Physicians

Please Choose One

flying cadeuciiPlease choose one:

The three words blink in front of me on the computer screen.

Please choose one:
Patient is-

Male     Female 

I click FEMALE.

I watch as the auto-template feature fills in the paragraph for me based on my choices.

Patient #879302045

Patient is: 38-year-old female status post motor vehicle accident. Please acknowledge you have reviewed her allergies, medications, and past medical history.

I click YES.

Have you counseled her about smoking cessation?

I click NO.

A little animated icon of a doctor pops up on the screen. His mouth begins to move as if speaking. A speech bubble from a comic strip appears next to it.

“Tip of the day: smoking cessation is important for both the patient’s health and part of a complete billing record.”

The animated doctor smiles and swings his stethoscope like a lasso.

I click ACKNOWLEDGE.

A new screen appears.

Please choose one:
The patient’s current emotional state is best described as-
☐ Distraught     Calm      Agitated

I turn away from the computer to look at the patient. She lies curled in a ball on her side. Her bare feet stick out below the sheets halfway off the gurney. I notice she has a turquoise blue toe ring. She stares straight ahead. She plays with her patient ID band, twisting it round and round with her other hand. Makeup is smeared around small brown eyes. She stares blankly at the wall behind me. I clear my throat. She doesn’t blink. I clear it louder. Still nothing.

I look back to the computer. The same screen is still there.

Please choose one:
The patient’s current emotional state is best described as- 
☐ Distraught     Calm      Agitated

I turn back around.

Blonde hair is matted to the right side of her face where tears have dried it to her skin. A thick strand of it hangs across her eyes and I wonder if it annoys her. I watch as tears reform in her eyes and run sideways across her face. A teardrop starts to grow on the side of her cheek. More tears are added until finally it falls from her face onto her tear soaked pillow.

Her chest rises and falls at a rapid pace. She is breathing fast, almost panting. It is a raspy sound. I bet if she spoke right now her voice would sound raw, the kind of scratchy raw that comes after too much screaming. But she doesn’t speak. She just lies there breathing with a thousand yard stare fixed to her face.

The computer dings.

Please choose one.

I click DISTRAUGHT.

The computer takes me to a new screen.

Please choose one:
Patient’s primary reason for being distraught-
Emotional     Physical     Other

The patient starts moaning. I look over. A guttural sound that is part wail, part cry spills out of her just loud enough for me to hear.

I click EMOTIONAL.

That selection triggers a new screen for me with new choices:

Please choose one:
What is the reason for patient’s emotional problem?
Intoxication   ☐Psychiatric   ☐Neurologic

Hmm, I look at her trying to decide which to choose. She is in a hospital gown. Her clothes were cut off with the trauma shears when she came in. She still smells like gasoline and blood and burnt plastic smoke. It burns my nose sitting this close to her and makes my eyes water.

There’s dried blood mixed with car oil and dirt on her chest. There is a lot of it. It covers her shoulders and the top of her breasts like a red patchy shawl, yet she is not injured. She has been examined and x-rayed and CAT scanned from head to toe. Her body is fine.

The computer dings again impatiently, prompting me to choose one.

Please choose one:
What is the reason for patient’s emotional problem?
Intoxication   ☐Psychiatric   ☐Neurologic

I click the Next arrow at the bottom of the screen to try and advance the page without choosing one.

PAGE INCOMPLETE- YOU MUST CHOOSE ONE pops up.

My mouse circles the screen hesitantly. I guess I will click… PSYCHIATRIC. In a way emotions are psychiatric, I tell myself.

Choosing psychiatric has opened a new screen.

The patient shifts on the bed. A glimmer on her head, reflecting the fluorescent lights above, attracts my attention. I lean in closer. There are shards of broken up windshield glass scattered throughout her hair. Some are brown from dirt from where she lay on the ground, some are stuck to her head from blood, and some are scattered on the sheet below her. The shards twinkle on the bed like little stars.

I frown, the nurse was supposed to clean her up. I wheel backwards on my doctor stool across the trauma room to the door. I lean my head out through the curtain.

I look around. I spot the patient’s nurse. She is sitting on the other side of the ER, working at a computer. I know she is trying to enter data from the patient’s visit to get her charting done. Well, I think, maybe someone else can help us.

I scan the ER. There are doctors and nurses everywhere down here, yet every single one that I see sits at a computer with their eyes chained to the screens and a scowl on their faces while they click and type, click and type. I bet the hospital could burn down around them and they wouldn’t notice.

“Hey!” I yell.

No one even looks up. The clicking and typing continue.

An old man standing in the doorway of another patient room makes eye contact with me. He scowls as he surveys our ER. He shakes his head in disgust. I blush and duck back into the room behind the curtain.

The computer dings twice now, prompting me to hurry up. I remember my patient throughput time is monitored and reported and compared to the national average. A timer has appeared on the bottom of the screen, letting me know that I am four minutes twenty-eight seconds past the average ER doctor throughput time.

The numbers keep climbing. If I spend too much time on one patient, I will get a letter from administration for not meeting my throughput quota. I wheel back up to the computer.

Please choose one:
Because you chose Psychiatric, patient was offered-
Counseling     ☐Medications     ☐Inpatient Care

A sob wracks my patient’s body interrupting me again. She shifts in the bed, leaving clumps of brown dirt crumbling on white sheets. She is absolutely filthy. I wonder how long she lay in that field before someone found her. She still stares at the wall, unresponsive.

I look back at the computer. I didn’t offer her any of these things. Maybe I should lie and click counseling so that I can finish her chart.

I click Next.

YOU MUST CHOOSE ONE pops up again.

Please choose one:
Because you chose Psychiatric, patient was offered-
Counseling    ☐Medications   ☐Inpatient Services

I try alt tab. No luck.

YOU MUST CHOOSE ONE.

I give up and click COUNSELING.

Another screen.

Please choose one:
Patient responded to counseling with:
Excellent Improvement Some Improvement No Improvement

I click NO IMPROVEMENT.

