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In a recent Forbes editorial, conservative commentator John Goodman argues that the Texas Medical Board is sending the state back to “the middle ages” because they are trying to limit the practice of medicine in the absence of a face-to-face, doctor-patient relationship. He believes that telemedicine should have an unfettered role in healthcare – diagnosis and treatment should be available to anyone who wishes to share their medical record with a physician via phone. This improves access, saves money, and is the way of the future, he argues.
He is right that it costs less to call a stranger and receive a prescription via phone than it does to be examined by a physician in an office setting. But he is wrong that this represents quality healthcare. As I wrote in my last blog post, much is learned during the physical exam that you simply cannot ascertain without an in-person encounter. Moreover, if you’ve never met the patient before, it is even more likely that you do not understand the full context of a patient’s complaint. Access to their medical records can be helpful, but only so much as the records are thorough and easy to navigate. As the saying goes: garbage in, garbage out. And with EMRs these days, auto-populated data and carry-forward errors may form the bulk of the “narrative.”
Telemedicine works beautifully as an extension of a previously established relationship. Expanding a physician’s ability to connect with his/her patients remotely, saves money and improves access. But bypassing the personal knowledge piece assures lower quality care.
I currently see patients in the hospital setting. I run a busy consult service in several hospital systems, and I have access to a large number of medical records, test results, and expert analyses for each patient I meet. Out of curiosity, I’ve been tracking how my treatment plans change before and after I meet the patient. I read as much as possible in the medical record prior to my encounter, and ask myself what I expect to find and what I plan to do. When medical students are with me, we discuss this together – so that our time with the patient is focused on filling in our knowledge gaps.
After years of pre and post meeting analysis, I would say that 25% of my encounters result in a major treatment plan change, and 33% result in small but significant changes. Nearly 100% result in record clarifications or tweaks to my orders. That means that in roughly 1 in 4 cases, the patient’s chief complaint or diagnosis wasn’t what I expected, based on the medical record and consult request that I received from my peers.
If my educated presumptions (in an ideal setting for minimizing error) are wrong 25% of the time, what does this mean for telemedicine? The patient may believe that they need a simple renewal of their dizziness medicine, for example, but in reality they may be having heart problems, internal bleeding, or a dangerous infection. Let’s say for the sake of argument that the patient is correct about their needs up to 75% of the time. Are we comfortable with a >25% error rate in healthcare practiced between strangers?
Goodman’s cynical view of the Texas Medical Board’s blocking of telemedicine businesses for the sake of preserving member income does not tell the whole story. I myself have no dog in this fight, but would side with Texas on this one – because patients’ lives matter. We must find ways to expand physician reach without eroding the personal relationship that makes diagnosis and treatment more customized and accurate. Texas is not returning healthcare “to the middle ages” but bringing it forward to the modern age of personalized medicine. Telemedicine is the right platform for connecting known parties, but if the two are strangers – it’s like using Facebook without access to friends and family. An unsatisfying, and occasionally dangerous, proposition.
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Popular TV doctor, Gregory House’s favorite adage about patients is: “everybody lies.” I used to believe that this was a cynical and inaccurate statement, but I had to revisit it recently when faced with a patient whose signs and symptoms were consistent with a diagnosis that she vehemently denied.
A young woman was admitted to my rehab unit with brain damage of unclear cause. She adamantly denied drug or alcohol use, and I couldn’t help but wonder if she was suffering from a genetic or autoimmune disorder that the academic neurology team had somehow overlooked. I had recently read the New York Times best-seller, Brain on Fire and feared that I would be like one of those dismissive physicians who missed the author’s unusual diagnosis and nearly killed her from their inaction.
But staring me in the face were the specific physical manifestations of drug and alcohol abuse, though her urine toxicology screen proved she hadn’t used in the very recent past. I asked her again and again if she recalled any exposure to them – probing for an admission of even a small amount of recreational use. She remained adamant. An exhaustive work up had in fact revealed some vitamin deficiencies, the only hard evidence of anything that could explain her very real and devastating impairments. This was not a case of faking symptoms – at least I was sure of that much. Yet her situation continued to haunt me, because until she came clean about the cause of her condition, lingering doubt would drive me to continue the “million dollar work up.”
And for this young and desperately lonely person, the “million dollar work up” may have been her only chance at experiencing ongoing concern for her well being from others. If she admitted to drug use, then the only people who seemed to care about her (sadly, even if it was mostly because she could make a “great case for Grand Rounds”) would probably turn their backs. With the mystery solved, this fascinating neurological conundrum would become a garden variety drug abuser. A person who was, perhaps, not so much a victim as a perpetrator of their own condition.
