Too Many Cookies

Did your mother ever equate learning to your brain being a cookie jar, with each new bit of information we learned like a cookie being stored in that jar? My wife, Cheryl, used that analogy to her son as a positive incentive to learning, and it worked until the study cramming session when Aaron declared, “Mom, my cookie jar is full! I can’t learn anything else new unless I throw out some old cookies that are in there now.” Sometimes the wisdom of children trumps even the wisdom of mothers — but as mothers always do, Cheryl had captured the essence of truth with the cookie jar analogy. That perspective is being proven by research on how people process information to make decisions, what improves the decision-making process, and what degrades those choices. A key feature, of course, is the amount and presentation of the information. Data input affects our choices in a bell curve fashion: some information is good, and more information is better for correct decisions — but only up to a point. Beyond this optimal amount of information, the more input we receive, the worse our choices become. Take a restaurant menu: the more appetizers, entrees, salads, and desserts I see, the more likely I am to give up and order the last thing I looked at when the server demands my dinner selection. Invariably, I will hate my dinner selection — and all this is just as decision science would have predicted. In fact, decision science has become a legitimate subject not only for university courses but also for college majors and even established institutes. Our information overload world of Twitter, Facebook, Snapchat, YouTube, and other electronic media blasts along with 24-hour newscasts resulted in the term “information fatigue” being added to the Oxford English Dictionary in 2009. The physiology of this condition is being researched by Angelika Dimoka, PhD, the director of the Center for Neural Decision Making at Temple University. Dr. Dimoka has studied volunteers who were exposed to increasingly complex sets of information then asked to make theoretical choices while their brain activity was measured by functional magnetic resonance imaging. The result was that activity in the dorsolateral prefrontal cortex (PFC), an area of the brain responsible for decision making and emotion control, became more and more active — until abruptly it fell off, when the information burden (the cookie overload) became overwhelming. At that point, the participants began to make errors and poor choices, followed by frustration, as the brain emotion regions, previously held in check by the dorsolateral PFC, cut loose. Ultimately, the participants just stopped making any decisions at all. This brings us to care transitions and how the information fatigue phenomenon affects our patients. We now have a neurophysiologic explanation for why a patient might not carry out the instructions on changing medications, following up with a physician, or obtaining a follow-up computed tomography scan or other discharge items we may feel are both critical and obvious. I submit my theory: we are overwhelming our transitioning patients with so much regulatory and legalistic required information, much of it having little relevance to that particular patient, that the key information is lost. I can support my thinking with some anecdotal personal experience. I had the pleasure of being part of a project that implemented an inter-rater reliability method to ensure accuracy and consistency in the Beneficiary and Family Centered-Care Quality Improvement Organization’s (BFCC-QIO) case review process. After reviewing randomly selected charts, I noted a number of patterns:1.The charts were never less than 100 to 200 pages, and frequently they were over 400 pages. (These were for a hospital stays that were, by definition, less than 48 hours.)2.The discharge instructions were regularly in excess of 40 pages.3.All the instructions were in English.4.Even with a medical degree, I often found the instructions dense and difficult to follow.5.The instructions were definitely not patient-centered to the individuals being transitioned. Among the boilerplate sets of discharge instructions in the charts I reviewed, I found these gems:•A patient was given a set of similar — only slightly different — instructions to those already provided less than a week before when the same patient was discharged from the same hospital.•A 92-year-old man was given instructions to not take his discharge medications with birth control pills.•Patients who had already received flu and pneumonia vaccines were given information about obtaining both.•A patient whose admission history and physical indicated he spoke no English received instructions in English.•A patient whose history and physical stated “Patient is blind” was given written instructions. Nor did the instructions generally make any reference to the patients’ socioeconomic conditions — such as whether they were infirm, blind, or cognitively impaired, whether they needed to obtain the medications themselves or were being cared for at home, or whether they could drive or even afford the medications.Clinicians provide too much information to transitioning patients. Overwhelming dump of discharge instructions lowers our decision-making capacity, causing patients to do nothing at all. Other data overload problems are in play with discharge instructions. First, as decision science advocates have noted, in a data overload situation people will tend to recall the most recent data received, irrespective of its source. Thus, after the typical lineup of clinicians have presented their hospital discharge information (the hospitalist, pulmonologist, cardiologist, dietician, discharge planner, and others), the memory a patient will internalize will be the last person’s instructions — regardless of licensure, professional discipline or specialty, content, or relative importance for outcomes. Second, the more information showered upon us, the poorer our decisions become. Third, overwhelming data dumps do not cause us to do the wrong thing — rather, they prompt us to do nothing at all. At the beginning of my involvement in care transitions, I believed clinicians were providing too little information to transitioning patients and their families. Now I contend we provide too much information — by too many members of the clinical care team, in an uncoordinated and rapid-fire way, without tailoring it to the needs of the transitioning patients. After we have asked our patients to attempt to drink from a firehose of information, we provide them with a 40-page set of discharge directions to ensure compliance, with no regard to their language, reading or visual ability, or health literacy. I believe the answer is to assess our patients to determine their level of ability to understand and implement discharge instructions, as proposed by Jackie Vance, RNC, BSN, my friend, colleague, and former staffer with AMDA — The Society for Post-Acute and Long-Term Care Medicine. Doing so allows the discharging entity to determine the best avenue to effectively craft a discharge plan that is not only appropriate but can actually be implemented by the patient. What would such an evaluation look for? Here are some thoughts:•Is any sensory impairment present (inability to hear, see, speak, etc.)?•Can the patient read?•What is the patient’s health literacy level?•Does the patient use English as a second language?•Does the patient have cognition, memory, or judgment issues? (This would include such problems as dementing disease, delirium, mental health issues, and substance abuse.)•Can the patient provide self-care? If not, how is care to be provided?•Does the patient have the financial resources to purchase medications and medical equipment or meet other discharge medical needs?•In any transitioning patient with the type of concerns listed here, will family or a caregiver be present at the time the instructions are provided?•Can the discharge instructions be provided by a single person, summating all instructions? Part of the discharge/transition process should always include an assessment of the patient’s (or surrogate’s) understanding of the instructions. Preferably this assessment should include a teach-back or similar aspect to ensure that the patient or surrogate can articulate the critical elements of the instructions. Informed, engaged patients and families are at the heart of good transitions. So let us consider not only the number and type of cookies we provide to our transitioning patients but also the size and characteristics of the cookie jar we use as our discharge instructions. Dr. Lett is a Society past president, past chair of the Society’s Transitions of Care Committee, and previous editor of this column. Dr. Saltsman (pictured above) is the section chief of geriatrics and transitional care for Lahey Health, Burlington, MA. He is the chair of the Society’s Transitions of Care Committee.