On inpatient medical services, it’s common to hear patients’ laboratory results presented with statements sounding like “CALCE-MAG-FOSS were normal.” The efficiency of this reporting is part of the secret handshake of one insider communicating with another. Contraction of three serum ions resembles children learning the alphabet through song: A, B, C, D are sung as discrete letters, but eventually LMNO spills out all at once as if it were one of the English alphabet’s 23 letters. Singing “elemeno” isn’t a problem unless children actually believe it’s a single letter.
But often verbal constructions and other shortcuts are tightly linked with behaviors. Not only do some physicians report the results of serum calcium, magnesium, and phosphate simultaneously, they often order these tests together — a reflex where their behavior mirrors the contractions in their speech — even though there are many more reasons to check a calcium than a magnesium. The result here is needless tests and avoidable costs.
We call this the LMNO problem: Contractions of language or contractions of behavior that reinforce each other. Once you recognize your first LMNO problem, you see them all over medicine.
Many patients in our neurointensive care units receive tube feedings, and few of them were achieving their recommended calorie or protein targets, nutrition deficits that prolong care and delay recovery. One culprit was the order, “NPO after midnight.” Like LMNO, it rolls off the tongue, but in this case it also finds its way into the orders for any patient with a procedure planned the next day. For people who eat orally, NPO (nil per os, or nothing by mouth) after midnight really means “don’t give the patient breakfast.” Turning off tube feedings from midnight to 8 a.m. loses a third of a day’s intake in a setting where it’s hard to catch up later — worse if, as often happens, what was scheduled for 8 a.m. is postponed until 1 p.m. Procedures are safer when stomachs are empty, but for the many patients whose nutrition depends on liquid food delivered through a tube, the time between when feedings stop and a procedure begins has more consequence and needs more specificity.
It’s not clear which came first, the behavior or verbal contraction. Either way, breaking the behavioral habit seems harder once the verbal contraction takes hold. If you’re used to saying CALCE-MAG-FOSS, maybe it’s harder to order the calcium alone. Good design makes doing the right thing easier than the wrong thing — recycle aluminum cans in the bins with circular holes and paper in the bins with slots. In the jargon of medicine, we should also make the right thing easier to say, because the easiest thing to say often defines the path taken. Pharmaceutical companies name their molecules with improbable sequences of letters (alprazolam), but they assign brand names so easy to say you could read them backwards (Xanax). It’s no wonder that prescribing generic equivalents isn’t as high as it might be.
Mario Cuomo, the former New York governor, said you campaign in poetry and govern in prose. When we write, “NPO after midnight,” what we really mean is, “make sure there isn’t any food in this patient’s stomach before surgery.” But where’s the poetry in that? Patient care is governing, not campaigning, so poetic contractions in this context fall short, as many oversimplified campaign promises do.
In another example, the reflex order “VS Q4H” inevitably interrupts inpatients’ sleep to get their temperature, pulse, blood pressure, and respiratory rate measured round the clock, and it also wastes nursing resources because few patients need this much vigilance. Patients on one of our inpatient services were averaging only four hours of sleep a night, delaying recovery and lengthening stays. Among the tested interventions was changing the default to a “sleep-friendly order set” to minimize interruptions. Early results suggest a 30% reduction in interruptions and three more hours of patient sleep per night. Ingrained operational norms and busy care team members working on tight schedules make it hard to achieve patient goals, especially when the goal — better patient sleep — is typically unwitnessed and unmeasured. But it costs little to be more intentional about who really needs the “VS Q4H” that so easily rolls off the tongue.
Other simple medical orders, like “admit Mr. Smith,” aren’t always what they seem. Here, the order is more a behavioral contraction than a verbal one. For many patients in emergency rooms, what this really means is, “I’m a bit worried about him, so let’s keep an eye on him to make sure he’s safe.” Once, again, verbal and behavioral contractions reinforce each other, forming a cognitive shortcut, too. The easiest thing to say (“admit”) is also the easiest thing to do, because historically there has been no low-friction path to make sure discharged patients are watched over.
But an intervention called PATH, in which emergency medicine physicians are given the “practical alternative to hospitalization” of sending the patient home with a rapid follow-up, disassembles LMNO into just the letters needed — sometimes a next-day laboratory test, sometimes an infusion, sometimes a clinical exam, each of which might be possible outside the hospital.
We often can’t recognize our verbal or behavioral contractions until we see the individual letters spelled out. After instituting PATH, about 12% of patients about to be admitted were instead discharged, avoiding six hours of emergency room boarding and 3.4 hospital days per patient.
Not only is changing habits hard, but the need to do it is often unrecognized by the insiders who have already internalized the contracted speech, thought, or behavior. “Why don’t QAnon followers realize they are in a cult?” ask the people who believe 80-hour work weeks are normal.
But when non-experts question conventions (“why do it that way?”) or external forces like fewer nurses, no empty hospital beds, or negative margins create urgent reasons to reexamine each step of comfortable process, change is more possible.
Beyond recognition, the change itself doesn’t happen unless new ways of doing things are dramatically easier or more pleasant than the old ways. No one wants to leave patients underfed, but getting past blunt “NPO after midnight” orders has proven difficult in part because we haven’t yet been able to expand the contraction into something both specific and easy enough to match our complex intent. Interventions that change defaults, like sleep-friendly order sets, grease the path in the right direction, but sometimes you also need to impede the old path, perhaps by making staff sign in at patients’ doors at night to justify the interruption, or by making physicians explain why it’s important to check the magnesium when checking the calcium. Explicit friction management like this slows down the alphabet so you can hear the individual letters.
In the end, children learn that LMNO is made up of four letters, and that you can choose the ones you need with precision. Adults, too, can learn that the language we recite most reflexively could benefit from some scrutiny and refinement. Imprecisely directed actions don’t serve us well in the high stakes setting of medicine.
David A. Asch is an internal medicine physician and the John Morgan professor at the Perelman School of Medicine and the Wharton School at the University of Pennsylvania. Roy Rosin is chief innovation officer of Penn Medicine.