The little doctor figure reappears on the screen. He’s holding up his index finger and a light bulb appears over his head as if he’s just had a fantastic idea he can’t wait to share with me.

“Dr. Tom Tip reminds you: Did you try offering a drink of water or a tissue? Surveys show that sometimes it’s the little things that make patients feel better.”

I look over at her. I can’t bring myself to offer her water. Her knuckles are blanched white from the death grip she has on the side rail. She’s mouthing the word NO over and over to herself and shaking her head back and forth. Her eyes are wide with terror and do not see me. The skin of her face is pulled taut with fear.

I know that look. She is seeing the moment. I know she is going to see it again and again for the rest of her life. It will come in nightmares, it will come in dreams, it will come at the worst possible moment of what should be happy occasions, more likely than not it will even come at the moment just before her own death no matter how long she lives. She will never escape it. Sixty-eight minutes ago her brain burned an image into the inside of her skull that she will never be able to unsee.

I click SKIP.

The doctor icon disappears, replaced by text.

Please choose one:
Did you offer the patient water?
Yes     No

I click NO.

The little figure pops up again this time with a stern look on his face and his arms crossed.

“Surveys show patients like it when their doctors offer them water or a tissue. Patient satisfaction scores go up. Try it, you might be surprised.” He uncrosses his arms and holds out a little of glass of water.

For a brief second I imagine punching my fist through the computer screen. It would feel so good to climb the stairs to the top floor of the hospital with the computer stuck on my arm. I imagine spinning in a circle and launching it as hard as I can off the roof of the hospital towards the pavement below. I would give anything to see it smashed and destroyed and ruined, just as it has done to this profession I once loved.

But I know they would just replace it with another computer and just as quickly with another doctor.

I sigh and look around the room.

There is a cup on the counter.

I frown, it is awfully dirty.

I pick it up and turn it over.

A child’s tiny, bloody shoe falls out onto the counter.

The woman cries out, Oh God Oh God Oh God and grabs the child’s shoe before I can pick it up.

She holds it next to her face. She’s sobbing now and starting to scream. Oh God Oh God Oh God Oh God Oh God. She clenches the shoe to her chest. The blood on the shoe matches the blood on her chest.

The computer dings.

“Did you give the patient a cup of water?”

I lie and click YES.

“Good job!” The computer trumpets out a happy horn sound. It’s hard to hear over the patient’s screaming. The little doctor gives me a thumbs up and high fives a hand that appears on the screen next to him.

“Sometimes it’s the little things that make people feel better.” The doctor says.

I click NEXT.

The Patient Disposition Screen loads.

Please choose one:
Where is the patient going after the ER?
Home     ☐Admitted     ☐Transferred

I hover the mouse on the screen for a second, trying to decide.

I click HOME.

Please choose one:
How is the patient doing after your care for her?
Improved      ☐Not Improved     ☐Other

I look at her again.

I click NOT IMPROVED.

*WARNING*

This time the whole screen flashes. The little doctor is back, hands on his hips. His face is stern as the speech bubble appears next to his head. The letters are in red this time.

“Patients who are NOT improved should NOT be sent home. You clicked Psychiatric as her primary issue. Perhaps some medications would help the Healthcare Consumer. Would you like me to recommend some choices available on the hospital formulary?”

I ponder the question. Is there a drug for this? Something that will make her feel better? Something that doesn’t wear off like, ever?

I click NO.

Are you sure? The computer asks again.

I click YES.

A big red flag now pops up on screen and the computer buzzes like a half time buzzer in a sports game that I have just lost.

A note of this patient encounter has been sent to your Hospital Administrator for chart review of this patient. It is the goal of our healthcare facility to make patients feel better before they are discharged. You have acknowledged that you failed to do so. You will likely receive a lower patient satisfaction score for this.

Please acknowledge.

I click NO.

It flashes again.

Please acknowledge.

I click NO.

Please acknowledge.

I click NO.

A box pops up.

I am sorry, Valued Healthcare Provider, do you not understand the question? Would you like to fill out a service ticket?

Yes   No

Please choose one.

The words blink at me on the screen.

I look over at the patient. She is on her side again, sobbing as she cradles the tiny shoe to her chest. Her eyes are squeezed shut and she’s rocking back and forth so hard the whole gurney is shaking.

I look back at the computer.

Please choose one.

I look back at my patient.

Please choose one.

Suddenly I get it. I choose.

I reach down and unplug the computer. The screen goes black.

Without the noise of the computer fan whirring, the room is suddenly silent- save for her quiet sobs.

A strange feeling comes over me, one I almost forgot existed after so many years.

I remember who I am and why I am here.

I stand up and take a deep breath. I step towards the patient and begin the long and tedious process of gently picking out the shards of bloody glass stuck throughout her hair. As I start to work she opens her eyes and blinks.

She sees me.

The terror filling them fades just a tiny bit.

For once the computer stays quiet.

I pick through the strands of her hair. The three words blink in my mind over and over.

Please choose one…

Please choose one…

Please choose one…

 

The author is an ER physician practicing in Walla Walla, Washington.

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Categories: Physicians, THCB

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88 replies »

  1. Well, I see the haters and the racists are here today in force spewing the venom they have been commanded to repeat by Rush Limbaugh and Glenn Beck.

  2. I am afraid this satire is not really far from the reality..Healthcare system evolution is probably following this trend which probably tries to comply both with ever complex regulations and cost control by using machines instead….

  3. “it was a non-issue.”

    That is fine. The people were given a choice so those that didn’t want people moving toward the alternate choice made things better. Choice doesn’t necessarily mean something new. Sometimes all it does is make those in control do more of what the people need and want in order to keep in control.

    The Quebec decision calling the specific Canadian waiting times inhumane was a total success based upon what you are telling me. Some Canadians tell me another Quebec decision would improve care even more.

    “Dr. Welch’s research has focused on the problems created by medicine’s efforts to detect disease early: physicians test too often, treat too aggressively and tell too many people that they are sick.”

