I was actually the 8th resident to take care of this patient due to multiple transfers in and out of the ICU. Anyways, kudos to my attending on her discharge day because THAT chest CT finding had fallen off the problem list in my massively copy-forwarded note and this attending had a ritual prior to discharge of going through every imaging study from the whole admission to see if there were any incidental findings needing follow-up.
A: Kudos to that attending for catching the lung nodule. .. Of course, I’m seeing patients with lung nodules all the time in my pulmonary clinic, but this must come up a lot on the inpatient side with all the CTs people get, but I’m curious how common is it to find incidental lung nodules?
J: It’s waaay more common than I thought. I read a recent review in JAMA that said that lung nodules are seen in approximately 30% of chest CTs.
J: Yeah this works out to be that about 1.6 million people in the US each year are newly diagnosed with lung nodule. That’s a similar incidence to new cases of diabetes per year. Which is insane, I mean we talk all the time about initiating therapy for diabetes but I can’t say I know that much about lung nodules
A: I think that’s probably true for most people who aren’t pulmonologists
J: Exactly, so I turned to a Dr. Anil Vachani, a pulmonologist who researches lung nodules at the University of Pennsylvania. And for our first deep drive, I asked him, what’s his approach to work-up of nodules and deciding on inpatient vs outpatient workup? He had some helpful rules of thumbs based on size.
Dr. Anil Vachani: Most nodules, somewhere between 80 and 90% of the nodules, we identify incidentally will be below eight millimeters in size eight or smaller. And the statistics are with us here, which is that if a nodules eight millimeters or smaller, the rate of cancer will be 1% or less. So we can be quite confident that in a size range of eight millimeters or smaller that, um, surveillance imaging is the right strategy.
A: Okay maybe this is why i didnt fully appreciate how common they are because even if nodules are in 30% Chest CTs, most are gonna be so small that they can be observed or don’t need to be followed at all.
Dr. Anil Vachani: Eight millimeters are larger is where it gets frankly much more complicated. Uh, oftentimes as we are evaluating nodules, um, in that size range, we’re using prediction tools like the Mayo clinic risk model or similar models to estimate the pretest probability of cancer in a nodule. It’s a combination of sort of, you know, patient performance status, pretest probability, the location of the nodule and difficulty and biopsying it. All those factors that are going into decision you making on, whether it still makes sense to maybe do short term surveillance or to do a pet scan or to do a biopsy.
J: And then above 15 mm is where it starts to gets even more complicated
Dr. Anil Vachani: Certainly as nodules get above 15 millimeters in size, we will usually end up at least during a pet scan immediately. And a biopsy if a pet scan shows concerning findings, but there are still gray zones where surveillance could be appropriate where a biopsy could be appropriate.
A: Ok, so looking at the size of the nodule is helpful for pre-test probability of cancer, but I think the question for your patient was inpatient or outpatient workup right? So she has a 2.5cm nodule, so she needs something to happen, but she’s being discharged today… so did you talk about inpatient vs outpatient work-up.
J: Yeah when deciding inpatient or outpatient, I think pre-test probability of this being cancer is factor number 1, but factor 2 is how likely is this to get done as an outpatient? So I spoke to Dr. Karin Ouchida, a Geriatrician at Cornell about something she and her team calls Fast Forward Rounds which can be used to help decide how challenging it will be for something to happen as an outpatient.
Dr. Karin Ouchida: The idea was, I think it was born out of how we all get into care transitions because you see a transition go wrong and it frustrates you because we spend all this time and energy in the hospital trying to figure out what’s what’s going on with people. And, and we all go into medicine because we wanna fix it. And then you help someone and you get them better. And then the readmission is like a total failure. Like you just feel like all our work was for nothing… and so I think Dr. LoFaso came up with this concept of, well, if we on rounds, like talked about like fast forwarding in time to when this person is home, what would they need? What follow up would they need? Then maybe we could help. It was a way of thinking. Maybe we could help prevent those readmissions.
A: It seems like fast forward rounds isn’t just about preventing readmissions, it’s about thinking through what’s gonna be best for their patient and really setting them up for success.
J: Why I really appreciate Fast forward rounds, is that it allows me to pause and anticipate the probability of my plan actually happening. And of course by thinking through it I can more readily recognize what’s likely to be a difficult plan and allows me to adjust the plan, if needed, to make a higher fidelity version.
