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Tilting At Windmills In Washington

Once again, I have to thank Dr. Val Jones for setting up the Putting Patients First event at the National Press Club in Washington DC on Friday. For a full summary of the pagentry, Dr. Rich does a much better job summarizing the whole event than I ever could, though I was uh, surprised about what he said of me (thanks, dude).

But one thing he forgot to mention was the moment when our moderator asked us what struck us most about what Congressman Paul Ryan had to say in his speech to us. I, being ever soft-spoken, piped up that I was struck that no one had read the bill and it was already on its way to the floor after being completely “marked up” early that very same morning.

So, while we might not have been chasing windmills at this event, I couldn’t help but wonder if it might come to this (with appologies to GA Harker, whose illustration I couldn’t help but Photoshop):

Click image to enlarge

-Wes

*This blog post was originally published at Dr. Wes*

Physician Burnout Is The Biggest Threat To Healthcare Reform

It was supposed to be delayed gratification.

After all, that’s the American way: work hard, put your nose to the grindstone, get good grades, be obsessively perfectionistic, then you’ll be rewarded if you just stay with it long enough. It’s the myth that perpetuated through medical school, residency and fellowship, and our poor residents, purposefully shielded from the workload they’re about to inherit, march on.

But then they graduate and find that just as the population is aging, chronic and infectious diseases are becoming more challenging, health advances and potential are exploding. Just then, we decide to launch a full scale attack on physicians and their patients with increased documentation requirements, call hours, larger geographic coverage of their specialties, reduced ancillary workforce, and shorter patient vists.

Physicians get it – burn out and dissatisfaction are higher now than ever before. This is probably the greatest real threat to the doctor-patient relationship and health care reform discussions don’t even put it this on the table.

At the same time that we expect our doctors to be devoted, available, enthusiastic, meticulous and at the top of their game with perfect “quality” and “perfect performance,” while simultaneously cutting their pay, increasing documentation reqirements and oversight, limiting independence, questioning their professional judgment, and extending their working hours. We must become more efficient!

Deal?

*This blog post was originally published at Dr. Wes*

Information Overload: The New Electronic Administrative Burden

I filter through progress notes looking for the few sentences different from the day before, only to find them sandwiching pages and pages of electronically-produced babble dutifully and automatically mass-reproduced in every note. I wonder, has anyone ever looked retrospectively at the mess created by this process developed to assure doctors were doing what they said they were doing? Ironically, I find we’re rarely reading most of what we re-create each day.

But we’re sure good at following the rules.

Next.

I now see prescription refills for each and every bottle of prescriptions ever filled by a patient, the date a patient filled it, and how many pills they received with each prescription. I’m not sure why. I sat awestruck in clinic yesterday when the list extended 94 pages, double-spaced, since January, 2009. No one, and I mean no one, filled that many prescriptions, did they? Or did they? Am I supposed to correct that list? Oh, by the way dear referring doctor, my note’s at the bottom of that listing.

Next.

I get pre-surgical notifications, even though I was the one to notify everyone else about the need for admission, just so I can click on the patient’s name again, lest it not appear I’m not doing enough, I guess.

Next.

I get EKG results forwarded for me to sign electronically, even though I’ve already read them, and signed them, by hand, on the EKG. I get notified again that the order I entered for that EKG now has a result, and I have to click on that to tell the computer, “I know.” But that, you see, is not enough. I must also log in, review, and sign off on my EKG’s on the EKG server, too. After all, I’m responsible, and it’s all about quality.

Quality three times over.

Now, multiply that same process for each and every other test I have ordered.

Next.

I see orders for things I’m not sure I ordered, just to be sure I’m responsible, and watching, literally hundreds of times per day.

Next.

I get e-mails and electronic notifications, and electronic communications, as if I know the difference.

Next.

I bypass nursing notes that are mere QA checklists and say nothing about the patient, except that a nurse was there last night.

Next.

I feel guilty entering data as I talk to my patient while serving my electronic master. Yet I find the stakes are high to assure accuracy and timeliness in clinical electronic reporting. After all, you never hear the bullet that hits you.

Next.

I go home on call, am paged, and reprimanded by a patient who wonders why I can’t look up their medication list on-line, even though I’m standing in the grocery store.

Next.

Worst of all, I find myself sending myself messages, just to make sure I do something tomorrow that I could not get done today.

Killing me softly …

… with information overload.

*This blog post was originally published at Dr. Wes*

Tormented: EMRs’ Linguistic Handicaps

There are some things that Electronic Medical Records do well and there are some things that Electronic Medical Records do poorly. To say that I need Electronic Medical Records to help me type is nothing short of ridiculous. Unfortunately, when engineers meet computer programmers and try to help health care professionals type in the health care record in the name of “safety,” the results can torment those they’re trying to help.

Take auto-spelling, for instance. I have the nasty habit of typing “Lungs: Claer to A&P” and marvel at the auto-correction feature automatically correcting my typing to “Lungs: Clear to A&P.” This is an example of the wonders of electronics.

But when I type “DC Cardioversion” and the computer won’t left me type “DC” because it wants to know if I mean “discharge” or “discontinue,” the computer becomes intrusive, obstructive, and performs a service that should be right up there with water-boarding. I mean, is someone really going to mistaken that I mean “Discontinue cardioversion” or “Discharge cardioversion” when I’m typing my operative report? I could see this being a problem in the order-entry portion of the software, but when I’m typing by progress note or operative note?

Please.

Even better are the wonderfully useful letters “MS.” These might mean “magnesium sulfate,” “mental status,” mitral stenosis, “MS Contin,” “multiple sclerosis,” “musculoskeletal,” “Ms.,” or maybe even “Mississipi.” So, instead of being able to type a logical sentence without interruption, the doctor finds that that a drop-down pick list prevents those magic letters from being typed. It seems the chance that a nurse will wonder if you’re prescribing a drug in a southern state trumps the ability to enter a simple sentence on the computer. This is, after all, how we’re preventing medical errors.

But I wonder if these computer engineering road blocks are doing something much more insidious and detrimental to our health care delivery of tomorrow: like devaluing independent thought, reason, permitting the subtleties of context, and common sense.

No, better to torment instead.

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