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End-of-Round Time Compression in Physician Handoff Sessions—Reply

End-of-Round Time Compression in Physician Handoff Sessions—Reply In reply We appreciate the opportunity to respond to Jones and colleagues' comment on our recent publication.1 Brevity constraints of the Research Letter prevented our supplying a fuller discussion that might have obviated the authors' main misunderstanding. We did not claim that the problem facing clinicians when they use their scarce handoff time to discuss a portfolio of patients could be reduced to a formal portfolio management problem. We completely agree with the authors that the formal conditions for such a framing are not met in actual practice. Furthermore, we fully agree that psychological evidence shows clearly that human beings perform badly in time allocation problems. It is just such results that suggest to us that the bias toward spending excess time on early cases that was measured in our original report is probably widespread. On the possible confounds, we can agree that it would be interesting to measure other variables and relate them to length of patient discussions. However, as we pointed out in our Research Letter and online supplement, the possibly related variables are effectively randomized by following lists in bed number or alphabetical order. Our discussion of the portfolio problem2—the issue of how to allocate scarce time across multiple patients—is not presented as a solution, as suggested in Jones and colleagues' comment, but rather as an important organizational challenge that clinicians encounter when they handoff sets of patients. Moreover, we find a portfolio effect, wherein the average time allocated for handoff discussion declines steadily with increasing ordinal position. In our study, patients discussed earlier in the handoff received disproportionately more time than later patients, despite the order of the cases being effectively random. We hope that other researchers will investigate to see whether the portfolio effect is a widespread problem with handoffs. If so, the portfolio effect has important organizational and policy implications. We are gratified to see that Kannampallil et al have a similar finding for a related activity: clinical rounds.3 To say that it is difficult to make optimal allocations of time, a point with which we agree, should not mean that no improvement is possible over the current method, which amounts to allocating excess time to randomly selected patients in the overall portfolio. Many practical procedures can be devised by clinicians that will do better than the current common practice, once they are made aware of the potential for the portfolio effect. Back to top Article Information Correspondence: Dr Christianson, Rotman School of Management, University of Toronto, 105 S George St, Toronto, ON M5S 3E6, Canada (marlys.christianson@rotman.utoronto.ca). Conflict of Interest Disclosures: None reported. Additional Contributions: Although Michael D. Cohen, PhD, is not listed as an author on this reply, his ideas form the core of our argument. Dr Cohen, the lead author on our original publication, passed away February 2, 2013, but remained engaged in this research on handoffs, a topic about which he was passionate, until the end. References 1. Cohen MD, Ilan R, Garrett L, LeBaron C, Christianson MK. The earlier the longer: disproportionate time allocated to patients discussed early in attending physician handoff sessions. Arch Intern Med. 2012;172(22):1762-176423405408PubMedGoogle ScholarCrossref 2. Hilligoss PB, Cohen MD. Hospital handoffs as multifunctional situated routines: implications for researchers and administrators. In: Blair JD, Fottler M, Savage G, Friedman LH, eds. Biennial Review of Health Care Management (Advances in Health Care Management). Vol 11. Bingley, England: Emerald Group Publishing; 2011:91-132 3. Kannampallil T, Jones L, Buchman T, Franklin A. Last patients finish last: end of round time compression during CT ICU clinical rounds [abstract]. Crit Care Med. 2011;39:(suppl 12) 176Google Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Internal Medicine American Medical Association

End-of-Round Time Compression in Physician Handoff Sessions—Reply

JAMA Internal Medicine , Volume 173 (11) – Jun 10, 2013

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Publisher
American Medical Association
Copyright
Copyright © 2013 American Medical Association. All Rights Reserved.
ISSN
2168-6106
eISSN
2168-6114
DOI
10.1001/jamainternmed.2013.1254
Publisher site
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Abstract

In reply We appreciate the opportunity to respond to Jones and colleagues' comment on our recent publication.1 Brevity constraints of the Research Letter prevented our supplying a fuller discussion that might have obviated the authors' main misunderstanding. We did not claim that the problem facing clinicians when they use their scarce handoff time to discuss a portfolio of patients could be reduced to a formal portfolio management problem. We completely agree with the authors that the formal conditions for such a framing are not met in actual practice. Furthermore, we fully agree that psychological evidence shows clearly that human beings perform badly in time allocation problems. It is just such results that suggest to us that the bias toward spending excess time on early cases that was measured in our original report is probably widespread. On the possible confounds, we can agree that it would be interesting to measure other variables and relate them to length of patient discussions. However, as we pointed out in our Research Letter and online supplement, the possibly related variables are effectively randomized by following lists in bed number or alphabetical order. Our discussion of the portfolio problem2—the issue of how to allocate scarce time across multiple patients—is not presented as a solution, as suggested in Jones and colleagues' comment, but rather as an important organizational challenge that clinicians encounter when they handoff sets of patients. Moreover, we find a portfolio effect, wherein the average time allocated for handoff discussion declines steadily with increasing ordinal position. In our study, patients discussed earlier in the handoff received disproportionately more time than later patients, despite the order of the cases being effectively random. We hope that other researchers will investigate to see whether the portfolio effect is a widespread problem with handoffs. If so, the portfolio effect has important organizational and policy implications. We are gratified to see that Kannampallil et al have a similar finding for a related activity: clinical rounds.3 To say that it is difficult to make optimal allocations of time, a point with which we agree, should not mean that no improvement is possible over the current method, which amounts to allocating excess time to randomly selected patients in the overall portfolio. Many practical procedures can be devised by clinicians that will do better than the current common practice, once they are made aware of the potential for the portfolio effect. Back to top Article Information Correspondence: Dr Christianson, Rotman School of Management, University of Toronto, 105 S George St, Toronto, ON M5S 3E6, Canada (marlys.christianson@rotman.utoronto.ca). Conflict of Interest Disclosures: None reported. Additional Contributions: Although Michael D. Cohen, PhD, is not listed as an author on this reply, his ideas form the core of our argument. Dr Cohen, the lead author on our original publication, passed away February 2, 2013, but remained engaged in this research on handoffs, a topic about which he was passionate, until the end. References 1. Cohen MD, Ilan R, Garrett L, LeBaron C, Christianson MK. The earlier the longer: disproportionate time allocated to patients discussed early in attending physician handoff sessions. Arch Intern Med. 2012;172(22):1762-176423405408PubMedGoogle ScholarCrossref 2. Hilligoss PB, Cohen MD. Hospital handoffs as multifunctional situated routines: implications for researchers and administrators. In: Blair JD, Fottler M, Savage G, Friedman LH, eds. Biennial Review of Health Care Management (Advances in Health Care Management). Vol 11. Bingley, England: Emerald Group Publishing; 2011:91-132 3. Kannampallil T, Jones L, Buchman T, Franklin A. Last patients finish last: end of round time compression during CT ICU clinical rounds [abstract]. Crit Care Med. 2011;39:(suppl 12) 176Google Scholar

Journal

JAMA Internal MedicineAmerican Medical Association

Published: Jun 10, 2013

References