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Dr. Darrell White's Personal Blog

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The Stages of Exuberance Sunday musings…1/13/19

1) Toddler. We are hosting the Man Cub for a few days as his parents prepare to move into a new house.

I. Am. Exhausted.

2) Strategy. Trample the wounded and hurdle the dead is neither a growth strategy nor is it a viable marketing tactic.

3) Snowpocalypse When I sit down to write I enjoy looking out over the lake as I wait for inspiration to sit down and chat. At the moment my view is blocked by 1/2″ of ice on all north facing windows at Casa Blanco.

The Ice Man cometh.

4) Irrational. Whenever a new technology or concept surfaces it is often met with irrational exuberance. Early adopters behave more like acolytes than simple adherents. Potential issues with the new idea are swept aside and those who propose that all is not so new or wonderful are labeled as too dense or simple to understand the brilliance of the new new thing. In a similar vein behavior by the creator of the new idea that would otherwise be a possible signal that all is not as it seems is either ignored or explained away without any real investigation. This particular phase is more intense and tends to last longer if it is associated with something that contravenes, and more so actively seeks to disrupt the status quo. A “cool kid” factor also magnifies the exuberance.

Rare is the new idea that does not then enter a phase one could call irrational dissaffectation in which both early adopters who become disillusioned and outsiders who become interested by the buzz created by the exuberance begin to look closely at not only the idea or product itself, but also at the behavior of both the “inventor” and the company that provides the service/product. The vehemence of this response is directly related to the buzz and fervor that exists among those who continue to be excited about the new thing. During this phase it is quite likely that there will continue to be newcomers to the technology who exhibit many, if not all of the characteristics of those people who claimed “first flag” discovery enthusiasm in the earliest days of adoption.

What comes next is either some degree of general acceptance of the new thing with a concomitant adoption into general use, or a slide into irrelevance as it becomes little more than a footnote in whatever historical space it inhabited.

As it happens both my professional life and a very large part of my non-professional activity each have a very significant player/thing that is entering this third phase. You may recall that I am an eye surgeon, in particular one who operates on the front of the eye. My expertise is in surgeries that both improve vision and liberate individuals from the need to wear glasses or contact lenses. In the LASIK world what was largely a PR battle between mechanical “flap makers” and those that created the LASIK flap using a laser was eventually won by the makers (and early users) of the laser. While I still feel that the introduction of the femtosecond laser to make a LASIK flap was a solution to a problem that had already been solved by 4th generation mechanical devices, the allure of an “all-laser LASIK” proved too powerful in the marketplace. Any “bad behavior” in the middle phase was marketing related. Even though it was more expensive, the laser won.

Cataract surgery also has a femtosecond laser entrant in the game. While the technology is actually quite stunning FLACS has never been shown to be more than slightly superior (if even that according to the most recent studies) to what it was developed to replace (the surgeon’s hands). Similar fear-mongering to the LASIK experience in the middle phase was buried in an avalanche of data reiterating the treasure trove of safety statistics and outstanding outcomes achieved with “traditional” surgery. Some really nice people got run over by some not so very nice people as companies were bought and sold. The most likely outcome as FLACS enters the third phase is that it becomes a niche procedure where hopefully the surgeons push back against industry in order to shield patients from predatory pricing; this laser is more expensive, and that has been its downfall.

When thinking about my non-professional activities over the last 12 or 13 years CrossFit is the obvious topic. In my entire life I have never been a part of anything quite so exciting as the first several years I spent in the CrossFit world. When I first found CF in 2005 there were about 100 gyms and maybe 5000 of us doing it on a regular basis. We were self-proclaimed fitness infidels, rising up against a cynical entrenched fitness orthodoxy and industry. Man, it was cool, and we were cool because of that. Not only did (does) it work if done properly, but we all had that same kind of first flag planted buzz you get when you discover something that becomes a phenomenon. Think being in your local in the 80′s and Nirvana is the house band kind of cool. It was like that.