A: I love this idea of fast forwards rounds. So let’s take a stab at this on your incidental lung nodule finding because I love the lung…
J: So you’re the discharging clinician, and then fast-forward, you put yourself in the shoes of the PCP at that first post-discharge clinic visit… what do you need to do at that appointment?
A: Yeah let me think… okay so I’m the PCP, do I do a PET scan or a go straight to biopsy, or who do I refer them to – is it pulmonary, interventional pulmonary, thoracic surgery, interventional radiology? And then if she does need a biopsy, what am I supposed to do with her anticoagulation? Does she need bridging for the DVT she got in the hospital, if she does, how am I going to operationalize that with this non-english speaking older adult. Does she can have someone who can help her with enoxaparin injections – gosh this is hard. There are so many moving parts that are coming up that need to all fall into place for this to happen as an outpatient.
J: YES! This is why I am such a big fan of fast forward rounds !! We get so excited about clinical reasoning when we are admitting patients, but we think of discharges as checking some logistical boxes. But the reality is that discharging is some of the most complex clinical reasoning we do in the hospitalization because it requires incorporating not just medical knowledge, but also systems based practice, communication with patients, other providers it’s like all 6 ACGME competencies.
A: I’m definitely guilty of just writing as knee-jerk reflex “follow up pulmonary nodule as outpatient”, but doing the fast forwards rounds with you, it seems like she has a high risk nodule and this not a fool proof discharge plan because so many things can fall through the cracks so maybe this is something we should do inpatient.
J: I hear you, but turns out in speaking to Dr. Vachani, he actually actually argued that most incidental nodules are better evaluated in the outpatient setting.
Dr. Anil Vachani: That’s because where you’re, you’re really able to have that multidisciplinary conversation that we often do in our group, which is, you know, we will oftentimes present lung nodules at tumor boards or, well, we now have nodule boards and discuss them with our colleagues from thoracic surgery and intervention, radiology and oncology and radiation oncology to make sure we’ve aligned on what the differential is, what the appropriate diagnostic procedure should be, what the treatments are that could be offered afterwards.
J: He also brought up a surprising observation on the complications of doing biopsy inpatient as opposed outpatient.
Dr. Anil Vachani: Now there’s a lot of sort confounders here that I haven’t sorted out yet. Right. But essentially that the risk of pneumothorax risk of hemorrhage, those are all greater when a diagnostic procedure is done on the inpatient setting.
A: Whoa thats surprising to me, especially since its usually the same proceduralist who would do it as an inpatient vs. outpatient procedure.
Dr. Anil Vachani: Part of that is just because probably the patients are obviously sicker. That’s why they are in the hospital. So they’re at greater risk, but there is something to this, right? That goes being on that, which is this idea that I don’t, I don’t really like doing a biopsy on an inpatient if whatever reason they’re in the hospital or whatever, their sort of current medical sort of milieu is raises their risk of a complication. So I’m still very much a believer in these patients should make it outta the hospital. They should recuperate for a few days. They should, you know, ideally get back to a place of optimal health before we then put them through an invasive procedure. So I’m still in most settings, not really, uh, enthusiastic about, in about an inpatient workup when I can transition them safely to an outpatient setting.
J: This tells me if I’m going to do this inpatient, it should be towards the end of the hospitalization when other acute things have resolved.
A: But then, if we do try to defer it to the outpatient, we are always at a risk that the lung nodule will get lost to follow up.
J: Dr. Vachani actually tried out an intervention for that!
Dr. Anil Vachani: We hired a nurse practitioner for a year who essentially spent her entire time reviewing inpatients nd identify any incidental findings on their chest CT scans. And she would then, um, prior to discharge, discuss those findings with the patient, send a, a fax or note, uh, to the primary care provider arranged for their next study, whatever there was a CT or an ultrasound or whatever was needed as an outpatient. Um, and it worked right? We were able to show that we could really improve our follow rate from about 50%, to about 90%, but it was very expensive to do, as you can imagine, look, the health system doesn’t want to have to pay, you know, uh, a nurse practitioner for essentially sort of a non-billable service and it just became not sustainable. We were able to show a pretty good outcome, but we couldn’t quite quite come up with the right financial model to support work like that.