I don’t believe that those whose conditions are contributed to by their behaviors receive poorer medical care (consider the smoker with lung cancer, or the person with multiple fractures from a bridge-jump suicide attempt – their quality of care will be similar to non-smokers with lung cancer or people with orthopedic needs from a motor vehicle accident). But there may be a subtle and unspoken judgmental attitude held by some of their caregivers and providers.
Fellow friend and blogger, Kerri Morrone Sparling suggests that fear of judgment, and the guilt and shame associated with self-induced harm, are the main reasons why people with diabetes may not come clean to their endocrinologists about their eating and exercise habits. She writes,
Finding enough confidence in myself to admit my shortcomings to my doctor, who I aim to impress with my efforts, was a tall order. For me, it took finding an endocrinologist I trusted with the truth, including the parts of the truth that weren’t so pretty. I know the best doctor for me is one who cares about my emotional response to diabetes, as well as my physical response. It took some trial-and-error, but eventually I found an endo who I felt didn’t judge, but listened and helped me find reasonable solutions to my problems with “reasonable” defined as something I would actually follow through on. Instead of a blanket response of “Do everything. Try harder,” my endo helps me build off of small successes in pursuit of better outcomes.
So patients lie to their doctors because they don’t want to be abandoned, judged, or shamed. And until they are quite certain that this will not happen to them, they are likely to continue withholding information from those who are ostensibly trying to help. The problem of lying does not rest squarely on the shoulders of patients – it is also the responsibility of physicians to make it safe for them to tell the truth. They will commit to honesty when we commit to compassion.
As I look back at my interactions with the young woman with the “mystery” illness, it is not so much the fear of missing the right diagnosis that haunts me now. It is that I did not make her feel safe enough to tell me the truth. In the end, the “million dollar work up” offered her little value for the cost and used up precious healthcare resources.
What she needed was a safe place to live, a supportive environment, a program for drug counseling, and job training for those with disabilities. I missed out on really helping this patient because I was more comfortable with searching for a rare diagnosis than pursuing treatment for the all-too-common, nebulous cycle of social ills that poverty, drugs and abuse cause. Maybe I wanted to believe her lie because at least then there was a chance I could fix her?
As it turns out, I was as invested in her lie as she was – we just had different reasons for it. While she did not want to be abandoned or shamed, I did not want to have to face the fact that I had very little to offer her.
Dr. House was right – under certain circumstances, patients are likely to lie. The other side of the coin, though rarely discussed, is that sometimes doctors are complicit in keeping those lies going.
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It’s no secret that physicians are experiencing burnout at an exponentially increasing rate in our progressively bureaucratic healthcare system. Many are looking for “alternative careers” as their salvation. I receive emails from physicians all the time, asking for advice about getting out of clinical medicine, since I have spent a few years outside it myself. As my own career pendulum has swung from full time clinical work to full time editorial and/or consulting work, I’ve found that the best mix is somewhere in between.
If you’re like me, you’re happiest using both halves of your brain. You have a creative side (I’m a cartoonist and blogger) and an analytic side (hospital-based physician). It’s not easy to make a living as a cartoonist or writer, and it’s soul-sucking to work 80 hour weeks in the hospital without rest. So how do you make a living, but participate in all the things you love? You work as a traveling physician (aka locum tenens) one third of your time, and spend the other two-thirds doing the creative things you also enjoy.
“But I couldn’t survive on 1/3 of my salary,” you say. Actually, I make the equivalent of a full-time academic physiatrist salary while working ~14 weeks a year as a traveling physician. Really? Yes, really. Because when I’m filling in at a hospital with an acute need, the work hours are long, and I’m paid by the hour. It can be grueling, but it is short, and the pay is fair so morale remains high. Drawing a flat employee salary (and then often discovering that the work load requires double the time estimated by the employer) can cause a lot of unconscious resentment. But when you are paid for your time, long hours aren’t as dread-worthy. This is what attorneys have been doing from day one, so why not physicians?
“But if all physicians suddenly dropped to half or 1/3 time, wouldn’t that do irreparable damage to patient access?” you cry. Yes, it could be catastrophic. However, if physicians stay the course and do nothing about our burnout, then the powers that be will continue tightening the vice – targeting physician reimbursement, increasing the burden of bureaucratic monitoring, pay for performance measures, and meeting “meaningless abuse” requirements for our electronic medical records systems. If there are no consequences to their actions, why would they ever stop?
