Sunday, November 26, 2017

Thanksgiving 2017

The nation pauses to give thanks for health and family and freedom.  As during any holiday or celebration, some of us are in the valley or have been there.  There is always a way forward, even if the pathway is obscured. 

We gather together.

The First Thanksgiving

We converse amiably.

'I'll kill you!'

We dine.

Blessed with bounty...

We talk turkey.

Pardon me?

Saturday, November 18, 2017

When Electronic Medical Records Crash

The computerized era has introduced all of us to a genre of errors that never existed during the archaic pen and paper era.   The paper medical chart I used during most of my career never ‘crashed’.  Now, when our electronic medical records (EMR) freezes, malfunctions, or simply goes on strike, our office is paralyzed.  Although I appear to the patients as a breathing and willing medical practitioner, I might as well be a storefront mannequin who appears lifelike, but cannot function.  We cannot access the patients’ records, write a prescription or enter a new office visit. 

Mannequins appear lifelife but don't function well.

Of course, like any business who faces this crisis, we expect instantaneous rescue from our IT professionals, as if we are their only client and they are permanently stationed in our waiting room just waiting for us to sound the alarm.

This is among one of the most frustrating aspects of EMR for medical professionals.   We simply don’t have the time or psychic reserve to absorb unexpected loss of computer service.  We are not playing computer games (although sometimes it feels as if we are.)  We have a live patient facing us as we face a blank screen.  It is frustrating and awkward.   The patients understand this reality as they undoubtedly have endured similar frustrations in their own lives.  

Yes, we resort to writing a note in longhand and scanning it into the EMR later, but this is problematic.  First, a scanned document cannot be ‘read’ by our EMR as this document is not ‘part of the EMR family’.  It can’t be tracked, as we do routinely with laboratory and x-ray data.  More importantly, I will be offering medical advice without any access to the prior medical record, which may span years.  If the patient has a complex, chronic condition with a history of extensive testing and medication changes, moving blindly could lead me into a blind alley or through a trap door.

I propose no solution to all of this.  No technological system can perform perfectly.  It’s another example of our ever increasing reliance and dependency on technology – more than we really need, in my view.  I have no choice but to accept EMR in my professional life.  But, there are opportunities when we can stand up and push technology back.

Do we really need Alexa to turn on our lights?

Sunday, November 12, 2017

Why Curbside Consults are Dangerous

One of the skills and stresses about being a doctor, is giving advice to or about patients we have never seen.  If readers think these are rare events, it happens nearly every day.  Often during weekend or evening hours when I am on call, my partners’ patients will call with questions on their condition or about their medications.  Radiology departments contact me during off hours with abnormal CAT scan results of patients I do not know.  Or, a doctor may call me during the day for some informal advice about one of his patients.  These physician-to-physician inquiries are called ‘curbside consults’, which are appropriate for simple questions that do not require a formal face to face consultations.

Physicians must be cautious when providing a curbside opinion on a patient he has not seen as even informal advice could result in legal exposure if the patient later files a medical malpractice claim.  Consider this hypothetical example.

An internist contacts a gastroenterologist for a curbside opinion on an elderly patient who had some mild rectal bleeding.  The internist suspects hemorrhoids and doesn’t want to refer the patient for a colonoscopy as the patient had one 3 years ago at which time hemorrhoids were discovered.  The gastroenterologist reassures the physician that the bleeding is probably from hemorrhoids, which is a very rationale conjecture.  But, it may be wrong.  The bleeding now may be from a colon cancer that was either missed on the last colonoscopy or has developed since.  The cancer won’t be discovered for another year.  Is the 'curbside' gastroenterologist responsible here?

I think so because, even though he hasn’t seen the patient, he has rendered medical advice directed toward a specific patient, rather than simply offer generic comments.  Indeed, the internist may have told the patient and his family that the 'curbside' gastroenterologist agreed that no testing was necessary.  Had the gastroenterologist pushed back against the internist and insisted on arranging for a colonoscopy or seeing the patient in the office, then the outcome may have been different.

