Sunday, March 27, 2022

EMR - Promises Made, Promises Broken

 Over the past 15 years or so, I have endured several electronic medical record (EMR) systems. Indeed, there is an entire category, EMR Quality, on this blog where I share with readers the good, the bad and the ugly in the EMR space.  If you are suffering from insomnia, I invite you to review these posts nightly.

When EMR was creeping onto the medical landscape, physician grunts like me were salivating over the prospect that one of our thorniest and frustrating challenges was about to be solved.  EMR promised that all of our patients’ records could be accessed with a couple of keystrokes in our own offices.  This made sense as we all knew that the digital world could create linkages that would permit access to all of a patient’s medical experiences.  Regrettably, this promise that was made to medical professionals and the public remains unfulfilled.

Here’s why physicians were so ripe for the EMR seduction.  Consider this typical scenario in the pre-EMR era.

A patient comes to my office with stomach pain.  She was seen for this complaint at 2 local emergency rooms (ER) which fully evaluated the patient with laboratory studies, CAT scans, an EKG and history and physical examinations  (It is likely that the 2nd emergency room repeated everything that was done in the 1st emergency room as they might not have known of the initial ER visit or they had difficulty obtaining the records, especially if the 2nd visit occurred at night.)  The patient then followed up with her primary care physician (PCP) who repeated labs that he told her were abnormal in the emergency room.

Seeing patients without records was like wearing a blindfold.

When I see such a patient today, I may have none of the above records when the patient is before me.  Do readers think that these records might be helpful  to properly advise the patient?   If the patient tells me that the CAT scan results were normal, do I rely upon this without viewing the actual reports?  When she tells me that the first ER physician sent her home with some kind of antibiotic, which the 2nd ER physician told her wasn’t necessary, might I need to know more about this?  

Every physician over a certain age can recall thousands of similar scenarios.  In my hypothetical vignette above, in the olden days we would send both ER’s and the PCP signed authorizations to forward the medical records to my office.  It might take weeks to hear back.  Or we might not hear back at all.  Or we might get only a portion of the requested records.  Or, we might get records we didn’t request at all.  There were instances, for example, when I requested a CAT scan report and a mammogram result arrived weeks later.  

Can you imagine how difficult it is to treat the patient above who had ongoing abdominal pain without the prior records?

Can you imagine how often patients have unnecessary medical testing that had already been done elsewhere but this was not known to the ordering physician?

Can you imagine why medical professionals believed the seduction that EMR was the holy grail for accessing patients’ medical data from near and far?




Sunday, March 20, 2022

Is the West Doing Enough for Ukraine?

 The world is watching as a maniacal dictator methodically levels a country, displaces millions of citizens and attacks civilian infrastructure and lives.  The Ukrainian response has been unexpected, effective and downright inspiring.  To paraphrase JFK’s iconic remark in a 1963 speech in West Berlin, ich bin ein Berliner, we are all Ukrainians today.

By all accounts, the Russian military assault or war or invasion has stalled.  Their current ‘military’ strategy now appears to be that if you can’t occupy a Ukrainian city, then destroy it.  The ghastly footage is reminiscent of newsreel footage from London in 1941, when the city was bombed for months by another maniacal dictator.  The entire world, except one country, is aware of the deliberate targeting of maternity wards, schools, residential neighborhoods and civilians.  Of course, the Russians deny all of this and maintain that they are liberating Ukraine from genocide and other crimes.

The West, under the guidance of the American administration, has responded superbly, certainly beyond expectations.  Americans are united over this issue more than any other issue in recent times.  While there are additional actions contemplated to support Ukraine and to isolate Russia, we have generally hit all of the right notes, short of entering the conflict directly.  There are debates over sending aircraft into Ukraine or cutting off the purchase of all Russian energy. 

Many counsel restraint so as not to escalate the situation and risk a Russian response.  But who is the aggressor and the escalator here?  Who should be dictating the terms?

Should we hold back on certain actions because we fear the unlawful and immoral aggressor might act out? 

What will be the cost to free peoples if Ukraine is lost or dismembered?

Does anyone maintain that if Ukraine is Russified, that Putin’s appetite for expansion will have been satisfied?

Isn’t it easier and preferred to crush a bully sooner than later?  Had we responded differently in 2014 when Russia seized the Crimea, would we be in the current situation now?  I doubt it.

Of course, I don’t know the right answers here.  I trust that seasoned professionals in a broad coalition of nations are carefully weighing the risks and benefits of a variety of actions.  But as a general principle, I don’t support allowing a murderous aggressor to be limiting and confining our actions to save millions of people who only seek to be free and to be left alone.  We should be restraining his actions.