I don’t think that most physicians will read this blog post and quit their jobs. I’m not worried about a sudden reduction in the physician work force. What I am offering is a suggestion for those of you who have a secret passion outside of clinical practice – a pathway that allows you to continue practicing medicine, and also enjoy cultivating your other talents. I’m hoping my advice will actually reduce the full drop out rate (if you believe the polls, up to 60% of PCPs would retire today if they had the means) to partial drop out rate (keeping those wanting to quit completely working part time).
So if there’s something you’ve always wanted to do (A non-profit endeavor? A low-paying, but rewarding job? Running a small business that can’t pay all the bills but is fun to do?) I say do it! Life is too short to get caught on the clinical treadmill, driving your spirits into the ground. You love your patients but can’t tolerate the work pace? Don’t quit altogether… you can still be a fantastic, caring, clinician in fewer hours/week and make the salary you need to maintain a reasonable lifestyle.
Please see my previous blog post to gain more insight into whether or not locum tenens might work for you.
And here’s a video of my recent thoughts about locum tenens work:
The Benefits Of Locum Tenens Work
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Moose, A Therapy Pet In Idaho
As a traveling physician, I’m often asked if I have a favorite place to work. Since I have licenses in 14 states, I have an usual vantage point from which to compare hospitals. I know that people who ask this question presume that my answer will be heavily influenced by the town where the job is located, and all the associated extra-curriculars, environmental peculiarities (ocean, mountains, desert), and potential amenities. The truth is that very little of that is important. Over the years I’ve found that it doesn’t matter so much where you are, as whom you’re with.
As I’ve argued previously, true quality health care is not always predicted by reputation or academic prowess. It has a lot more to do with local hospital culture, and how invested the staff are in giving patients their all. In my experience, some of the very best institutions (in terms of reduced medical error rates, evidence-based practices, and an avoidance of over-testing/treating) are in rural areas. They are not on the America’s Best Hospitals list, but are hidden gems scattered throughout the country. Of course, I’ve also seen some abysmal care in out-of-the way places. My point is that hospital location and reputation is not directly correlated with career satisfaction or excellent patient care.
My favorite hospital is populated by perpetually cheerful staff. Their energy, enthusiasm, and constant supportiveness is remarkable. I once commented that I felt like a therapy pet when I arrived on the unit – everyone was so happy to see me, it was as if I were a golden retriever who had shown up for play time. That feeling can carry me through the most difficult work hours or complicated patient problems. It is so emotionally sunny in that hospital that the surrounding environment could be an Alaskan winter and I’d be ok with it.
Alternatively, there are hospitals where I’m regularly greeted with all the affection that Jerry shows Newman in the Seinfeld sitcom. You know, the eye-rolling, sarcasm-dripping “Helloooo Newman…” Yeah. In those hospitals where I’m made to feel like an unwanted nuisance, time goes by so slowly I can barely stand it. I fight to keep my spirits up for my patients’ sakes, but in the end, the negativity takes its toll. I could be located in the middle of northern California wine country at harvest season and want to get the first flight out. Seriously, your micro-environment is so critical to your happiness. Do not underestimate the importance of liking your peers when you choose your job.
Which leads me to my final point – if you’re thinking about relocating, but aren’t sure if you’ll be happy, why not “try before you buy?” Become a traveling physician (aka locum tenens) for a while to gain some exposure to different places and work environments. Your pre-conceived notions may be off-base. You may fall in love with a place you wouldn’t have thought twice about based on a state map… Because a map won’t tell you where you’ll be welcomed with open arms, versus ostracized by hostile peers. Find out if you’ll be a Newman or a therapy pet at your next hospital. It makes all the difference in the world.
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The digital revolution in healthcare has transformed most hospitals into EMR-dependent worksites, dotted with computer terminals that receive more attention than the patients themselves. I admit that my own yearning for the “good old days” was beginning to wane, as my memory of paper charting and a patient-focused culture was becoming a distant memory. That is, until I filled in for a physician at a rural hospital where digital mandates, like a bad zombie movie, had bitten their victim but his full conversion to undead status had not been completed. At this hospital in its “incubation period,” electronic records consisted of collated scans of hand-written notes, rather than auto-populated templates. I’m not necessarily recommending the return of the microfiche, but what I experienced in this environment surprised me.