CrossFit, too, is now in the earliest days of its own third phase. Having turned away from the strong (at least outward appearing) emphasis on CrossFit as sport, the company has pivoted back to something that sounds and feels more like what we all were doing prior to 2010 or so. Quite frankly I was personally too close to many of the primary personalities in phases 1 and 2 to objectively assess the players and how they played. Where CrossFit places its emphasis now is where I always felt it belonged, high intensity functional fitness as health rather than as sport. Which “laser” will CrossFit emulate as it leaves the stages of exuberance? What kind of laser company will CrossFit, Inc. be like if it, like the femtosecond laser, is proven to be only one among several ways to achieve the desired outcome in fitness and health?

In my day job phase three means a femtosecond laser for LASIK but not for cataract surgery. I am largely indifferent to the companies involved.

 

Eyecare Out Loud Episode 7: EMR Follies Part 1

Here is the direct link to my “anything goes” podcast on eyecare. In this episode I introduce the background behind EMR and computers in medicine in general.

https://www.healio.com/ophthalmology/podcasts/eye-care-out-loud/episode-7

Copy and past into your browser, at least until I figure out how to put a hyperlink into this blog!

The End of the Age of Volunteerism

Ladies and gentlemen, we are gathered here today to mourn the death of the Age of Volunteerism. While there exist tiny spaces where true volunteers live and thrive in a bilateral exchange of freely given goodwill, by and large volunteerism has been extinguished by the actions of its historical recipients. Sunday marks my last day ever of hospital ER call, the end of 2 years of receiving token payment for making my expertise available following 25 years of doing so for free. My experience is typical, as is this denouement.

Once upon a time all of your doctors were in private practice. We all had tiny little cottage businesses, did our work, and billed you or your insurance company for the work we did. Some of us worked in tiny little groups, but it was the rare doctor who was part of a large group or business whether in a big city or out in the country. Even the slickest Madison Avenue internist was basically a country doc, just with a better, more expensive wardrobe. In addition to having a greater familiarity with our patients we also enjoyed a very clubby relationship with all of the other doctors where we practiced. There was a collegiality, a sense that we were all in the struggle together. Folks who shirked their duties, foisting them off on other docs, were quickly educated about proper protocol or left to toil alone.

Hospitals were different, too. Local or regional, they were hardly the gargantuan mega-businesses they’ve become. The org chart was shallow, and most local doctors were on a first name basis with the few administrators on the hospital payroll. You took call for the ER as a volunteer; the ER respected that you were donating your skill and your time and handled everything it could before calling you. Same thing for consultations. Your colleague only called you if they couldn’t figure out a problem or ran out beyond their scope of practice. There was a faint air of apology with each request, and a definite unspoken appreciation for the help that would be given. You helped because you were appreciated.

This is really no different from all manner of volunteerism in America. Smallish, closely knit organizations depending on the goodwill and generosity of members of their community pitching in to ensure success. Think local memorial 5K races, or CrossFit Games Regionals in the days before ESPN or the Home Depot Center. Countless small private schools that depended on the largesse and time offered by the families who sent their children there. You gladly accepted the opportunity to volunteer because you knew that without you the organization would not be able to function. You also knew that the recipient of your generosity not only appreciated your contribution, they really had no other options. Not only that, but if that organization somehow existed in your professional space you knew that it would never, not ever, abuse the trust necessary for volunteers to continue.

What happened? Money. Money and size and the distance that they create between an organization and its volunteers. Let’s go back to the hospital and the ER for a minute. Where once your efforts as a volunteer were deeply appreciated and those efforts rewarded with respect and care for your time and your expertise, the growth of employment of doctors by hospitals opened a gap between colleagues. No longer was there the esprit de corps, the shared notion that the primary target of our efforts was the patient was replaced by so very many doctors by the reality that they worked first for a business as faceless and uncaring as GM. Work that was once done by your colleague was now pushed to the volunteers whenever possible. It’s cheaper that way. Worse, boxes to be checked by the employed (to maximize revenue and minimize risk) meant demands made of volunteers, not requests. Worse, still, were discoveries that some “volunteers” were more equal than others: they were paid.