    I have some agreement, but that doesn’t change what the NBER study said when it compared Canada less favorably to the USA with the exception of cost. I also don’t want to detect disease too late and I want treatments that are aggressive when needed to help the patient. By the way, too many snake oil salesmen, capitated providers, and people that care more about making a patient like him instead of curing the patient let patient’s think they are well when treatment should have been provided. Dead patients tell no stories.

    I’m not interested in Dr. Welch’s book. I am interested in the studies proving his case.

  4. “according to the Quebec courts is inhumane treatment of Canadian patients when they ruled against the government. I am sure many Canadians in need of quicker care say thank God for that decision in Quebec because without it They would be waiting even longer.”

    allan, that Quebec Supreme Court decision is years old now. But if you’re interested in the outcome, after that decision Quebecers were allowed to buy private insurance, the result was that not one policy was purchased. So, for a vast majority of Quebecers it was a non-issue.

    As an addition to Ca v US I just got an email about a lecture at UNC hospitals which you may fine interesting (not that you can attend) as it relates to the NBER report you linked and cancer outcomes.

    “Dr. Welch is a general internist at the White River Junction VA and a professor of Medicine at the Dartmouth Institute for Health Policy and Clinical Research. Dr. Welch’s research has focused on the problems created by medicine’s efforts to detect disease early: physicians test too often, treat too aggressively and tell too many people that they are sick. Much of his work has focused on overdiagnosis in cancer screening: in particular, screening for melanoma, thyroid, lung, breast and prostate cancer. He is the author of Should I be Tested for Cancer? Maybe Not and Here’s Why (UC Press 2004), an author of Overdiagnosed: Making People Sick in the Pursuit of Health (Beacon Press 2011) and has just completed his newest book: Less Medicine, More Health: 7 Assumptions that Drive Too Much Medical Care (Beacon Press 2015).”

    Dr. Welch has a book available on Amazon.

  5. This sounds like a nightmarish system. That it takes valuable time away from interacting with the patient is unacceptable. Sorry you have to suffer with it.

  6. “allan, I’m not sure if you read the whole paper or what you draw from it.”

    The paper helps one learn how to evaluate things. I didn’t intend to demonstrate that the US is better than Canada for I have already told you that different countries need different things and I leave it up to the citizens of the various nations to decide what is best for them.

    You seem a bit defensive because immediately you jumped to the one item the study demonstrated the US clearly has fallen behind in, cost. It’s true, but the cause is not the lack of socialism, rather too much socialism in the healthcare sector that contrasts with American capitalist interests. That hybrid makes costs worse than they would be with either choice. But when it comes to outcomes (‘doc will I live or die? Will I get better?’) the US seems to be doing better. They found better access for those with chronic disease, shorter waiting times (that also impacts families in different fashions), more screening for major forms of cancer, and lower mortality rates for cancer just to mention a few points in the article.

    That you asked if I read the entire article points to your insecurities. Yes, I read it when it was produced and again before posting.

    You make two claims. One, Canada is doing well considering its expenditures. I won’t disagree, but be careful. Some of Canada’s costs are hidden. You also mention that Canada has improved with regard to wait times. The Fraser report from Canada indicates that might be so, but that many of the wait times remain terribly long and that according to the Quebec courts is inhumane treatment of Canadian patients when they ruled against the government. I am sure many Canadians in need of quicker care say thank God for that decision in Quebec because without it They would be waiting even longer.

  7. allan, I’m not sure if you read the whole paper or what you draw from it. I know that concerning wait times, Canada is probably doing better now than in 2007 as it appointed a commission to address the issue and established wait time targets and reporting as well as expending more money.

    But the paper made a very significant point:

    “One important issue that we do not address concerns the large differential in per capita health care expenditures which are about twice as large in the U.S. Is the U.S. getting sufficient additional benefits to justify these greater expenditures and where should we cut back if cutbacks must be made? Alternatively, what would Canada have to spend to increase their technical capital and specialized medical personnel to match American levels or to eliminate the longer waiting times? And would it be worthwhile to them to do so? To answer these questions more research is needed along the lines of the recent study
    by Henry Aaron and William Schwartz (2005) that examines the British system in depth and in comparison to the U.S. system.”

    So actually Canada is doing pretty well (by this paper) considering it’s expenditures. If you’re really concerned about costs then Canada seems to have a much better handle on that.

  8. Peter1, I thought you might be interested in another article on health status between Canada and the US that is from the NBER. I don’t attach too much emphasis on any one study, but there are others that indicate the same things. I also believe that all countries have a lot of warts in their respective healthcare systems and have different needs so I don’t fault Canada for it is a different country than the US. The abstract is as follows:

    “Does Canada’s publicly funded, single payer health care system deliver better health outcomes and distribute health resources more equitably than the multi-payer heavily private U.S. system? We show that the efficacy of health care systems cannot be usefully evaluated by comparisons of infant mortality and life expectancy. We analyze several alternative measures of health status using JCUSH (The Joint Canada/U.S. Survey of Health) and other surveys. We find a somewhat higher incidence of chronic health conditions in the U.S. than in Canada but somewhat greater U.S. access to treatment for these conditions. Moreover, a significantly higher percentage of U.S. women and men are screened for major forms of cancer. Although health status, measured in various ways is similar in both countries, mortality/incidence ratios for various cancers tend to be higher in Canada. The need to ration resources in Canada, where care is delivered “free”, ultimately leads to long waits. In the U.S., costs are more often a source of unmet needs. We also find that Canada has no more abolished the tendency for health status to improve with income than have other countries. Indeed, the health-income gradient is slightly steeper in Canada than it is in the U.S.”

    If you desire the entire study it is working paper No.13429. If you don’t have access just provide your email and I will have it sent to you. The data set was from the Joint Canada/ U.S. Survey of Health (JCUSH). Additionally survey information was obtained where more U.S.residents than Canadians answered fully satisfied and excellent. (I don’t personally put too much credence on surveys, but thought, based upon some of your comments, this might interest you.) They also say that Canada is on the way to a two tiered system.