1. Everyone read my notes. Because everything I wrote was relevant (not just a re-hash of data from another part of the medical record), reading became high-yield. Just as people have adapted to ignoring internet advertising (Does anyone even look at the right hand rails of web pages anymore?), EMR-users have become accustomed to skimming and ignoring notes because the “nuggets” of useful input are so sparse and difficult to find that no has time to do so. The entire team was more informed and up to date with my treatment plan because they could easily read what I was thinking.
2. I was able to draw diagrams again. Sometimes a picture is worth 1000 words – and when given a pen and paper, it is great to have the chance to quickly draw a wound site, or visually capture the anatomical concerns a patient may have, or even add an arrow, underline, or circle for emphasis. Thorough neuro exams are so much easier to document with stick figures and motor scores/reflexes added.
3. I could see at a glance if a consultant had stopped by to see a patient. It used to be customary for specialists to leave a note in the paper record immediately after examining a patient. If they didn’t have time to jot down a full consult, they would at least leave me their summary statement – with critical conclusions and next steps. It was a real time-saver to know when a consulting physician had evaluated a patient and get their key feedback if you missed them in person.
Nowadays consultants often see patients and order tests and medications in the EMR without speaking to the requesting attending physician. It may take days for their notes or dictation to show up in the electronic medical record, and depending on the complexity of the system, they may be nearly impossible to find. The result is redundant phone calling (asking the consultant’s admin, NP, PA etc. if they know if he’s seen the patient and what the plan is), and sometimes missed steps in the timely ordering of tests and procedures. At times I simply resort to asking the patient if Dr. So-And-So has stopped by, and if they know what he was planning to do. This doesn’t inspire confidence on the patient’s part, I can tell you.
4. I could order anything I wanted. EMR order entry systems force you to select from drop down menus that may not reflect your intentions. When you have a pen and paper – imagine this – you can very clearly and accurately capture what you’d like to order for the patient! There is no confusion about drug taper schedules, wound care instructions, weight bearing status, exercise precautions. It’s all as clear as free text. You can even explain why substitutes are not acceptable, thus heading off a follow up pharmacist call.
5. The patient became the focus. Since I didn’t need to spend all my time entering data into a computer system in real time, I was able to focus more carefully and clearly on the patients. My attention was not constantly being distracted by EMR alerts, unimportant drug interaction warnings, or forced entry of irrelevant information in order to complete a task. I felt more relaxed, I had more time to think, and I got more important work done.
In conclusion, it is obvious to me that we have a long way to go in making EMRs fit our natural pre-zombification hospital workflow. At the very least, we should be developing the following tools:
1. We need better ways to separate the signal from the noise. Even something as simple as a different font color for the new information that we doctors enter (in a given progress note) would help the eye latch on to what’s important. There should be a simple, visual way to distinguish between template and free text.
2. We need a pen feature that allows authors to signify emphasis. Wouldn’t it be nice if there could be an overlay that allowed us to circle words or add arrows or underlines? If the TV weather man can do this on his digital map, why can’t EMRs allow this layer? For example, physicians would like to circle lab values that are changing, and indicate the direction of change.
3. We need boxes where we can draw diagrams. A simple tablet function would be easy enough to enable. Sure it would be nice to have a stylus, but I’d settle for mouse or track pad entry. This is not a feature of most EMRs I’ve used, but could easily become one. Perhaps not everyone will want to use this feature, but for the artistic among us, it would be a god-send.
4. We need a Four-Square check in type feature so that physicians immediately know if their patient has been seen by the requested consultants. Their impressions should be quickly accessible (perhaps with a voice text to the ordering MD) while their formal consultation notes are grinding their way through the system days later.
5. We need to pare down the unnecessary EMR alerts, and off load data entry required to meet billing requirements to non-clinical staff. Physicians need to focus on their patient care, not spin their wheels figuring out coding subtleties and CMS documentation requirements that could be completed by others.
6. We need more flexibility in data order entry – so that treatment intentions are captured, not forced into an ill-fitting box. Currently, physicians are finding ways to free text their orders in bizarre “work arounds” just to get them on the record somewhere. This is a recipe for disaster, as lost orders are fairly commonplace when staff aren’t on the same page regarding where to look for free text orders. I feel badly for the nurses, since “note to nurse” seems to be the favored way to enter a complicated pharmacy order.
I am grateful that I got one last look at hospital care as it used to be – so that I can put my finger on why our new digital system is not working well. I just hope that my suggestions help to make processes better for all of us medical zombies in the new digital world.
More advice for EMR Vendors here.
Pluses and minuses of EMRs.