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Is Marital Status in a Febrile 5-year-old Child Important?

My pediatric practice is one which harkens back to days long ago when physicians knew their patients and pertinent medical histories by heart. My 81-year-old father and I were in practice together for the past 16 years; he still used the very sophisticated “hunt and peck” to compose emails. The task of transitioning to an electronic record system seemed insurmountable, so we remain on paper. Our medical record system has not changed in almost five decades. I would not have it any other way.

This past spring, he walked into my office shaking his head in disbelief after thumbing through a stack of faxes. “Can you believe this 16-page emergency room note has no helpful information about the patient?”

This was not a shock to me. The future of medicine will include robots who are paid to collect reams of useless data to provide nothing in the way of health or care. Regardless, the government and third-party payors will extoll upon the virtues of their inept system as life expectancy falls.

Fifty years ago, there was a close relationship between a physician and their patient grounded in years of familiarity. Physicians took a history, performed a physical exam, and developed an assessment and plan. Diagnosis in a child with fever would be descriptive, like Bacterial Infection, Otitis Media, Fever of Unknown Cause, or Viral Illness. Parents were advised to provide supportive care, involving clear liquids, fever medication, and follow up precautions if the child worsened.

At the dawn of the technological age, the effortless simplicity previously existing between physicians and patients has all but evaporated. It was traded away without our consent, relegating the role of physician to that of a data-entry clerk. Physicians are discouraged from synthesizing information and utilizing it to guide our decision making. Today, a 16-page document “appears” to contain crucial elements such as chief complaint, past medical and surgical history, medication list, and allergies, however, the information is then followed by more than a dozen pages of waste.

The particular case to which my father was referring involved a 5-year-old child with fever. The provider documented the sexual history of this child, whether he was single or married, and whether or not he had children of his own. My dad and I started chuckling as we contemplated collecting this kind of extraneous information from a child who had not even entered puberty. As one would suspect, our young patient was single, as in not married; he had no children (which is physiologically impossible), and his years of formal education were noted “not pertinent to his medical situation.” Interestingly enough, I volunteer at the school where this young boy attended kindergarten; his classroom was next door to the one with my second oldest child. Three of his classmates were out with febrile illnesses, however technology cannot incorporate this kind of alternative data.

We kept reading and laughing. Occupational history was recorded as not on file; running a bustling lemonade stand in his neighborhood apparently was not clinically relevant. It came as quite a relief that at the tender and impressionable age of five, this boy had managed to steer clear of regularly smoking cigarettes. It was comforting to discover he had never used smokeless tobacco either; and for some reason, I never thought to inquire about such things before (insert eye roll.) He also denied alcohol use, restoring my faith in the fact that not every youngster was consuming alcohol during their formative childhood years.

Just when I thought things could not get more absurd, I came upon the sexual history; contemplating whether or not a five-year-old child was engaging in consensual intercourse was nauseating. I reminded myself that data entry clerks were devoid of emotion and instead were tasked with collecting “critical” details to practice by protocol. Sexual history: Not on file.

The final summary and diagnosis section was the most entertaining part, which read: “primary diagnosis: none.”  Seriously, are you kidding me? No diagnosis? This is the future, technology will seal the fate of our profession as one entirely devoid of the need for any cognitive skills. This earth-shattering conclusion after sixteen (16!) pages of documentation was utterly astonishing. Despite the considerable time and effort invested asking a febrile five-year-old whether he was married or having consensual sexual intercourse in his spare time, little to nothing was provided in regard to healthcare.

At this point, my father and I laughed so hard that tears were running down our cheeks. There is no other reasonable response to the sheer waste of time, resources, and education invested in becoming a physician. Doctors have spent decades honing their clinical skills and should be entitled to choose the documentation method they find most effective and efficient. Some physicians find electronic records helpful and should be encouraged to use them. My pediatric practice will keep surviving on a shoestring, a prayer, and good old-fashioned paper. It warms my heart to know each chart note contains helpful information and not one human being leaves with NONE as their diagnosis.

Footnote: Page 16 states: “This chart is intended to document the majority of the information from this patient’s visit today. Other items, such as the patient’s care timeline, are reported elsewhere and should be reviewed to better understand this encounter.” (More eye rolling.)

By all means, if 16 pages did not cut it, twenty more should make sense of arriving at no diagnosis. Forgive me for not running out and requesting those records immediately.

Niran al-Agba is a pediatrician practicing in Washington state.

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3 replies »

  1. Point taken Steve. If it makes you feel better, I am the type who lists Down syndrome or 21q deletion each time. It’s important, it’s efficient and in my absence another physician has a succinct overview available. Thanks for reading.

  2. Contrasts nicely with the H&P from the local pediatrician who says he is never going electronic. A two liner that says “developmental delay”, forgetting the part about the severe seizure disorder, or that the kid had dup 15 q syndrome. Or last week the kid with Downs who had an AV canal repair with an H&P that said “chest clear”, no significant family history. (As a matter of principle, one I don’t understand, he never records Downs or trisomy 21 on his H&P, so it is always a surprise. Thank goodness those kids never have any problems that might affect their surgical course.)

    All of which is to say that I also see those long, mostly useless records. EPIC is famous for them. I really can’t laugh about them since they are such a waste of time, and I don’t have lots of time to waste. However, they also often have tons of useful information in them, stuff I just can’t get from some of the guys who do stuff on paper. So I don’t really see one as inherently better or worse. Either can be done poorly, or well. In this particular case, they are clearly using an adult template for kids. This strikes me as (probably) poor physician leadership. They should have this fixed. We ran into that on EPIC with our pediatric section. We made it a point to specifically hire a couple of good docs who also have excellent computer skills. (One trained as a systems engineer, the other with a computer science background.) We had it redone to reflect what we wanted for our pediatric patients. I suppose they could have an EMR so awful it can’t be changed, but I think it more likely they haven’t tried. Or have given up.

    Steve

  3. Sounds like a standard H & P that was scanned into the record and edited to be applicable. Must have been done around 3 AM in the ICU.

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