  9. “The problem I’ve found with many American attitudes such as yours is they think they know the ultimate truth and can do it better than anybody else, while not be accepting that there might be a another way.”

    Quite the opposite. You want to dictate, mandate, coerce etc. to get your way. That is the problem with your type of ideology. I want to do none of those things. I want a marketplace where people vote with their dollars.

    “I think it comes from the insulation America has been able to enjoy because of geography and economic power.”

    It comes from being free. …And America has proven its worth changing the world economically and ideologically where power comes from the people, not a king or dictator.

    “ “we don’t need anyone else’s opinion” ”

    We can look around for data and note what others have experienced, but in the end it is our opinions that count. Take note the American Constitution was written by our founders, but our founders adopted many concepts that came from somewhere else.

    “ America lives with it’s middle class being economically gutted ”

    That is due to leftist policies and a government that has grown too large. However, Americans in general especially compared to our European counterparts have more household amenities, larger living spaces, more cars and a higher income.

    “economic stability declining as it enters one failed military war after another.”

    I won’t defend all the interventions seen by the US. On the other hand if it weren’t for the US Europe would be speaking German.

    “At the same time “wealthy” Americans have the political power to skew the tax code in their favor and create an ever increasing divide between rich and poor.”

    Yes, when government and industry combine their resources as we have seen in recent years certain benefits tend to move in their direction causing pain to other Americans. But then one has to ask themselves what does socialism do except create such a type of co-operative management?

    I have no gripe against Canada though I don’t personally agree with everything Canadians do. It is a vibrant and beautiful country, mostly economically free by certain measures. I don’t want to tell Canadians how to manage their political problems. If you hear a comment from me about Canada it is not telling Canadians what to do rather it is one American to another telling America what not to do (or what to do, depending on the issue at hand)

  10. allan, as a Canadian and non-voting U.S. resident, who pays taxes just like you, I am also being “told” I must pay for it. Not just for ACA but for everything else “Americans” have determined who pays and who receives. I’m not happy with a lot of my tax subsidies, especially to successful and wealthy corporations and individuals. But I’m just part of the discussion, like you, but with no power to “tell” as I can’t vote.

    The problem I’ve found with many American attitudes such as yours is they think they know the ultimate truth and can do it better than anybody else, while not be accepting that there might be a another way. I think it comes from the insulation America has been able to enjoy because of geography and economic power. But this country is seeing that historical, “we don’t need anyone else’s opinion” approach being fractured as America lives with it’s middle class being economically gutted and its economic stability declining as it enters one failed military war after another.

    The ever increasing reliance on “subsidy” to poorer Americans is a sign of overall economic weakness. At the same time “wealthy” Americans have the political power to skew the tax code in their favor and create an ever increasing divide between rich and poor.

    Arguing I just need to mind my own business deflates any strength your arguments might hold because it has nothing to do with advancing ideas that might work better for Americans.

  11. “Not telling anyone what to do, but if they think they need to get something looked at, cost won’t interfere with the decision”

    You are not telling a woman to be tested, but you are telling someone else they must pay for it.

    Canada provides reasonable care. I leave it up to Canadians to determine what they want to do and what is in their nature. I want Americans to decide what they want to do with full knowledge of what they are getting into.

    You said you are not “telling anyone what to do”, but I hear quite the opposite on this blog. Not only are you telling others what to do, but as a Canadian you are telling Americans what to do.

    Canadians should do what they wish. We are not Canadians and have other things that are meaningful to us.

  12. “the left loves to tell others what to do whether they need it or not.”

    Not telling anyone what to do, but if they think they need to get something looked at, cost won’t interfere with the decision. Women are free to not get tested.

    “Canada ranks near the top where woman are concerned.”

    Not bad for a flaming socialist country that tells others what to do. :>)

    At half the cost BTW.

  13. You are a bit mixed up in your response Peter1. The ACA didn’t have to tell women in the US to get their Paps and Mammograms. But, the left loves to tell others what to do whether they need it or not.

    This comparison of who gets what exists in other parts of the healthcare debate as well. But, outcomes tell the story. The well respected CONCORD cancer study gives Canada good marks though they are not at the top if all the study results are averaged together. I think Canada provides good care none the less. The US is #1 followed by Australia and then France. Where Canada ends up I am not quite sure, but probably #4 or #5..

    Canada ranks near the top where woman are concerned. Breast cancer outcomes: Canada ranks #2, the US ranks #1. It ranks fairly high in this study for other diseases in women as well. Colorectal (women) Canada #3, US #2; Colon (women) Canada #4, US #2; Rectum (women) Canada #4 US #2;

    Canada doesn’t fare as well with men. Prostate: Canada #3, US #1; Colorectum: Canada #5, US #2; Colon: Canada #6, US #2; Rectum:Canada #5, US #2.

    [Outcomes answer the questions: ‘Will I live?’, ‘Will I get better?’ Other types of studies frequently use poor metrics so the meaning of the study is questionable at best.]

  14. I was urged to read this by a doctor here in Centralia. I remember Dr. Green, and his compassion in our ER here. This has brought tears to my eyes. I love the fact that you unplugged and showed compassion! The human factors are starting to be replaced! We need more Physicians who are willing to take a stand for what is right! EHR is great but should NEVER be allowed to be any more tgan a record! A physician should not be overridden or pushed through by any program! We are NOT parts on an assembly line, we are real people! God help us all!

  15. “Insured American women get more of both”

    So even before ACA insured American women got more of both. Good, now formally uninsured women get the same access unimpeded by cost.

    Now we can discuss what number is appropriate for everybody to bring down costs.

  16. Peter1, what are you trying to demonstrate by sending us to this site? “
    Affordable Care Act Rules on Expanding Access to Preventive Services for Women”

    Let’s take mammograms and pap smears the most commonly discussed ‘preventative’ care for women. Insured American women get more of both than the insured Canadian woman! In fact when it comes to the uninsured American woman she gets the same number of tests as Canadian women.

    Were you trying to demonstrate that Canada needs the ACA to improve their preventative services?