A: Wow, those are staggering numbers, and now I’m deeply concerned that without this dedicated nurse practitioner half of nodules could be lost to follow-up
J: I know right, but it fits with my anecdotal experience. And specifically with this patient, it’s not so straightforward for outpatient workup, she had a DVT less than a month ago so I gotta figure if she needs bridging, and then figure out who I’m referring her to for biopsy.
Dr. Anil Vachani: It may make sense to do it in the inpatient setting. And we certainly use, uh, anticoagulation. Um, you know, non-English speaking is also a big problem, right? Getting patients to their appointments with appropriate interpreters in place is certainly something that is a barrier and that can sometimes influence decisions on when to work up these findings, you know, poor social support, all those sorts of concerns around the, whether someone is more likely to them get lost, to follow up as an outpatient, all do go into our sort of consideration.
J: I kind of feel validated hearing that because we constantly hear “Oh that wasn’t the reason they were admitted, so it should be deferred to outpatient,.”
A: Yeah is that even a fair rule of thumb, especially since we are seeing it’s more complicated than that. It’s not even just can we get an interpreter to the appointment but can we get the patient to the appointment?
Dr. Karin Ouchida: Usually more often I’m on the receiving end of that… where I’m the house call doctor or I’m the outpatient a doctor and certainly for the house call patients, I’m like, I look at a discharge summary and there’s, you know, four or five follow up appointments made. And in the era before telemedicine, it was like, really like, who did you, did you think that this person who’s home bound, who we see at home and they never leave their home. They’re not really we going to get to all these things and now we have to prioritize with them like what’s actually what matters. Like what are we asking these people to do? You know, like what are we physically asking them to do? And do they understand themselves?
A: Gosh I feel like im getting whiplash, we can make a good case for outpatient or inpatient workup for a >15 mm lung nodule. So sounds like reasons to consider doing this outpatient, especially for lung nodules, is that there can be a lot more support outpatient with these tumor boards, seems like procedures might be less risky because people are less sick, but on the other hand as an inpatient you’re much more likely to make sure the biopsy happens, which is especially important when you have people with certain social determinants of health that make it really hard for people to follow up as an outpatient like being non-English speaking, or having poor social supports, or being house bound. So what did you do?
J: We ultimately decided to defer this to outpatient. I have to admit, it was a weekend discharge after I had just met the patient, they were going to a SNF, they needed an interpreter. And I’ll be honest I don’t know if I hit everything in our predischarge communication after a 60 day hospitalization… I don’t actually remember whether we talked about the nodule.
A: And realistically Jason, all of that would likely have been impossible regardless of what day of the week it was.
J: But I wrote a heck of a discharge summary (I know because I’ve looked back at it) that listed every possible transitional issue, of which there were several with this lung finding that we’ve spent so long talking about being just one of them.
A: So Jason, I’ll be honest, reflecting back I’m certain I’ve discharged patients and just wrote in their transitional issue this pulmonary nodule needs to be followed up as an outpatient, feeling like I did what I needed to do. But the more we talk through this, I’m starting to question that practice, especially in this case, I mean wasn’t your patient’s nodule in the high risk category? It was greater than 15mm right?
J: Right, it was 25mm and… ok, im just plugging this into the mayo clinic risk prediction model online…. Gosh, for a former smoker (which she was) 72 years old with a upper lobe solitary lung nodule of 25mm, that’s a 68% probability it is cancer. 86% if it’s spiculated. If I knew those numbers, I might have not chosen to do this as an outpatient.
A: Those numbers are so striking because that might actually change how I think about this as a pulmonary consultant. If the risk of cancer is THAT high, we need to make sure that biopsy happens.
J: Right, even if there is a 10% chance of this not happening outpatient, this is way too high risk. And we heard 50% of lung nodules are lost to follow-up!
A: Of course in hindsight we’re saying maybe you should have kept her inpatient, and honestly I do agree, but we will never know for certain if that was better because we just heard there can be more risks with inpatient biopsies.
J: Yeah I gotta be honest, I did feel a little relieved when I heard Dr. Vachani frequently discharges patients for follow up outpatient of their lung nodule.