Innumerable examples are there for the picking. Some times it was just a case of laziness. Other times the insult was a clear effort to dump work on the volunteer. A critical care fellow requested a consult for acute narrow angle glaucoma. For those of you not medical this is one of the few “drop everything and go” consultations in eye care. When I arrived in the ICU I found a young patient with a black cornea who was mildly uncomfortable. I did what every highly experienced specialist does when they start a consultation, I asked the patient: “Hey, what’s up with your eye?” Turns out they had a blind, painful eye as the result of a surgical mishap, and surgery to remove the eye was already scheduled. Their discomfort was because none of the eye medications had been ordered; the fellow never asked. No doctor (or nurse) would have allowed this to happen in the Age of Volunteerism.

While this is nothing short of tragic in health care, it was inevitable once medical businesses were incentivized to grow ever larger. It is not confined to health care by any means. How do you think that volunteer at a Spartan Race feels when he learns how much his “team leader” is being paid? Have you ever “discovered” how much the Executive VP of your favorite professional organization is paid? As a people we Americans are generous to a fault. That generosity usually continues right up until we discover that we have been duped, and even worse that we have been purposely duped by the people who run the organizations for which we volunteer.

And so we gather here to mourn the passing of the Age of Volunteerism. Like so many things of wonder and goodness there remain pockets of resistance, little oases where the goodwill, honesty, and appreciation beget the kind of ebb and flow that made things so much better, kinder, more collegial at the apex of Volunteerism. My friend Tom Gardner was just named the president of the Society of Alumni of our Alma Mater. Tom has given tirelessly of his “spaces”, his timespace, brainspace and emotionalspace to help shepherd tiny Williams College as it flows on though time. Is this truly different? A tiny refuge from the Zombie Apocalypse of corporatization of all things to which we once volunteered?

We can only hope. Hope that Tom and those like him who continue to find places and causes where their volunteerism is met with what we in medicine have had to bid farewell. We can only hope that there will be places where being a volunteer means receiving the respect and appreciation and even a kind of love in return for what we have given. We can only hope that there will continue to be places where the incessant drive to grow ever bigger, size measured on a spreadsheet rather than by heart, will be resisted. For if it can happen in medicine, if volunteerism can be killed in what is arguably the most noble of all endeavors, I fear that it is doomed everywhere.

We mourn the end of the Age of Volunteerism. We wait with equal parts sadness and fear for arrival of whatever comes next.

 

Thoughts About Kate Spade and Anthony Bourdain at 28,000 Feet

As is often the case when flying I was rewarded for offering a greeting to my row mate on the plane with a bit of insight and knowledge I’d have missed had I not simply reached out a hand and said “Hi, I’m Darrell.” My momentary companion (we each moved to more spacious seats) had been a schoolmate of the recently deceased Kate Spade. He confirmed her years-long struggle with a depression that defied logic and was thus a depression that was as pathological as diabetes or heart disease or cancer. Opening my Sunday papers brings stories from the friends of Anthony Bourdain, also deceased, and his decades long struggles with the same demon disease.

Like so many others, both Mrs. Spade and Mr. Bourdain were killed by illness, cause of death: suicide.

First, a couple of statistics. Suicide is presently the 10th most frequent cause of death in the U.S. currently responsible for taking roughly 45,000 lives each year. I am a physician. Doctors die from suicide at a rate 0f 40 per 100,000, the highest rate of any profession and twice the rate of Americans in general. Suicide is the second leading cause of death among teenagers (behind accidents), having surpassed homicide for the first time in 2017. [As an aside, the U.S. loses more young lives from all causes than any other developed country. This drag on life-expectancy should always be considered when you compare the health outcomes of various countries] A very large percentage of these deaths occur in those who suffer from some kind of mental illness, of which depression is far and away the most common.

It is time for us in America to reframe our conversation about suicide for the good of those who are at risk as well as those who have lost a loved one for whom the cause of death was suicide. Let us start, as we should in all serious discussions, with the language we use. For decades at least we have used the phrase “committed suicide” when describing such deaths. It is well past time for us to retire this phrase, at least for people like Kate Spade and Anthony Bourdain. To commit is to perform a willful act while under the full control of all of your faculties. Commitment implies the performance of an action that is the culmination of rational thought. Outside of war, the act of taking a life after rational thought is the purview of the psychopath; it bespeaks the presence of evil.