Many years after the Rwandan genocide, President Bill Clinton expressed regret for failing to respond.  Years from now, will the world be issuing a similar statement?

Sunday, March 13, 2022

A Plea for Medical Education Reform

On the day before writing this, I attended a seminar on medical professionalism.  The room was filled with physicians at all stages of our careers.  I enjoy opportunities to think about aspects of my profession that are beyond the digestive organs that I dally with daily.   At the seminar, a video clip was shown from the 1991 movie The Doctor.  The scene depicted an attending physician berating an intern in the presence of the medical team after he casually referred to the next patient to be seen as being ‘terminal’ without identifying him by name.  If fact, it became clear that the young doctor did not even know the patient’s name.  While the attending physician was correct to recognize that patients are living breathing human beings, not diseases or hospital room numbers, it was a breach of professionalism to humiliate an intern in public.

After a few comments were offered by seminar attendees chastising the senior physician’s cruel approach to an intern, I raised my hand.  I shared that his behavior was very typical of my medical school experience in NYC decades ago.  On a regular basis, I and other students were humiliated.  It seemed that abusive behavior and publicly exposing the ignorance of team members who are lower on the medical hierarchy was an actual pedagogic technique.  I asked at the seminar  if others in the room had  similar experiences and nearly every hand was raised. Indeed, very recently I spoke with a 3rd year medical student who is attending a different medical school in NYC, and the vignettes she shared were very reminiscent of my student days.

Here’s a typical medical hierarchy schema:

Attending Physician
Chief Resident
3rd Year Resident
2nd Year Resident
Medical Student
Medical Student’s Pets
Pet's Chew Toys

To paraphrase a common aphorism, the excrement flows downhill.

The hapless intern gets blamed for everything and is eligible for direct criticism from any of the layers above..   If the intern is up all night and performs a hundred tasks admirably, but has not yet had time to check on a lab result, guess what feedback he or she is likely to hear when the team assembles in the morning?   To those who are outside of the medical profession, imagine that you are an intern.  You are given tremendous responsibility, often without adequate supervision, with a very limited medical knowledge base while suffering from chronic sleep deprivation.   I’ll let readers ponder if adding public humiliation to the intern’s job description is likely to enhance job performance and professionalism.   (I’ll give you a hint.  It doesn’t.)  It is more likely to create jaded interns who will later assume an abusive posture as they ascend the medical hierarchy. 

A somnambulating intern cares for complex patients.

The intern has but one avenue of relief.  While he or she is low on the ladder, luckily the medical students hang on the lowest rung below.   So, if the intern feels a need to unload, guess who the target will be?

Of course, there were and are physician role models very different from those I have described above.  But, the darker culture I have presented still exists.   If you were designing a medical training system to cultivate and model humanity, empathy and compassion, would it resemble the one I described? 

Sunday, March 6, 2022

Reforming Medical Education

Medical school, residency and specialty fellowship cannot prepare physicians for every eventuality.  Many important skills must be acquired on the job.  And, of course, physicians need to remain current with respect to cognitive and procedural advancements.  Here are just few critical subjects that I was not prepared for when I entered the healing profession.

What happened to my phone medicine lectures?

  • Phone medicine.  Treating a patient with abdominal pain at night on the phone requires different skills than when the patient is in my exam room. And, te phone call may be the first time I have ever spoken to this patient.
  • Breaking bad news to patients and their families.  Wouldn’t you think that we would have received training for such a critical skill?
  • Nutrition.  Patients are understandably amazed at my paucity of nutritional knowledge.  I suspect that most gastroenterologists can make the same claim.  Wouldn't you think that nutrition science would be part of a gastroenterologist's skill set?
  • Leadership skills   I have done my best in 30 years to treat my staff well, earn their loyalty, reward their performance and to set an example.  I hope I have done well in this regard, but I have had no formal instruction in this discipline.
  • Attracting patient referrals from potential referring physicians.   Might this important to a medical practice?
  • Caring for difficult and demanding patients.  It’s easy to treat cooperative and appreciative patients.   But, caring for patients who are angry or entitled requires special skills.  Shouldn’t these be taught?
And, we never received any training in the business aspects of the profession.  I was in private practice for 20 years, although I am currently a happily employed physician.  As a private business owner,  I had to grapple with overhead, payroll, medical coverage and retirement benefits for my staff, landlord issues, tax and accounting issues, scope purchases and repair, physician referral patterns to the practice,  cash flow, our competition and office personnel issues..   How much training in these skills do you readers think I have had?  Let me enlighten you. Zero!   I was smart enough, however, to know how ill equipped I was so we hired real professionals to make it all work smoothly.

Perhaps, medical educators should have a word with us grunts in the field to find out what was omitted in our training.