Dr. Anil Vachani: I think that this is perfectly appropriate. I think the key risk though, as you’ve pointed out in this case and in others, is that we lose track of incidental findings quite frequently on the inpatient setting.
J: So how do we not lose track of it? We don’t want to miss a resectable cancer that then metastasizes. So for our second deep drive, I asked our experts what can we do to optimize the transition of care?
A: Maybe we can start with what seems like low-hanging fruit of the discharge summary since everyone is required to write one.
Dr. Corinne Rhodes: One study found that only 23% of patients requiring follow-up according to Fleischner society guidelines for lung nodules had the nodule listed on their discharge summary.
J: That’s Dr. Corinne Rhodes, who is Associate Medical Director of Quality for the Primary Care Service Line at Penn Medicine.
A: Okay so sounds like step one make sure that incidental finding makes it into the discharge summary.
Dr. Corrine Rhodes: But mention of the nodule and the heading of the radiology report, explicit recommendation for follow up for, from the, and the use of the medical discharging service were associated with inclusion in the summary. I have no data to say this, but I will say as a PCP that within the discharge summary itself again, where you place it and how you call attention to, to it again can be helpful.
J: This makes a lot of sense, so where the radiologist puts it in their report and where we list it in our discharge summary can make a difference in terms of people seeing it.
A: I have to say, when I was a resident I was so meticulous about documenting transitional issues in my discharge summary. Because then I felt like I was absolved of responsibility… I’ve done my part.
J: Yeah, I was the same way, it’s in the discharge summary, my job is done. But as I reflect now, the discharge summary is not closed loop. But of course closed loop communication with a phone call, is time intensive for the discharging doctor and the PCP and probably impractical to do for EVERY incidental finding. SO I asked Dr. Ouchida about an alternative form of closed loop communication… email…
Dr. Karen Ouchida: It’s still one way, like you don’t, unless the person writes you back or engages with you, you don’t really know what was received and was it received in this the way you wanted it to be received? So it was like a 2009 study and they just used email because they had non-urgent findings. They didn’t wanna, you know, they didn’t seem like it necessitated a phone call. So they just send an email alert to the PCP, or maybe the ordering physician. And like, then they could see if they were viewed and like one in five times, like 20% of the time it was than even viewed. So it’s like, you don’t get it. It’s not, it’s not two way enough. Like, it’s just kind of a, the, you know, like a dumping.
A: 2009 is a long time ago in technology…
J: Right, in 2009 I had a blackberry
A: And I had a flip phone, so I definitely wasn’t checking email, so I’m sure people are looking at their email more often than that now, but I also know I miss emails sometimes, so it’s not a perfect closed loop system.
J: Right I miss emails too sometimes. But when people actually do respond to your email or to your phone call there’s a benefit beyond just information transfer. When we email or talk on the phone about a shared patient, we have an opportunity to discuss what the fast forward is going to look like… and when I’m the outpatient provider who is receiving the handoff I really like that I can ask questions and oftentimes together we make a much higher fidelity transition plan because of that interaction.
Dr. Anil Vachani: You could try and you know, create some redundancy in the system, right? Make appointments, make cat scan appointments, you know, book ’em also for a pulmonologist. You know, you, you could try and create a little bit of redundancy that somewhere. Someone’s going to make sure that that, that one of these appointments gets met and that the follow up happens.
J: But he also acknowledges that these won’t completely eliminate the risk of something important being lost…
Dr. Anil Vachani: I think the problem is that we do a terrible job though, of like, of, closing the gap of closing the loop, I guess, is what I’m trying to say, which is that even as an outpatient provider, if I order a cat scan for a patient with a lung nodule at an outpatient visit for their next outpatient visit and they don’t show, I have very little safety net around that, right beyond the fact that they’re gonna fall off my schedule, their cat scan’s gonna get served clothes because they were a no-show no, one’s gonna tell me unless I go look where there no show visit, certainly radiology doesn’t, at least at our institution has no sort of safety net for getting people back… people just drop off into the ether.
A: This is one of my biggest fears in outpatient pulm clinic. I have no good way of knowing if these things are getting lost, and honestly it could be happening right now and I would have no idea.