Had I been asked for a curbside opinion regarding above inquiry, I would have been much more circumspect with my response, and ideally, I would have entered a chart note in my electronic medical records.  Memories of physicians and patients can fade over time.  I would feel more secure if my chart note recorded that I recommended that the patient be sent to me for an office consultation.

Some questions should never be answered ‘from the curb’.  I would not, for example, give informal advice to an internist about changing his patient’s medications for Crohn’s disease.

If I have any discomfort in responding to an inquiry on the phone, then I recommend an office visit when I can provide a thoughtful and informed opinion. 

Some inquiries are so innocuous that I respond readily even without entering a chart note.  These generic questions do not directly connect me to an actual patient.  To clarify, I will list a few examples.

What’s the proper schedule for the hepatitis B vaccine?
Is the generic for Nexium equally effective?
Are ulcers caused by stress?

There’s a skill set physicians need when we are advising strangers.  Sometimes, the skill is knowing when to remain silent or when to push back.  If you're not careful, it's easy to trip over the curb.

Sunday, November 5, 2017

Polypharmacy in the Elderly: Who's Responsible?

There's a common affliction that's rampant in my practice, but it's not a gastrointestinal condition.  It's called polypharmacy, and it refers to patients who are receiving a pile of prescription and other medications.  I see this daily in the office and in the hospital.   It's common enough to see patients who are receiving 10 or more medications, usually from 3 or 4 medical specialists. 

Of course, every doctor feels that he is prescribing only what is truly necessary.  If an individual has an internist, a cardiologist, a gastroenterologist, a urologist and a dermatologist which is not unusual - and each prescribes only 2 or 3 essential medicines, then polypharmacy is created.  Each day, the patient swallows a chemistry set.

First of all, I don't know how these patients, who are often elderly, manage the logistics of taking various medicines throughout the day and evening, before meals, after meals and at bedtime.  Who can keep track of this?  Nurses in the hospital can barely manage this overwhelming schedule.  This has to negatively affect one's quality of life as the daily calendar of events is predominantly pill popping events.  

Keep in mind that the drugs we doctors prescribe are not that smart.  Does the Nexium I prescribe to hundreds of patients only act on just the right amount of stomach acid to relieve the patient's reflux?  Doesn't the drug reach every organ of the body having potentially deleterious effects that we might not be aware of?  Could Nexium be interacting with other medicines in an unfavorable manner?  While we are quick to demonize stomach acid as an enemy of mankind, isn't the acid that Nexium is reducing there for a reason?  Are we smarter than a few million years of natural selection?

I'm betting on Darwin's theory.

Extrapolate the Nexium example above to a situation when 10 or 12 drugs are cruising throughout the body on a Fantastic Voyage journey, colliding with each other and smashing into organs far away from the drugs' intended targets.  

We also function in a culture where every symptom demands a pharmaceutical response.  While depression, hyperactivity and insomnia are real illnesses, can anyone dispute that the medical community is over prescribing medicines for these conditions?

I wonder how many folks who are suffering from unexplained nausea, balance issues, confusion, dizziness, falls, bowel disturbances and abdominal pain are actually getting a taste of their own medicine.   When they present these symptoms to their doctor, they may end up with yet another prescription thrown onto the pile, when the solution is to diminish the pile which is causing side-effects.

Challenge your internist and your specialists to verify that every drug is truly needed. Insist on the lowest dose that will accomplish the mission.  Are the doctors on your team communicating adequately with each other?  Is someone in charge? 

In my experience, the biggest risk factor for polypharmacy is polydoctor.   More medicines and more physicians aren't better medicine.  Primum non nocere, first do no harm, still deserves to be the mantra of the medical profession.  In medicine, less is more.  On your next visit, ask your doctor to please do less for you.