People like Spade and Bourdain who are killed by suicide are not evil.

We will all come upon well-meaning entreaties from those around us offering help should one be considering suicide. We will see headlines and the like proclaiming that “Suicide can be prevented”. Can it? Can suicide be prevented by addressing suicide and the thought of suicide itself? By and large suicide is an effect, not a cause. Some suicides do, indeed, follow the rapid appearance of dismay and despair, and these may very well respond to the well-meaning aid of those who offer a phone number, an ear, or a ride to a doctor or therapist. For some, especially the young, suicide is an impulsive reaction to an overwhelming emotion. For those left behind these are the hardest for we all surely ask “what if”, and we all as surely respond “if only.”

There is suicide that kills as the consequence of illness too long in development, even with the best of care possible. Depression, Bi-polar Disease, Schizophrenia and their ilk sometimes prove untreatable in the exact same manner as cancer or heart disease. Suicide is the cause of death in the same way that liver failure might take someone with widespread cancer that began in another organ; the ultimate cause was neither the failed liver nor the suicide but the underlying disease. It is so very, very important for the family and friends and acquaintances of those who ultimately pass by suicide to understand and accept this, especially if their loved one was being actively treated. Here, in these circumstances, we the living must guard against “what if” and “if only” as if our own lives depended on it.

Because they do.

I have known you all, you who have lost and who are still here to remember. I am one of you. Friends and acquaintances, friends and family members of acquaintances–I, too, have losses. “What if” and “If only” haunt us all. For us, as it so often is, the solution lies in love and kindness extended not only to those who are suffering, but to those we have lost and most especially to ourselves. No one who loved us as we loved them would have chosen to hurt us in life; how they ultimately died was not a choice to hurt us in the passing. We will surely hurt but we must not allow ourselves to feel that we have been hurt on purpose. More so, in time we must forgive ourselves for that which we could not change as surely as we could not have saved the parent or the sibling or the friend who died from cancer. We must forgive ourselves, be kind and loving to ourselves and all of the others who share our loss, for the alternative for us is despair and dismay.

We can begin this cycle of kindness and love by choosing a different way to discuss suicide and calling it what it is: the cause of death. Do reach out to those you know who have been buried by despair and are drowning in dismay, for they might be saved. Fight for the right to do so. Do champion the recognition that mental health diseases that have no outward signs such as true depression are as real as an open fracture at the scene of an accident; they should be treated as seriously and with the same sense of urgency. Fight for the right to have these diseases treated the same way. Doing so will save lives. Love those you love as much as they will let you for as long as they are alive for the loving, and let them do the same for you.

Peace and grace be upon those who have lost loved ones who were killed by suicide. Joy and love to all who have stood with toes across the precipice and stepped back, and to those who were there to embrace them when they did.

 

Fitness or Sport? A Proper Place For High Intensity Training

The CrossFit Games Regionals were on ESPN yesterday afternoon. What? Wait. No? No, I guess you’re right. It wasn’t ESPN, was it. As it turns out the Games have shifted over to CBS Sports. Totally missed that memo. Of course, I only surf to the Games site once or twice a week anymore so I can be forgiven. Thankfully I was marooned at home with nothing left on either my Honey-Do list or my own Wish List, and ESPNU was all kinds of messed up so I couldn’t watch the D1 Lacrosse quarterfinals. Surfboring around cable I stumbled on the Regionals and received my annual reminder about what CrossFit is and who is supposed to do it.

In short the CrossFit Games as exhibited in this year’s Regionals is to CrossFit as the Indy 500 is to your daily commute: almost everyone needs to do the latter, but almost no one can, or should, do the former.

You could certainly say that I am treading on thin ice by proclaiming that you and I have no business doing anything but gawking at Regionals athletes doing full-on Regionals WODs here on .com. Fine. Here is why I feel this way; the incessant urge to emulate Games-level athletes and to turn every CrossFit WOD into a training session for competition risks the undoing of what makes CrossFit (and other high-intensity offshoots) a potential solution (or integral part of an irreducible Rx, to coin a phrase) in solving the population health problem in Western societies. It really could be as easy as eating fewer processed carbohydrates, being stronger, and training at relatively high intensity for periods of time in the 8-20:00 range. Stronger and leaner with greater aerobic capacity is all pretty much any of us needs.