  17. What are you talking about? There are now mandates for preventative care and most of that is useless.

    Take note there is a difference between a free marketplace as envisioned by Adam Smith and the socialism some prefer. We have seen the marketplace far exceed the socialists and communists. Even the communist Chinese have learned about the benefits of the marketplace and we have seen their economy grow.

  18. allan, the ACA doesn’t promote anything more than the system did/does without the ACA. The ACA IS the system, as it uses the private insurance and health care system we all love and hate to provide access to people who did not have access before, through subsidies that were only available to the very poor and the middle/upper class prior to ACA.

    I don’t like the ACA because it does not tackle costs. But I imagine that if it did you’d rail against it for that because it imposed restrictions on private business and citizens.

  19. “I stay away from doctors and especially hospitals until I’m on deaths bed. We’d all be better with less doctors”

    Then most certainly you must hate the ACA. It promotes doctoring where doctoring doesn’t do much good. Ex: Useless preventative care benefits, the promotion of excessive doctor and hi tech use, etc.

    You sound right up my alley. Many complain that we have too few doctors and I keep wondering if we have too many.

  20. Doc999, who is your beef with? Our modern society and the industrial medical complex or me? I don’t own a cell phone. My wife uses an old non-contract Tracfone for outgoing only. We replace only when absolutely necessary and not when the hype tries to convince us our life will be better with more complicated, less quality, planned obsolescence stuff. I fix my own 10+ year old cars and computer. I stay away from doctors and especially hospitals until I’m on deaths bed. We’d all be better with less doctors – retired out.

    BUT, I’m not a hospital or running a doctor’s office with more and more information load being demanded every day and everyone wanting that information available instantly.

    If you really want simplicity become a Mennonite or Amish.

    BTW, my 40 year career nurse wife (looking to be also retired out) has caught plenty errors by more “educated” docs, and I have lost count of wrong diagnosis by docs in the stuff I thought I’d give them a chance to solve, only to find my own journey worked much better.

  21. Peter1 says: He is being sarcastic- great- but please note which statements(assuming all are) are sarcasm because
    EMRs were based only on billing at the last five places I have used one
    (admittedly only hospitals)
    My car my phone my camera and my lap top WASTE at least an hour a day more than the ones they replaced, I OFTEN go back to the old ones(not the camera or laptop) when I need to get something accomplished quickly precisely because of the “improvements”- thankfully the old car phone and desktop are usable, though in need of repair
    I take twice as long to throughput patients when the EMR is UP than when it is DOWN
    I would think it was only dissaffectation, except that I may still directly compare.
    But Peter, you sound much like my well educated friends, I ask you to go to medical school, because we have almost retired all of the physicians in our country who are able to quit, when Canadian doctors see that they can make more supervising NP’s(nurses seeing patients) or PAs(other health care workers impersonating doctors) You will thank me for you being able to catch the errors made by limited education practitioners and EMRs

    waiting for the sarcasm….

  22. “Would a bottom up approach resulted in a better EHR?”

    Saurabh, I don’t know if you were on the scene when computers first started to be used in physician offices. I remember my first ‘EHR’ in the mid 1980’s that I was able to access by phone. Being 1/1 I didn’t have the funds available to permit me to adequately link up with my lab and the hospital. My lab, dealing with thousands, did have those funds and was willing to pay some of the costs. The Stark Laws prevented this from being satisfactorily done. That is about 30 years ago. Think of how these voluntary ‘EHR’s’ would have progressed over those thirty years. Today taxpayer money along with coercion is being used to get something that could have existed decades ago without the use of taxpayer monies

  23. I can totally relate as the wife of a (unfortunately) frequent ER patient. My husband has been battling CLL for the past 17 years. This past year he’s been admitted 8 times. One of those times it was from his PC doctor directly to the ER, where his ID band wasn’t working for the nurses. They tried for 15 minutes to order medicine to no avail until they figured out that they needed to get a new ID band on his wrist issued from the ER, not the doctor’s office. It was really frustrating for the nurses because they were just trying to care for him and were being stopped by the computer system.

    I do have to say that his caregivers in the hospital make a real effort to spend time interacting with us directly when they’re in the room. (Although, your depiction of staff in the halls staring at the computer screens is totally accurate – it’s kind of creepy).

  24. “Standardization doesn’t work well when it is govt bureaucrat defined and driven.”

    I think you’re letting your distrust for anything “government” obscure reality.

    Energy conservation standards, food safety standards, and all sorts of appliance safety standards including automobiles and airplanes.

    As to your cell phone example what if government enacted tower sharing regulations, do you think we’d have less visually obtrusive towers at less cost and better geographic coverage, then let the cell providers compete on service and price.

    An oversimplification, but all government had to do for EHR was say there has to be complete interoperability, then let the market determine how to best achieve that.

  25. Peter1,

    I think perhaps you are right…..they did want standardization (among other things)…..but it hasn’t worked out very well (predictably if you ask me).

    Standardization doesn’t work well when it is govt bureaucrat defined and driven.

    Paul

  26. “I don’t think standardization was the goal….if it were I don’t think there would be so many problems with “interoperability” amongst ehr systems now…so many years after the mandates/inducements/penalties were introduced.”

    “And, standardization is best left to the “bottom up” designers….they make it happen when it is needed by the market”

    Trying to connect those two opposite statements. Yes, standardization would have been good, no we don’t need standardization – because the market hasn’t required it yet. Which market hasn’t required it if you think it would have been good?

  27. Saburabh,

    You may well know more than I do, but I don’t think standardization was the goal….if it were I don’t think there would be so many problems with “interoperability” amongst ehr systems now…so many years after the mandates/inducements/penalties were introduced.

    And, standardization is best left to the “bottom up” designers….they make it happen when it is needed by the market….i.e. my iphone interfaces just find with my android phone friends and with my computer and with just about every website on the planet.

    If top down govt entities define the standardization it most surely will be a mess. In my cell phone example I suspect they would have used the Motorola Startac system as model as it was the best…..and having decreed that standard they certainly would have hindered (if not stopped) the development of today’s smartphone….no one had any idea what capabilities could be put into a cell phone.