J: I feel like it could be happening to me too. And to Dr. Vachani’s point on creating redundancy, another way to create safety net is to educate our patients and their loved ones
Dr. Anil Vachani: Even if I can’t pull up a cat scan, I will literally take a piece of white paper and draw two lungs, like literally a circles and say, here’s a dot, this is what you have in your lung. And it shouldn’t be there. Give them some sort of visual to try and remember that there is a real abnormality that we want to keep track of. And then I try and lay context, which is the likelihood of cancer here is going to be low. It’s one out of a hundred, it’s 10 out of hundred. It’s 50 out of a hundred, whatever the number is. And that, because, you know, it’s this low or because it’s high enough that we really, really want to make sure that we, you know, get an evaluation done in this timeframe. But I do try and give them a visual. And if I, if I do it on a piece of paper, I actually give them the piece of paper and say, take this home and keep it with you.
A: A+ to the power of visuals in patient education!
J: Haha, yeah I’m all about patient education too but sometimes what we tell the patient is not what the patient actually hears
Dr. Corinne Rhodes: And sometimes we both know when there’s so much going on, it’s just hard to take in too much information, right. If someone is very sick, um, due to another reason and you know, they’re in the hospital, I think you said 60 days, he might be so sick that this is just not pertinent to work up right now. We’re not sure how this person’s going to recover. Thinking about, um, are patients who are recovering, there’s so much inform you take in, can you really expect the patient to be their own advocate when there’s so much going on that they might truly not understand what is a nodule, right. Um, what is even that word nodule versus mass, it has different interpretations how much we choose to, to reveal to the patient.
A: So what I’m taking away from deep dive 2, is that we often oversimplify these decisions about inpatient versus outpatient work up into 2 buckets, toss in the d/c summary and hope for the best or deal with inpatient.
J: Yeah there’s the Minimalist and Maximalist approach.
A: But it sounds like, if I can summarize, there are many gray layers in between..
J: Ali are you just get our show title into every episode?
A:It’s worked so far! But yeah it’s not just d/c summary or inpatient workup, there’s looping in the PCP, involving a specialized service to oversee the workup, doing teach back with your patients. All of these things take different amounts of time and have different degrees of reliability.
J: Yeah, this where having a risk adapted approach is helpful. Something with a 68% risk of being cancer, it needs all the layers of redundancy to avoid a swiss cheese situation.
A: Yeah agreed, so getting back to the case. I feel like there’s been a ton of build up. Something must have happened with the lung nodules right?
J: Yeah, well I would have never known, but about 9 months after all this I was a heme-onc fellow. And I was just incidentally at lung tumor board and one of the many cases discussed that day was a name that sounded really familiar. And I thought, gosh, that can’t be the same person, but then they pulled up the chest CT from 9 months earlier and the current one which now showed a 10cm lung mass and a MRI showed 2 brain metastases.
A: Oh man, I was worried that was where this was going, but that’s so awful.
J: I know. Of course I felt horrible and immediately started to try to figure out what happened.
A: What did you find out?
J: Long story short the patient went to rehab for about a month, and made a great recovery and was discharged back home. When she saw her PCP for the first time after that, the PCP had the discharge summary from the rehab but didn’t have the discharge summary that I wrote from the hospitalization... and the patient didn’t mention the incidental finding, and I can’t blame them given everything else that was going on at the time, it definitely wasn’t their priority.
A: Ugh thats horrible, but I could so see how this could happen… but wait didn’t you say she smoked cigarettes in the past? Shouldn’t she have been getting CTs for lung cancer screening?
J: This was before chest CT screening for lung cancer had become more common and so the patient seemingly didn’t have any reason to have any more CT scans. So the nodule, which turned out to be non-small cell lung cancer grew and metastasized and she actually presented due to complications related to that brain metastases and after that tumor board she ended up opting for comfort care and passed away not too long after diagnosis.
A: That so awful. But Jason, honestly something that could have happened to any of us. I know we’ve talked about regrets in the past. I’m curious what has come up for you.
J:I have a lot of reflections and lessons learned from this case but one thing I think whenever you look back on a case with a bad outcome you can ask was this because I made a bad decision or was it a good decision that just happened to have a bad outcome this time? But I think with this case, knowing what I know now about how high risk a 25mm nodule is, this was a bad decision and if there was another case like this tomorrow it would be a bad decision to discharge them.