Everyone who has ever owned a Box or coached a CrossFit class has seen the danger of extending the “you vs. you” competition outward into the “Sport of Fitness (TM)”. Clients who leave a gym because the trainer refuses to teach them how to do a CTB butterfly PU when they can barely do a single dead hang PU. Fledgling CrossFitters who insist on rebounding box jumps instead of stepping down because their times suffer when they do. “Linda” or “Diane” done As Rx’d with rounded lower backs, chins held high because, you know, you gotta Rx the Open WODs if you want to go to the Games. It’s really hard to exaggerate how disheartening it is to listen to a client say they are leaving a gym because they don’t feel like you are the best fit for them. Then you look at their data and discover that they are down 15% BW fat, have doubled their 1RM Deadlift, can now do “Fran” Rx’d in half the time they first did it with an empty bar and a green band, all injury-free.

Form, then consistency, then and only then intensity. This is what you need for fitness. The siren song of competition is strong, especially during our Games season. Shout out to those trainers, both within the CrossFit business universe and out, who continue to hue to this orthodoxy. Functional movements, irreducible exercises performed properly at a level of intensity that is high for an individual, coupled with a diet that is designed to fuel performance in the gym and in life is what we 99.9%’ers need. Distilling this prescription into a measurable and repeatable program is the essential genius of CrossFit. That some of us get to do it as part of a community is that much better; friendships formed through shared experiences, especially shared strife (and what is “Fran” if not shared strife), are also an integral part of being healthy.

After my (ca. 2006) WOD I sat down with some left-over steak and a handful of nuts to see how Dani Horan was doing in the East. A little sore and energized, the only thing that was missing was another CrossFitter there to join me in watching the spectacle.

Mental Health is Part of Health

Some time ago I wrote about creating a way to measure health. Real health. Health that encompasses every aspect of what it means to be alive and well. As a CrossFitter I definitely included Coach Glassman’s Disease -> Health -> Wellness continuum, and I also acknowledged the critical importance of his concept of “Fitness over Time”. As a classically trained physician/scientist there is clearly a place for more traditional metrics like blood pressure, serum lipids and the like, although they may, indeed, be an variable that is ultimately tied to fitness.

Where my thoughts on defining and measuring health seem to depart from most current trends is in the recognition that mental health–emotional wellbeing—is as much a part of being healthy as any other thing we might examine.

Think about it for just a moment. Most of what we would classify as mental illness has as many outward signs that we can see as diabetes and hypertension. Which is to say, none. Yet we—all of us, not just CrossFitters—see nothing but the good in treating diseases like diabetes openly and aggressively. There is no stigma attached to seeking care for your hypertension or your elevated LDL. To the contrary, if someone who loves you discovers you quit measuring your glucose before you bolus your insulin, they are for sure gonna get in your grill.

For whatever reason, mental illnesses are looked at quite differently. No one is asking the person with chronic depression whether she is taking her life-saving medication, for example. We might notice an insulin pump on a friend or family member, but then it’s quickly forgotten. Everyone seems to be very uncomfortable around the young man who has very obvious hand tremors from the life-saving medication he takes for his Bipolar disease. We all seem to be so much more understanding when we have to wait for a response from someone suffering from Parkinson’s Disease than from the young women who has the same symptoms as a side-effect from the medicine that quiets the dangerous thoughts in her head from Schizophrenia.

It’s not even necessary to look only at these kinds of severe mental illnesses when we are examining the importance of mental or emotional wellbeing as an integral part of being healthy. What good does it do to have a 5:00 mile, a 500 lb. deadlift, and a 1:59 “Fran” if it was self-loathing that drove you in the gym to get there? You may be quite accomplished, the envy of your peers, at the peak of whatever life mountain you wished to climb, and yet you cannot feel joy. How is it possible to be healthy without joy? I look at Usain Bolt and what I see is quite possibly the healthiest man alive. My friend Tim, the writer, tells me that Justin Gatlin has nearly everything that Bolt has—youth, fitness, wealth—but the combination of failure to knock off Bolt, and the public disapproval reigned on him as boos from the Rio stands has left him emotionally broken. It’s subtle, but if you look at his face in the blocks of the 100M Final it’s there.