    We still can get back on the better path for EHR’s….repeal the mandates/inducements/penalties…..let Epic and others focus on making the systems compelling on their own merits for doctors, hospital systems and patients….only then will Epic really focus on the users and make these systems really enhance quality and productivity.

  28. It’s an interesting analogy with other technologies.

    Would a bottom up approach resulted in a better EHR? Arguably, yes, given its track record in other technologies.

    But the aim of EHR was rather different. It wasn’t so much to achieve effficiency as to achieve standardization.

    If standardization is the goal, then it should not surprise anyone that standardization will be the means.

  29. Peter1

    The govt. is telling you to buy a system or face penalties…..and the default is Epic. I might have changed my cell phone example to simply saying the govt was requiring/inducing everyone to buy a cell phone….the default would have been Motorola Startac. It doesn’t change the analysis.

    Once the govt. mandates/inducements are removed each buyer decides when the benefit of buying outweighs the costs. That is how computers, cellphones, automobiles developed….and the systems get better and better (not perfection…just great value over time). Competition and propriety software are essential to the process, or we end up with the equivalent of Russia’s Volga automobiles.

  30. Paul, I don’t think government is telling you which system to buy – are they?

    Do you want to wait for the perfect system?

    I think government should have laid some competitive ground rules, such as interoperability, I think that would have leveled the playing field on systems, allowing more competition.

  31. Peter1, re your comments:

    “Saurabh, have all the electronic devices and systems in your life made it more complicated or less? Do you have so much more free time now than before electronics?”

    “Proprietary software and competition actually hinder better HIT.”

    Yes, our electronic devices are wonderful tools that enhance our lives…..and HIT/EMR technology might become great tools in the future. The problem is that they are being adopted now because of coercive penalties and subsidies…it is as if in 1990 the government decreed that we all had to buy Motorola Startac phones (the best at the time). It would have given Motorola (read Epic) such a dominant position their software would have become the standard…..and we never would have had Apple create its own software that led to the iphone. (Probably Motorola would have convinced the govt to prohibit new software in exchange for sharing their code).

    Much damage from too early adoption has already been done…but the best policy now would for congress to prohibit subsidies and penalties. The EMR technology would continue to develop….but now Epic (and who knows…even a new entrant…Apple?) would drive their development to make the software desirable to doctors and even patients.

  32. Good link Ron, but not startling research conclusions. Narrowly focused and constrained computer requirements make it easier to disconnect people from reality – I think we’ve all experienced that even outside of medicine.

    The research also said paper can distort reality as well as: “Many times EMRs do a dramatically better job of reflecting reality than paper ever could”. There have been past discussions on THCB about doctors notes and the ability of the patient to get access to them to verify the doctor’s perception over reality and how misperceptions get passed to other caregivers.

    The point about getting HIT systems be interconnected and more homogeneous has also been discussed here. Proprietary software and competition actually hinder better HIT.

    The researchers didn’t say going back to paper would save us. The reality is EMRs are here to stay.

  33. Thank you for posting that article. It was quite mind blowing for me to read as my only experience with EHR’s is at the end user state.

    I have thought a lot about this. If I could ask for only one thing to change, it would be this: EHR’s seem to be built on the assumption that a physician needs and wants every piece of information about a patient on the screen in front of them at every second in order to make informed decisions.

    The opposite is true, at least as an ER doctor. I work in an environment swimming with too much information and stimuli. I would love an EHR that cuts away every piece of text, every symbol, every icon, everything except the bare minimum of information I need to safely make a decision.

    When a patient is bleeding to death in front of me and I go to the computer to order blood I do not need to have on the screen that they have a remote history of high altitude sickness, that they have a safe living situation at home, or even that they have a history of bipolar disorder. I need only one thing. The blood transfusion order set. Yet to get it to it I have to wade through several other pages and lines of text that do nothing but slow me down and increase the likelihood I will miss something happening with the patient.

    A decade ago when we designed our own paper order sheets in the ER we made it as simple with the fewest choices on it we could. Then we added a blank where we could write in what we needed if it wasn’t one of the tests on the page. We did not list every test in the entire system on the one piece of paper. Couldn’t someone do the same with an EHR?

    Every extra piece of information in the EHR that the physician has to wade through adds another step, another decision, another chance for error, and lastly another moment away from caring for the actual person who is the patient.

    Just my two cents.

    Thanks for reading the story and your post.

  34. Here’s the non-satire version of this:

    J Am Med Inform Assoc. 2014 Jan; 21(1): 117–131.
    Published online 2013 Jun 25. doi: 10.1136/amiajnl-2012-001419
    PMCID: PMC3912703

    Healthcare information technology’s relativity problems: a typology of how patients’ physical reality, clinicians’ mental models, and healthcare information technology differ
    Sean W Smith1 and Ross Koppel2

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3912703/

  35. So now you are a sarcastic Canadian satirist with a penchant for irony!

    How has the entire enterprise of health information technology escape your sarcasm, Peter?

    Or is this a deliberate part of a bigger game of irony to which you have voluntarily conscripted yourself?!

    If so, a stroke of genius oh Master Bluffer.

  36. “Come on! It is hardly elitist to puncture holes in such poor reasoning.”

    Sorry, I thought your higher perception skills would recognize sarcasm.

  37. I do make assumptions, based on your comments, which are predictably, though amusingly, one-sided and seem to lack any skepticism whatsoever.

    Plus, you do make rookie errors, strawman arguments and logical fallacies that any teenager with a semi-decent high school education in Canada would be able to point out, such as this.

    “But, your country aside, if the U.S. has only two, 1759 must make India work much better by your extrapolation.”

    Come on! It is hardly elitist to puncture holes in such poor reasoning.

  38. “Well how judgmental of me to assume that someone so vested in one political party of the US…”

    Which party would that be, being more “judgmental” again? You assume I am more, “likely to stick to permanently eulogize one party.” Is that your higher learning kicking in? As a Canadian which party there do you think I support – careful now, it could be a trick question.