A: Yeah, I don’t know if it was a wrong decision, maybe if she had had more safety nets she would have followed up, but who knows. Knowing you, Jason, you took this all to heart, so how has this affected how you practice?
J: I feel like I went through some stages of grief after this. I swung from minimalist, just dump it all in the discharge summary, to maximalist work up every incidental finding inpatient, but neither approach was right for every patient and problem. I was only with time was I able to adopt that risk adapted approach.
A: What does that risk adapted approach look like when you are on bone marrow transplant service?
J: Well so I do that pre-discharge ritual that my attending did when I discharged this patient. I look through all the imaging and what tests are pending and we do fast forwards – we talk out loud about how we are going to make sure things happen. So frequently I’ll ask my team, so what are you going to do about that pending SPEP? And they often say, won’t you Jason get it in your results as the attending. That’s the chance for me to clarify blindspots in the system that lab tests don’t get pushed to me and we think about how we will keep track of it or who we will hand it off to.
A: That’s really helpful because the way I’ve been doing this is really just practicing on a fear based model where I just remember the things that would keep me up at night if they got missed, but that’s just not productive or effective so I’m gonna try doing this risk adapted approach and being more systematic about following things that might get lost.
A: Ok if we could rewind to young Jason who maybe would have done fast forward rounds, what would you have done differently.
J: Besides using a risk calculator to see how risky this nodule is, I’d tell him to fast forward and see if this follow-up plan seems likely to happen. And of course in this case there’s a million reasons it could have gone wrong, and it did, but if the patient really didn’t want to prolong their hospitalization to get the biopsy, I would have used a system to keep track of this high risk transitional issue. One thing I do is to future send an email to myself to come back to me in the amount of time where I know the results will be back, so I don’t have to check multiple times.
A: I think that’s a great idea and something I’ll try to do going forward. But it can still be tough not to lose track of things and we both really want to improve on this so I would love to ask our listeners if they could share with us ways that they follow up transitional issues to make sure these important aspects of patient care don’t get lost.
J: Ali, before I go on another tangent maybe this may be a good place to summarize our deep dives for this case
A: In our first deep dive we talked about how to approach an incidentally found lung nodule for an inpatient. If the nodule is 8mm or above, think about plugging it into a prediction tool like the Mayo clinic risk model to help you take a risk adapted approach to if the workup needs to happen inpatient or outpatient. The case for outpatient being that you have nodule or tumor boards and the biopsy risk outpatient may be less, but on the other hand if it’s a higher risk nodule and you have a patient with certain social determinants of health that make them more likely to get lost to follow up then maybe you should work them up as an inpatient.
J: And for our second deep dive, we talked about, if you do decide to defer something to outpatient, depending on how risky it is, we have to think of how to create as many layers of redundancy as possible. These layers range from patient education like drawing a lung nodule, where you put the transitional issues in the discharge summary, and closed loop communication with outpatient providers.
A: But humbly, even when we do our very best, some things do still fall through the cracks.
J: This case left me thinking, we spend so much time in medicine thinking about how we say hello, but not how we say goodbye. I really believe that discharging requires some of the most complex and important clinical reasoning we’ll do for the entire hospitalization. We hope this episode inspired people to think about they say goodbye.
A: And I have to say for our listeners, there so many other places we want to take this episode. You should have heard us practicing with all the things we deliberated including, and we hope to cover some of this in the future, but we would really love to hear from you all about challenges or areas where things that get lost that have come up for you when taking a risk adapted approach and doing fast forward rounds for your patients.
J: And that is a wrap for today! But we also love going through other cases so if you have a case that you want to bring to Grey Matters please let us know. If you found this episode helpful, please share with your team and colleagues and give it a rating on Apple podcasts or whatever podcast app you use! It really does help people find us!
A: If you have a case you’d like to bring on air, please email us at firstname.lastname@example.org. Thank you to Daksh Bhatia for the audio editing. Opinions expressed are our own and do not represent the opinions of any affiliated institutions.
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- Ouchida, K., LoFaso, V. M., Capello, C. F., Ramsaroop, S., & Reid, M. C. (2009). Fast forward rounds: an effective method for teaching medical students to transition patients safely across care settings. Journal of the American Geriatrics Society, 57(5), 910-917.
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Tags: communication, discharge summary, education, lung nodule, outpatient management, risk model