Sunday, October 22, 2017

The Curse of Medical Records Documentation

Let me post a question that neither I nor readers can answer.
How much of what I do during the course of a day directly benefits patients?
Perhaps, I don’t want to really know as I would be dismayed at how much of my effort benefits no one. Ask a nurse who works on a hospital ward, how much of his or her effort is directly applied to patient care.  I would recommend that you have a double dose of antacid in hand – one dose for you and the other for the nurse. 

Just today, I was gently reproved by a hospital physician administrator for a lapse in one of my recent progress notes, which I write after seeing every hospital patient I consult on.  Which of the following transgressions do you think I was cited for?  Only one answer is correct.
  • I did not perform an adequate physical examination
  • I failed to address the results of an abnormal CAT scan
  • I neglected to write the time of day along with the date of the note.
  • I did not discuss the case with the patient’s family.
Just last week at our medical staff meeting, all physicians were told of the requirement to record the exact time, as well as the date, of our hospital visits.   This requirement, which is not new, is not to improve patient care.  It is a requirement imposed by the Joint Commission, which certifies that a hospital is complying with all rules and regulations.   I would like my readers to know that in over a quarter of a century of hospital practice, the visit times were recorded in 1-2% of all hospital notes of all physicians.  No physician has felt that the lack of recorded visit times negatively affected patient care.   Writing down the time may seem to readers to be just a minor irritant which takes only a few seconds.  It is, however, a symptom of documentation requirements that have run amok.

When the Joint Commission visits a hospital, the entire medical and administrative staff are on edge.  Why?  Because there are hundreds of requirements of dubious value that will be assessed  I support the Commission’s mission and recognize that many of the requirements are completely valid.  We want clean operating rooms, safe parking lots and a culture of respecting patients’ privacy.  But, trust me, many of the mandates from them can be trivial or absurd.


Colonoscopy Wildfire!

As an example, in our ambulatory surgery center where we do colonoscopies, we are required by the government to declare before every procedure if the patient is facing a fire risk.  Please do not ask me to explain this, as I am incapable.  Apparently, because we administer oxygen and use cautery, there is a flammability risk.

I want to reassure my current and future patients that to date our endoscopy center has been a flame free zone.  Moreover, the only instance where a firefighter was in our office was when he was getting a colonoscopy performed. 

The public would be shocked and outraged to learn how much of our time is spent racing on the hamster wheel, a difficult and timewasting exercise that yields no progress. 

Sunday, October 15, 2017

I'm Taking a Knee on Journalism

Thanks to NFL players, our national anthem is getting more attention than ever.  Keep in mind that many of us could not recite its words without error, and fewer of us have the range to sing it.  Even fewer can cite the historical event being described.  This is the latest, but not the last, example of a solvable issue that is being exploited to divide us.  I lament that so many of controversial issues ricocheting in the public square are similarly solvable, and yet remain combustible.

The media stokes these conflicts, in my view.  Listen critically to how CNN and other networks package and deliver the news.   Not only is the reportage suffused with editorial content and slant, but it sows overt division and partisanship by design.  

Consider the following two hypothetical questions from a TV reporter.  Which one would the network be likely to air?

“Senator, what is your plan for tax reform?”

“Senator, the leader of the opposing party attacked your tax policy as a cruel attack on working families.  Is he right?”

The 2nd example, in my opinion, improves television ratings at the expense of journalistic professionalism.   

Many cable ‘news’ broadcasts have become extended panel discussions where folks along the political spectrum talk over one another spewing forth predictable drivel in a rhetorical food fight.   Again, these performances may be spirited and entertaining, but they are actually a demonstration by the networks that conflict sells. 


Knees in the News!

The ‘take a knee’ issue has been morphed from its original intent to protest against racial injustice in the criminal justice system to venerating the anthem and the flag.  Of course, there was a pathway forward had calmer minds and listening ears prevailed.  Why solve a problem when conflict can advance your agenda?   Peoples’ positions can harden despite that they have lost sight of the actual issue before them.

Are NFL players who are ‘on the clock’ in uniform permitted to protest on the sidelines?  Although I am not an attorney, I am not certain that sideline player protesting is constitutionally protected, as would speech be in the public square.   Would owners be entitled to issue a restraining directive if the players' actions were driving away fans and profits?  Would a racist player be permitted to engage in a hateful gesture while in uniform on the sidelines?  Lawyers reading this post can enlighten us if an owner can lawfully require that all players stand respectfully during the anthem. 

 In our medical practice, if our staff all wore shirts with a message that stated, ‘I SUPPORT EUTHANASIA’, would the physician owners have a right to limit this speech?

Regardless of one’s view on the legality or propriety of taking a knee, this issue did not have to have sliced the country apart.   I am not hopeful in the short run. As long as our leaders profit from our divisions, and with the public’s insatiable appetite for conflict,  the end zone will remain far out of reach.