Our complex and conflicted attitudes and feelings about mental illness are especially evident when the topic of suicide comes up. Just typing the word makes me uncomfortable. Even how we describe suicide is fraught with hidden meaning that reflects our discomfort: someone has “committed suicide”. Right? Someone committed an act that we simply cannot fathom, one that leaves the survivors completely without any understanding whatsoever. How could someone DO that? It’s as if every suicide is the same as the suicide of the crooked prison warden in The Shawshank Redemption when he looks out the window and sees his fate arrive in the front seat of a State Trooper’s car.

In reality most of the time it’s simply not like that at all. Nothing about it is simple at all.

The outer walls at the periphery of my world have been breeched by suicide twice in the last couple of weeks. One of them actually does feel a bit like that prison warden. Frankly, I am too conflicted, too aware of the external circumstances and not enough aware of the internal life of the deceased to offer much right now. The other one, however, just stopped me in my tracks when I heard. The loss was profound.It has also introduced to me a new vocabulary that I truly believe provides a starting line from which we can change how we think about not only suicide, but all of mental illness. A friendly acquaintance lost his wife when she was killed by suicide.

We don’t need to know all of the details of the story. Suffice it to say that in the face of a child’s illness she suffered quietly. Too quietly to be noticed. Perhaps she didn’t realize how badly she was suffering, or maybe she was like so many of us and couldn’t bring herself to see her illness for the life-threatening entity that it was. No one will ever know. What is clear, though, is that this was not anything about commitment. Kidney failure may be cause of death in a diabetic, but it is diabetes that kills him. There is no difference here. The cause of death was suicide. Her disease, her depression is what killed this young woman.

Each of us has a very few moments in our lifetimes that forever change us. On the second Tuesday of July in 2006, unbeknownst to me, one of those moments was transpiring in a lonely, dark corner. Joyfully, the moment was a beginning, not an ending. Regardless, once learning of the moment I was changed forever. Now I knew. You cannot see any marks from mental illness, no swollen appendage or insulin pump. But it is there all the same, and it must be acknowledged and accorded the same degree of care as any other disease that may take our loved ones from us. Mental illnesses are real, and they can be deadly. There ought not be any conflict or discomfort in treating them.

We may stop losing so many of our loved ones when start to see emotional wellbeing as part of being healthy.

Equality and a Just Society

“Life’s not fair.” –Scar

What does equality mean? What does it mean to be equal? This came up this week in my day job. A study was done that proports to show that male and female eye doctors are paid unequally. The conclusions are false at the outset in this particular case because by law, services in this particular arena are paid exactly the same no matter who performs them, when or where. Unfortunately, the sensational lede taps into all kinds of notions of fairness, and all kinds of perceptions about what people assume must be true, that women make less than men for equal work. There is no question that this is the case is some walks of life, but interestingly the data (some of which the authors ignore in their quest to prove their preconception) proves otherwise in medicine. An opportunity to examine real differences in how men and women practice medicine is thus lost in the pursuit of an examination of the spiritual quest to combat inequality, even where none exists.

Is this the unicorn of equality? Is payment under government programs the only place where equality actually exists? Heck if I know. What interests me is the fact that the first assumption is that inequality is present. Inequality is the default setting. That there is an inherent degree of unfairness in pretty much any and every setting. Know what I think? Equality doesn’t exist. It cannot exist if we are to have an ever-improving world. There is nothing unfair about that in the least.

A just civilization establishes a floor below which allowing people to live is ethically wrong. For example, in healthcare it is my contention that we have a moral obligation to see that every citizen has access to care when they are sick. Inherent in this contention is that there is a basic level of care that meets this moral obligation by ensuring the same outcome as any other level of care. One could apply this same concept to food, clothing, and housing without missing a beat. We can think of the rights enshrined in the U.S. Declaration of Independence as a proxy for this baseline if you’d like. Life, liberty, and the pursuit of happiness make a very fine baseline.

