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*
Or the other statements, “I could never do this” and “It takes a special person to be able to do this.”
These words are usually uttered by family members who walk into an ICU room to see me calmly managing a patient on drips and vent, hooked up to monitors and other various tubes and wires. I’m sure these words are spoken many many times every day all over the world.
I appreciate hearing it, but it always makes me think of the jobs that I could never do. Sure, there are lots of jobs that I’d simply be unhappy doing, but there are a few that I’d almost rather starve than do.
I could never be a dentist or hygienist. I cannot handle dealing with teeth. If I see that my intubated patient has a loose tooth, I’m done for.
I could never be an exterminator. In fact, I was talking to an exterminator the other day (If you don’t live in California, you are probably not aware that it is, in fact, resting atop a gigantic ant hill). He was friendly and chatty and I myself mentioned that I don’t know how he was able to do what he does because I literally shiver with disgust at the mere PICTURE of a large bug. He then asked what I did and I replied that I was a nurse. He looked at me for a moment and said that the site of blood completely freaks him out. There’s no way he’d ever work in the medical field.
Within my own profession, I can imagine doing almost any type of nursing. That isn’t to say that I’d enjoy it or even be good at it. But there is one branch of nursing that I will never go into. There is one patient population that I cannot even begin to cope with taking care of, and that is burn patients. I don’t know how you can cause someone so much pain day in and day out, even if it’s in the name of healing. Any burn unit nurses out there? How on earth do you work in such a unit?
I was looking through an article in Time Magazine recently and came across an article about healthcare reform. It spoke of the daunting task ahead and went through a list of the people at the table in the process of creating change. The list included politicians, hospital corporations, pharmaceutical companies, insurance companies, and lobbyists from certain large special-interest groups. Notably absent from the list was physicians and “normal” patients. I commented about this in a conversation with Val Jones, MD, and she said: “If you aren’t at the table, then you’re on the menu.”
She’s right. Up to now, the interests of the people who matter most – the doctor and patient in the exam room – were largely unheard. Folks said they knew our needs, but they all had their own agendas and so often got it wrong (either out of ignorance or out of self-interest). Even the organizations that are supposed to represent my needs, the AMA and the specialty societies to which I belong, are not composed of folks who spend most of their time in the exam room; they are people who have either retired to spend their time in Washington, or are full-time smart people (they know lots about other people’s business). There are very few people at the table who regularly see patients. There are also very few who represent patients without a particular axe to grind (elderly, people with chronic disease or disabilities).
But healthcare is about what goes on in the exam room. The entire point of healthcare is health care; it is about the care of the patient. It isn’t about the business, the drugs, the delivery system, or the insurance industry; it’s about optimizing how the system makes sick people better and keeps better people from becoming sick. Everything else is a means, not an end.
But those of use who are in the exam room are soon to be served up on the menu for the sake of political gain and special interest clout. They may or may not have a good plan, and they may or may not have good intentions. But they definitely do not have an understanding of what really goes on and won’t be affected much by the decisions they make. They are serving up a dinner of food they don’t know about and they won’t have to eat what they cook. How can they make good decisions?
A step in the right direction would be to listen to bloggers. As opposed to the lobbyists and pundits inundating Washington, we actually do healthcare. The doctor and patient blogs on the web represent the interests of the people who are in the middle of the healthcare universe. This universe doesn’t have Washington DC at its center, it has the patient and those who care for him or her.
A good parallel is the crisis in Iran. There are reporters and politicians who say they know what it’s all about – and in some ways they do – but the voice of the people living in Iran are crucial to understanding what is going on. Why are there riots? Ask a rioter. Was there rigging of the election? Ask someone who was there to witness the process. The people who are on the ground should always be listened to. They don’t give the entire perspective, but getting a true perspective is impossible without talking to them.
Don’t just listen to me; I represent a specific point of view, and don’t represent that of patients or specialists fully. Don’t just listen to patient blogs, as they often don’t have a clear understanding of the business of medicine or the complex medical realities (although I know some of them do know an awful lot). We need to force ourselves to the table. We need to give perspective that has previously been invisible.
Blogging matters because it gives perspective that could never come from anywhere else. Blogging is the journalistic equivalent of democracy, giving the average person a chance to make their voice heard.
In July, a group of us medical bloggers will be going to Washington to do what we can to make our voice heard (thanks to Val Jones’ hard work). Maybe it won’t make a difference; but at least we won’t be invisible any more.
For this week’s CBS Doc Dot Com segment, I thought I’d cover something completely non-controversial: what can weekend warriors learn from elite athletes? But I’m starting to believe that in this era of evidence-based medicine, nothing may be truly knowable. I went to the studios of the world famous Ballet Hispanico in New York City and spoke to athletic trainer Megan Richardson. She took me through the motions, emphasizing the importance of warming up and stretching in preventing injury. It sounded good and it felt good. But proving in the medical literature that it’s effective is another thing. An online search quickly produced multiple conflicting reports and advice: stretching definitely works, stretching definitely doesn’t work; stretching only works if you do it my way. Click here for a sampling:
My friend and CBS colleague, Richard Schlesinger, offered his solution. ”I get around it by neither stretching nor exercising.” Had I listened to Richard, my blog post would have ended right here. But I figured I needed at least one more paragraph so I contacted a true expert on the subject, Ian Shrier MD, PhD, a specialist in sports medicine and Associate Professor at McGill University. He has a PhD in physiology and is Past-President, Canadian Academy of Sport Medicine. He’s not a huge fan of stretching right before exercise.
“First, the stretching, whether with or without warmup, does not improve performance. It makes you run slower, jump not as high, and makes you weaker.” And “stretching definitely can hurt people if you overstretch; people do it all the time if they force the stretch.”
He added, “I don’t think it hurts you in general if you do it properly but it doesn’t prevent injury.” He’s more supportive of stretching at other times, including after exercise, saying, “Regular stretching at other times is beneficial. It makes you stronger, jump higher, etc, and there are three studies suggesting it reduces injuries as well, although the results were only significant in one.” He adds that “stretching is analgesic; it allows you to put your muscle through a wider range of motion without feeling tension. And that may be why ballerinas say that stretching helps them.” Dr. Shrier spells out his take on the subject in detail in a chapter called
“Does stretching help prevent injuries?”
For me, Dr. Shrier’s most interesting advice, especially for weekend warriors, was about the importance of warming up. He explained that muscles need energy to function properly. Energy is mainly produced inside of cells in structures called mitochondria. When you are resting, your mitochondria power down. During exercise, it takes awhile for the cell to rev up the enzymes needed for breaking down fat and carbohydrates for fuel and for using oxygen to make energy from that fuel. If you start running at full speed without warming up, your body will produce lactic acid. Lactic acid can impair muscle function for awhile, preventing you from sprinting efficiently at the end of the race.
So Dr. Shrier suggests gradually warming up. He estimated it takes about 3 to 5 minutes to efficiently go from one level of exercise to the next – for example, going from rest to a ten minute mile or going from a ten minute mile to a seven minute mile. If you go for a jog, “you walk, then jog slowly, and then pick it up. Elite marathoners might go for a fifteen to twenty minute jog before they run a marathon. That allows them to run faster at the beginning of the race. They run the second half of the marathon faster than the first.”
In summary – and I suspect that I am the first person today to tell you this – don’t outpace your mitochondria.
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