Electronic Medical Records - Broken Promises

I have written, or more accurately ranted, about electronic medical records (EMR) systems throughout this blog.  While the systems have clearly improved since their mandatory introduction into the medical universe, they have still not delivered on many of their promises.

Of course, EMR has brought tremendous advantages to the medical profession and we are all grateful for the technology.  But this progress has exacted a cost.  Many of them are clumsy to utilize.  When the technology breaks down or freezes, the office become paralyzed.  The systems are vulnerable to hackers who can exploit personal medical data or demand ransomware.  Many of the computerized notes  are so filled with pre-populated fluff carried over from prior visits, that it can be challenging to identify new medical information.  I often scroll through several pages in search of the physician’s thoughts and plans.  And a physician who is staring at a computer screen during an office visit will create a very different genre of a doctor-patient relationship. 

But here’s an EMR frustration that I am astonished is still torturing us.  In our digital era, different EMR systems cannot communicate with each other.  Indeed, one of the seductive promises of the EMR prophets was that physicians would have access to all of a patient’s medical data.  Imagine, for example, how useful this would be to an emergency room (ER) physician who is treating a sick patient who has been treated for the same condition elsewhere?

The Medical Records are in there somewhere!  

Every day in my office practice, I see patients with active conditions who have been treated by other physicians and at other hospital systems.  The patient before me with abdominal pain may have been seen for this in an ER a few weeks ago, and then seen by his own primary care physician days afterwards.  Shouldn’t I be able to have real time access to all of this data?  Wouldn’t this help me to make a more accurate diagnosis?  Might this prevent me from ordering an unnecessary medical test?  Is this vexing issue simply insurmountable?  ‘Is there no app for this’?

Patients are as frustrated over this as we are.   “Alexa, please get my this patient’s CAT scan report!”

There is Too Much Technology in Medicine

As promised, here is the continuation of last week's post where I discussed the loss of physicians' diagnostic skills which have been largely replaced by technology.

Of course, the medical community celebrates the miracles that technology has brought us.  Innovation has improved our lives and will continue to do.  On this issue, there is no debate. But, as with many advances, there is a cost.  Here's my take on the downsides of the technologization of the practice of medicine.  

Could a CAT Scan Do Damage?

Readers, Scan Below!

• Overreliance on technology has cost zillions of dollars.
• Much of the overdiagnosis and overtreatment in our health care system – which I have decried on this blog – is caused by medical technology.
• Technology has strained the doctor-patient relationship.  It is often easier to order a scan than to have a deeper conversation with patient who needs advice and counsel, particularly when physicians’ schedules are jammed.
• CAT scans and their ilk regularly find unrelated ‘abnormalities’ that would remain dormant for life, but now assume a life of their own as doctors must pursue them. 
• Technology is not perfect, even though we all tend to regard it as the Holy Grail.  A negative test result may blind us to the truth if we are not vigilant.  A patient with stomach pain and a normal CAT scan can still be in deep trouble. 
• Patients have taken heed of our technology obsession.  They regularly ask their doctors for testing that they may not need.  Every doctor has had a patient facing him insisting that a CAT scan be done.  The public understandably believes that more testing is better medicine.  Of course, this is false premise but try convincing a patient and their family of this.  I know from my own family; they don’t get it and the medical profession and our payment system is responsible for it. (Patients are more enthusiastic for testing that the insurance companies will pay for)
• There are financial conflicts of interests that drive the overuse of technology.  Yes, medicine is a business and we would should expect that the normal forces of profit seeking are operative.
• Technology has not only eroded physicians’ physical exam talents but has also diminished doctors’ skill and enthusiasm in obtaining patients’ medical history, the important narrative that the patient communicates to the physician.   

I often hear and read presentations of patients' medical history where the 3^rd sentence is “…and the CAT scan showed…”   This premature intrusion of a technology result - a physician spoiler - immediately prejudices the doctor who should have been given time just to hear the patient’s own story.  If you are told in advance of an important future development in a mystery story, will you still read the book as carefully as you would have otherswise?  The danger for doctors who are given a sneak preview of events is that we become less attentive and vigilant which can lure us into false passages.

Can Doctors Still Examine Patients?

Does your doctor really know how to use a stethoscope or palpate your abdomen?