Sunday, October 8, 2017

Why Are You Seeing A Gastroenterologist?

I write to you now from the west side of Cleveland in a coffee shop with my legs perched upon a chair.  Just finished the last Op-Ed of interest in today’s New York Times.  Do I sound relaxed?

I rounded this morning at both of the community hospitals that we serve.  There is not a day that goes by that doesn’t have blogworthy moments.  If I had the time and the talent, I would post daily instead of weekly.   Read on for yet another true medical insider’s disclosure.

Gastroenterologists, as specialists, are called upon by other doctors to address digestive issues in their patients.  For example, our daily office schedule is filled with patients sent by primary care physicians who want our advice or our technical testing skills to evaluate individuals with abdominal pain, bowel issues, heartburn, rectal bleeding and various other symptoms.  The same process occurs when we are called to see hospital patients.   If a hospital admitting physician, who is usually a hospitalist, wants an opinion or a test that is beyond his knowledge or skill level, then we are called in to assist. 

The highest quality referring physicians are those who ask us a specific question after they have given the issue considerable thought.  Contrast the following 3 scenarios and decide which referring physician you would select as your own doctor.
  • “Dr. Gastro.  Just met this patient for the first time with a month of stomach aches.  Please evaluate.”
  • “Why did your doctor send you here?” queried Dr. Gastro to the patient.  “No idea,” responded the patient.
  • “Dr. Gastro, please evaluate my patient with upper abdominal pain. I thought it might be an ulcer, but the pain has not changed after a month of ulcer medication.  The pain is not typical of the usual abdominal conditions we see.  Do you think a CAT scan of the abdomen or a scope exam of the stomach would be the next step?  Open to your suggestions.”
Sometimes, we have to deduce the reason the patient is seeing us!
As readers can surmise, I favor primary care and referring physicians who give thought prior to consulting me.   There are many reasons today why primary care physicians pull the specialty consult trigger quickly.  Sometimes, busy internists simply don’t have the time available to deeply contemplate patients’ symptoms.   Physicians have also referred patients to specialists with the hope of gaining litigation protection by passing the patient up the chain, although the medical malpractice crusade has eased over the past few years.  Oftentimes, patients drive the specialty consultation process by asking to be sent to specialists. 

More often than you would think, we see patients in our office or in the hospital when neither the patient nor I have a clue why they are there.  This adds excitement to our task.  In addition to being diagnosticians, we must also serve as detectives, divining the reason that the patient is before us!



Sunday, October 1, 2017

Does Secretary Tom Price Deserve Forgiveness?

What is the explanation for Tom Price, a physician and current Secretary of Health and Human Services, taking private charter flights costing taxpayers hundreds of thousands of dollars?  Keep in mind that when Price was a conservative congressman from Georgia, he would have railed against such fiscal profligacy.  Is it hubris?  Entitlement?  Or, do folks who ascend to positions of power simply rationalize that such excesses are absolute necessities for getting the job done?

By the time this piece is posted, Dr. Price, an orthopedic surgeon, may have been surgically excised from the government without anesthesia. 

While his behavior is not quite Watergate, it was wrong.  And, if it was not wrong, it demonstrated impaired judgment.  And, if was not simply a repeated exercise of misjudgments, then it exhibited bad optics.  And, if it somehow passed the optics test, it was just dumb. 

Would Price have been able to explain these expensive charter flights to average folks, half of whom elected the president to drain the swamp?

I watched Price’s reaction to all of this in several interviews.  Yes, he agreed to pay ‘his share’ of the flight costs, which represented a small fraction of the total costs incurred.  He stated that his department would desist from private charter flights in the future.  He admitted that the ‘optics were bad’ and that previous cabinet secretaries have engaged in similar behavior without suffering repercussions.  He didn’t appear to me to be a man consumed with guilt. 

Sounding the shofar, a call to repentence.  

Personally, I don’t think that Price thinks that he did anything improper.  He never clearly states that he was wrong.  Admitting that he had an ‘optics issue’ is not the same as a confession.   Pointing out that prior government officials committed similar acts with impunity doesn’t sound like a man who knows he has done wrong. 

If he did feel that his flights were proper, then why would he pay back the government anything or stop future charters?    He could have resigned simply because the president was angry and displeased, without offering a pseudo-confession to a transgression he did not believe he had committed. 

Yesterday at sundown, ended the Jewish Day of Atonement, Yom Kippur.  This culminates a 10 day period of reflection and penitence.   We are instructed to beseech forgiveness from the people in our lives before petitioning the Almighty for absolution.  We cannot receive atonement unless we have first admitted our errors, repented for them and strive not to repeat them.  While I am not a rabbi, I doubt that the Almighty would grant us a pardon if we looked skyward and cried out:  “My Lord, forgive me for demonstrating bad optics!”

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