    “But since you brought this up I think it is a teachable moment.”

    Spoken like a true elitist, which I think you’ll claim to detest.

    You assume quite a lot Saurabh, I think much more than you accuse me of doing, but I think it helps you feel more comfortable in sanctifying your opinions.

  39. So you don’t vote here Peter? Well how judgmental of me to assume that someone so vested in one political party of the US has never voted in an American election. Wrap! Wrap!

    I made no linear extrapolation. But since you brought this up I think it is a teachable moment.

    These two statements are not contradictory:

    a) Two is too few.

    b) Ten thousand too many.

    This might seem to be quite a bit for you to grasp. So let me help you out.

    a) 21 % oxygen is life sustaining.

    b) 100 % oxygen causes blindness.

    c) 5 % oxygen kills.

    Do you see the fallacy of linear extrapolation? If 5 % oxygen is bad, so more must be worse? If oxygen is good, more must be better?

    There is a term for this, Peter. It’s called optimality. It’s not an easy one to grasp, I warn you. It requires some shedding of the binary mindset.

    Is India better? By better do you mean more prosperous than the US? But you know the answer to that. You have watched Slumdog Millionaire.

    No, India is not more prosperous. But they are also less likely, at least recently, to fall for hopey-dopey promissory change. They are less likely to stick to permanently eulogize one party. They are less likely to be fooled twice.

    Amazing, that, Peter given how poor and uneducated they are!

  40. “which is particularly problematic in your country as you only have two options.”

    Well Jaurabh, you did say “your country” not “our” country, which assumes the U.S. is my country. My country is actually Canada.

    Et tu debonair?

    But, your country aside, if the U.S. has only two, 1759 must make India work much better by your extrapolation.

  41. A progressive assumes that someone with an Indian-sounding name must hail from India.

    How debonair Peter!

    You need to get out a bit more, old chap.

  42. “which is particularly problematic in your country as you only have two options.”

    Yes, India seems to have it just right.

    “As on 16 September 2014, 1759 was the total number of political parties in India which are registered with the Election Commission of India”

  43. Yes, we should redesign people for EHRs.

    Be careful Peter. Politicians prey on the binary mindset, which is particularly problematic in your country as you only have two options.

  44. Actually Saurabh, it’s bullets that kill people.

    EHRs aren’t the problem it’s the people who use them.

  45. “The issue with doctors and EHRs is they don’t want to do the inputs, not that EHRs are bad. They want others to be their EHR handmaidens.”

    Yes, I thought it would get to this.

    Peter, it seems you have nicely crafted your world in to useful binaries: good vs evil, us or the capitalists, with EHRs or with the terrorists, etc.

    For most of us who have to live, deal with shades of gray (not always 50 shades), the answer, alas, sir is not so clear cut.

    For one, EHRs have lost meaningful information.

    To which you might quip, EHRs are not to blame doctors are.

    To which I would remind you of a kindred quip, which you might find objectionable “guns don’t kill, people kill.”

  46. Saurabh, have all the electronic devices and systems in your life made it more complicated or less? Do you have so much more free time now than before electronics? Is your car less complicated and less expensive to repair with it’s safety and electronic emissions equipment?

    The issue with doctors and EHRs is they don’t want to do the inputs, not that EHRs are bad. They want others to be their EHR handmaidens.

  47. “Saurabh, if we had EHRs first, what would your argument be for changing to paper records?”

    That’s a good question because it implies, and implies correctly, that the burden of proof for the benefits of change lies with the agent of change.

    The proof for benefits of EHR was promissory not empirical. And it is proving to not live up to its promise. Actually, it is proving that proof is better than promise.

  48. Saurabh, if we had EHRs first, what would your argument be for changing to paper records?

    “What one can infer is that electronic health records are costlier than paper records.”

    Only because we already invested in paper records, any new technology requires additional money for implementation. If we were to require the same inputs for paper that now exist for EHR what do you think the cost would be. The key is intelligent inputing.

  49. He has not said that paper records are cost free.

    One cannot even infer that he stated that.

    What one can infer is that electronic health records are costlier than paper records.

    In fact, when you consider the enormous costs of maintaining privacy, the costs of EHR may be even greater than its already high implementation costs.

    It may amaze you Peter, but the state can err. They are made up of people, not prophets or God.

  50. Having worked at the ER not long ago, I’m chuckling at this.

    I thank the stars that the hospital administrators at where I was at had way more sense than this. Checklists are good, but they need to integrate seemlessly into the clinical workflow, rather than impede.

  51. “Here is a quote from the WSJ op-ed:”

    Paul, you may want us to believe paper records are cost free – but we all know they are not, especially if you add escalating storage costs. Where do you want to put all that stuff?

    No fan of “security” of electronic info (Anthem), but no industry is protecting our personal info right now.

  52. lawyerdoctor, yes, lawyers make our society less complicated and less costly while EHR makes it more complicated and costly.

  53. Mike’s idea sounds good. But here is a better one: congress should pass a law prohibiting paying incentives for ehr’s and prohibiting penalties on docs. The benefits for the healthcare system would be immediate and profound!

    Here is a quote from the WSJ op-ed:
    “the average five-physician primary-care practice would spend $162,000 to implement the system, followed by $85,000 in first-year maintenance costs. Like any business, physicians pass these costs along to their customers—patients.” (author J. Singer)

  54. One of my favorite implementation tricks that I can’t get a lot of doctors to do is to kill the laptop. Put a big screen in the room so both the patient and the doc can see what is going on. At a minimum it gets rid of the physical barrier the laptop screen creates between the patient and the doctor. At it’s best it creates patient engagement when the patient sees their record for the first time. Not a hospital person (office practices) so don’t know if it would go over there, but in the office every doc who I can convince to do it loves it, but most I can’t convince to do it because a) they haven’t worked on big screens before but they are familiar with laptops and b) they aren’t really ready for their patient’s to see what they are writing. But it is an absolute game changer in patient interaction.