Today’s physicians do not have the physical exam skills that our predecessors did.  We can argue if this truth has diminished medical quality – I’m not sure that it has.  But it has completely changed how medicine today is practiced.  The reason for declining physician exam skills is that technology has largely supplanted physicians’ hands, eyes and ears.  In the olden days, the stethoscope was the diagnostic tool for examining hearts.  I spent a month as a medical student with a legendary cardiologist who could make all kinds of cardiac diagnoses right at the bedside using 2 advanced medical instruments known as ears.  Surgeons and gastroenterologists in years past had to make  diagnoses of acute appendicitis and other abdominal emergencies based on feel and their ‘gut’.  Neurologists made accurate diagnoses of stroke just using their clinical skills.

An Advanced Medical Instrument

These days, there is really no need to be sleuth with a stethoscope since any murmur or extra click will be followed by an echocardiogram.  I can’t recall a case of appendicitis in my career that didn’t involve a CAT scan to confirm a surgeon’s suspicion.   And, if a stroke is suspected, a head CAT scan will be arranged.

Since, medical technology has in many cases taken over the physical examination, doctors’ hands-on skills have decayed.  There is much less pressure for our exam skills to be superb since we know that some rescue scan or diagnostic test that does it better will follow.  Conversely, if a physician were seeing a patient with stomach pain, and there was no technology available, I surmise that this doctor would do a more careful exam than he otherwise would.  Get my point?

Are patients better served with more accurate technology to make and exclude diagnoses?  Some have and many haven’t.  We all celebrate how technology in medicine has revolutionized the profession and has saved and improved lives.  I rely upon this every day in my practice.  But we must acknowledge that this progress has exacted many costs.

What’s the harm with ordering a CAT scan?  After all, it’s non-invasive.  Next week, I will address this issue in detail giving you a true ‘peek behind the curtain’, the raison d’etre of this blog.  Feel free to offer your own thoughts on this issue on this post in advance of next week’s full disclosure.

Can a Doctor Do a Medical Procedure Without Consent?

Some time ago, I performed a colonoscopy on a patient who was having serious internal bleeding.  He had already received multiple transfusions since he was admitted to the hospital.  After obtaining informed consent for the procedure, I performed the colon exam.   I encountered blood throughout the entire colon, but saw no definite bleeding site, raising the possibility that the source of blood might be higher up than the colon, such as from the stomach.  I had not considered this possibility when I met the patient, but this was now plausible.  Can I proceed with the upper scope test, which the patient did not consent to, while the patient is still sedated from the colon exam?

Could the Stomach be the Culprit?

Seasoned gastroenterologists can usually predict the site of internal bleeding based on numerous medical facts, but there are times that we are surprised or misled.  Patients don’t always behave according to the textbook presentations we learned. 

At this point, which of the following options are most reasonable?

• Do not scope the stomach now as the patient is still sedated from the colonoscopy and cannot give consent.  Once the patient has awakened and recovered, discuss the new diagnostic hypothesis and obtain informed consent to examine the stomach to look for a bleeding site.
• Forge ahead with the stomach scope exam while the patient is still sedated.  Assume informed consent and proceed.

I opted for the latter option.  Ethically, I felt that I was on terra firma as the patient had already consented to a colon exam to evaluate the bleeding.  It seemed absurd that he would have consented for a colonoscopy but withhold consent for a stomach exam that was now deemed essential to pursue the same diagnostic mission.   Moreover, the patient had received multiple transfusions so there was clearly a medical urgency to identify the bleeding site.

Assuming consent for a subsequent procedure that was not initially anticipated is rational and defensible if the test is clearly in parallel with the medical evaluation and there is a medical exigency present.  Presuming informed consent, however, is an exceptional event.  Physicians are not permitted to go rogue. 

The blood in the colon didn’t come from the colon, as I had wrongly suspected.  It came from a duodenal ulcer just beyond the stomach, which I easily spotted with the stomach scope exam. 

This patient didn’t go by the book.  Sometimes, we physicians need to deviate from established policies also. 

Whistleblower Holiday Cheer 2019!

‘Twas the night before Christmas,

And all through the House,

All the creatures were plotting,

Claiming Trump was a….RAT!