  55. An Op-Ed appearing in the 2/17 Wall Street Journal:
    “ObamaCare’s Electronic-Records Debacle” with subheading:
    “The rule raises health-care costs even as it means doctors see fewer patients while providing worse care.” author Jeffrey A Singer.
    Recommended.

  56. Idiocracy is here.

    Kurt was right in Player Piano. Start picking a book to memorize folks.
    I pick “Zen and the Art of Motorcycle Maintenance”.

  57. So Doc, if it’s fiction are the lame questions also fiction? OR are the real questions more to the point of protecting patients from ER error?

  58. yes, i hate epic but when you really get down to it is not epic, it is also not “quality Measures” documenting in three places that a patient is a smoker is not a quality measure. it is a measure of something but dont call it quality. Quality is listening to the patient with full attention and trying to figure out what the barriers are to them and smoking.

  59. Excellent article by Dr. Green!! Like most of us, I went to doctor school and not typing school. (but it WAS a long time ago, maybe now “data entry” is considered part of the core curriculum, along with gross anatomy and biochem)

    Fortunately for me, one of the locations at which I practice currently uses a template-based paper charting system for the physicians. Unfortunately for me, this is soon to be replaced, no doubt by a system designed to “maximize billing” and “meet all core measures,” which means it will be a clunky, inefficient, time-sucking, duplicative, bunch of crap that spits out a generic printed chart that looks exactly like every other generic printed chart.

  60. So, really, the problem isn’t Epic but all the quality measures you have to comply with.

  61. I wish I could say I fixed it, but I cannot. I am not a programmer, administrator, or IT person. I am just an ER doc slogging in the trenches.

    The only power I have is to try and turn away from the computer towards the patient as often as I can, even though that is becoming more difficult.

    Thanks for reading it and your reply.

  62. “It is fiction.”

    Well, not really, just the names have been changed to protect the innocent and fend off HIPPA.

    “So little time is left to sit face to face with the patients and treat them as a human being.”

    Gee Doc, sounds like my PCP. Less patient time to max out billing put through.

    So, how’d you fix it?

  63. i have been on epic since 2000, I have seen it morph from a fairly user friendly emr to the monstrosity that it is now. In fairness to the system every button on there could be considered a helpful button. but when there is 200 buttons per screen and ten administrators each wanting 10 clicks to satisfy some measure then it turns into a nightmare. I now have to document that the patient is a nonsmoker in three different locations. management has assured me that i have to do all three because different agencies want it in a different place, meaningful use wants the widget, ncqa wants it in the separate part of the note and one of the pilot programs we are in with medicare need it in a separate place. it has become that we service the computer and tolerate the patient.

  64. It is fiction. I tried to capture exactly what it feels like as an ER doc in this day and age trying to take care of patients while constantly being disrupted by computers. I wrote it after a shift where 99% of my time was spent clicking through screens, sitting at a desk, entering orders, acknowledging warnings that have no relevance at all to what I do.

    I wrote it to try to convey what it is like to have to be forced to answer questions about the patient’s sleep apnea risk factors when I am trying to get to a screen to order them blood as they are dying in trauma. But mostly I wrote it because the computer is all consuming now in the practice of medicine. So little time is left to sit face to face with the patients and treat them as a human being. The computer systems demand all our time and all our attention so as not make an error in the chaos of the ER. Somehow, capturing and entering the data about the patient has replaced the actual patient themselves.

    Thank you for reading it and your comments.

    Philip Green MD

  65. It’s a duality, Peter. If the writer has to explicitly state it the satire is killed. I can offer you no metrics or quality indicators for satire.

    Best satire is one which thinly skirts reality.

    It’s an acquired taste. I suspect that in our current “it’s someone’s fault and someone must fix it and what’s your solution?” managerial society, there will be an abundance of satire but a dearth of appreciators of satire.

  66. Using recognizable satire in writing, as with emotion, requires good skill. Doubt Doc green (or many of us) has it. How do you recognize sarcasm?

  67. “Seems nothing’s satire when docs discuss EHRs.”

    The same can be said about health policy.

    When you can’t distinguish between satire and policy, and I often can’t, you know the termites are feasting.

  68. “Peter, I think it is satire!”

    Is it, how do YOU know? Seems nothing’s satire when docs discuss EHRs.

    Not much if any of the computer prompts has anything to do with billing, unless the institution is getting paid by the question. Maybe future lawyer investigations.

    The article also leads the reader to think Doc Green is the only sane person there that cares about patient care – not too far from docs’ opinions about themselves.

  69. Exactly. I don’t use them, but most of my consultants do. It’s very hard to try to elicit the appropriate information on my patient between all the gobbledygoop in the EMR.

  70. Satire yes, but probably not that far removed from reality. Peter’s questions are valid.

  71. So who designed the questions? Were there no docs involved when the system was reviewed before buying? Was the system even reviewed? From the article it contends that no doctor was involved – why was that? Why would a hospital use such a checklist? Why doesn’t Doc Green bring this to management and the other docs?

    “I frown, the nurse was supposed to clean her up.”

    “I spot the patient’s nurse. She is sitting on the other side of the ER, working at a computer. I know she is trying to enter data from the patient’s visit to get her charting done. Well, I think, maybe someone else can help us.
    I scan the ER. There are doctors and nurses everywhere down here, yet every single one that I see sits at a computer with their eyes chained to the screens and a scowl on their faces while they click and type, click and type.”

    Did anyone involved in patient care get to give input on this system? Does no one in patient care bring these matters to the attention of management? If not why not? Does management isolate themselves from the patient floor and caregivers?

    Is it this way in all hospitals?

  72. Never give up. keep fighting for your patients and not allowing third party intrusion between doctor and patient we are blessed to be physicians and be practicing medicine ILLEGITIMI NON CARBORUNDUM

  73. I think we could easily write an expose’ type book that would be like Silent Spring and would cause the public to demand a reversal of the EHR back to the paper record. The author would be famous and would becomr rich. Easy pickings.

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