We have Schiff and Nadler

And, of course, Madame Speaker,

Who are as transparent,

As the Anonymous leaker!

Our Democracy might fail,

Our Dem statesmen teach,

So what choice do they have

But to hold hands and impeach.

When Mueller fell flat,

They all felt the pain,

But, the Lord heard their prayers

And POOF – came Ukraine!

With so many versions

How could we know

If Trump really offered

A quid pro quo.

The witnesses swore

Trump’s plan was – Extort!

Jim Jordan responded

With a loud bleating snort.

And with all of this static

Some can’t be heard,

When the candidates speak,

We hear nary a word.

So Warren and Bernie,

(And Blitzen and Dasher)

Have been squelched and muzzled.

By the Candidate Crashers.

When it all ends

And the Senate says, No!

No minds will change.

I told you so!

While the republic survives,

And impeachment will fail,

This won’t be the end

Of this harrowing tale. 

It’s easy to break

And harder to build

Has hope for our healing

Already been killed?

Let’s join together

In this land of plenty,

As we strive to get through

2020!

Joy and Peace!

'Doctor, What Would You Do?'

There’s a phrase that every physician hears repeatedly from patients, that requires a nuanced response.

Doctor, what would you do if you were me?

There are variations on this inquiry, such as ‘what would you do if I were your father’, but they all are aiming at the same target.  The patient, or often the patient’s family, asks the doctor what advice the physician would choose if he were in the patient’s place.  For example, if the physician were the patient would he opt for:

• Surgery
• Chemotherapy
• Experimental treatment
• Watchful waiting
• A second opinion
• A third opinion
• Alternative medicine
• Acupuncture
• Hospice

'Doctor, what would you do?

Patients erroneously believe that this form of inquiry is the magic bullet of finding out what the physician’s truly best advice is for a particular medical circumstance.  After all, if the doctor would recommend a treatment for his own mom, then surely this must be the best option.

Except, it isn’t.  Here’s why.

Physicians, as members of the human species, cannot be as objective with regard their own families or themselves as they are with their own patients.  This is why wise physicians do not treat family members.  Indeed, every physician has heard vignettes of inferior care that was rendered by a doctor to a close family member.   The reasons for this are beyond what I can express here, but the core of the explanation is tainted physician judgement resulting in delayed diagnoses and incorrect treatments.  When a close relative recently approached me to discuss recurrent stomach aches, I gave her good advice.  Make an appointment with a doctor.

Another circumstance when physicians are known to provide inferior care secondary to judgement lapses is when the doctor is treating a celebrity or VIP.

If you ask your doctor what he would do if he were you, the doctor’s response should be an explanation of why he can’t give you the answer you seek.

Are Female Gynecologists more Sensitive than Males?

Would you rather be right, wrong or interesting?  

When I was a medical student rotating on the OB-GYN rotation, the issue arose if female OB-GYNs were more sympathetic to patients than their male colleagues were.  Before reading on, what's your opinion here?

There was a view that females in this medical specialty would have more empathy for patients as they may have experienced menstrual cramps, pelvic pain and childbirth.  No man can relate to these symptoms and they might be expected to be more dismissive or distant over these ‘minor hormonal disturbances’.  In other words, men just don't get it.

A discrete GYN exam 200 years ago

It is true that one who has ‘walked the walk’ may connect more closely with one who hasn't.  For example, since I have never suffered from an addiction, I can never counsel a drug addict or alcoholic with the same street cred as one who has triumphed over these afflictions.

The chief of the OB-GYN department at my medical school was sitting with us students as this discussion unfolded.  The chief was a veteran physician and had trained several scores of OB-GYN physicians.  While this is not a scientific study, in this physician’s opinion, male gynecologists and obstetricians in the training program were consistently kinder and more understanding to patients than female physicians were.  The chief speculated that females, contrary to prevailing intuition, might be less empathic as they’ve had menstrual cramps, etc., and' they’re not that bad’.  Men, in contrast, might be more sympathetic to female pains and conditions as they tended to be spooked by symptoms that they will never have.

I am not offering an opinion on the issue, but am simply relating one chief's view.

Do you think the chief was male or female?  Might this have influenced the chief’s conclusion?

Is the chief right or wrong?   Can’t say, but it was interesting and I’ve never forgotten it, even 30 years later.