One’s right to “life” necessarily includes a right to be fed, would you agree? Equality would mean that if one among us dines on Beef Wellington, than each among us must do so as well. This is where unthinking and unquestioning fidelity to “equality” brings you. In so doing it forces everyone to expend energy protesting “inequality” better put toward fulfilling the moral obligation to see that no one goes without protein. In healthcare we see all kinds of protests againts the inequality of care demonstrated by the horror of a VIP of some sort or another recuperating from a procedure in a luxury suite, while the proletariat must recover in the equivalent of a Hotel 6. The reality is that the outcomes will be equal; the moral obligation has been fulfilled. Above a basic level in pretty much any domain you wish to examine, equality does not exist. Sorry. Scar is right. Life’s not fair.

Is he really though? Saying that it’s not fair is the same as saying that inequality above that level at which everyone has a right to live is wrong. Here is where I part company with those who hew to this viewpoint. What does it matter that someone drives a Cadillac while another drives a Kia? Do both not get you to work on time? Or that Beef Wellington again: do you not get the same amount of protein from a hamburger? The example I am using in another conversation about equality in healthcare is similar: if a medicine is effective taken 4 times a day, is the fact that someone can pay more for a version that must only be taken once a day a measurement of unfair inequality? I vote “no”.

My strong feeling is that energy spent in some way protesting “equality” is energy that is not expended on the much more important task of fulfilling the moral obligation of raising everyone to that acceptable basic level. In may, in fact, work against that effort. That constitutes unfairness in my opinion. Advocacy and protest should be directed there, toward making sure that everyone has that most basic obligation covered. Once universal entry is accomplished across all applicable domains, the next task is to continually raise that basic level for everyone, no matter how far the gulf may be between that level and whatever the “sky’s the limit” level might be. One need only look at “poverty” or “hunger” and how the bar has moved ever upward there to see how this might work.

We have a moral obligation to see that true rights are available to all. It is unfair to those who have not yet achieved that most basic level when efforts to help them are diverted to the pursuit of an unachievable conceptual goal that neither feeds nor clothes nor cures those in need: equality.

Adventures in EMR Vol 2 Postscript: Who Owns This Debacle?

The late, great Larry Weed, M.D., Professor of Medicine at the University of Vermont predicted both the age of EMR as well as the advent of IBM’s Watson, “Big Data”, and machine-learning in the practice of medicine. With the problem-oriented medical record in the form  of the SOAP note (Subjective -> Objective -> Assessment -> Plan) he codified a universal approach to essentially any medical problem evaluated in any patient. What was then called the Medical Center of Vermont implemented a data warehouse which allowed instant viewing of test data by computer throughout the institution ion the early 1980′s (the first “EMR” if you will), and sister institution the Maine Medical Center solved the problem of the handwritten order by adding computer order entry (CPOE) in 1984 or so. Despite all of the hoopla surrounding the Accountable Care Act’s carrot and stick drive to digitize the medical record, the horse was already out of the barn and slowly walking in that direction in the 1980′s.

Why, then, is the EMR landscape such a mess in 2018?

Our American healthcare landscape is blessed with a number of very large, prestigious institutions. They are self-professed and incessantly self-promoted as leaders in both thought and action when it comes to the advancement of medical care in all ways in the United States. It is right here in the laps of the leaders of those famed institutions that blame rests for the debacle that is the modern EMR. As early as 1990 and as recently as 2008 the opportunity to lead presented itself to our most august institutions. When given this opportunity to develop a new, better type of medical record that would aid in every aspect of caring for patients, our most important medical institutions punted.

When you think of the best medical care in the country, who do you think of? Pretty easy to answer that, I bet. The Cleveland Clinic, The Mayo Clinic, Yale, Stanford, the hospitals that made up what has become Harvard Pilgrim Health like Mass General, Brigham and Women’s and Beth Israel, Johns Hopkins, Baylor. Household names, all. Every single one of these institutions seeks to portray itself as the ultimate example of excellence in medical care, devoted above all else to the development and provision of care better than any and all competitors. Not only that, each wishes to project the most pious of images, one that espouses their monk-like devotion to doing what is best for their patients before all other considerations. With a building consensus that record keeping the old pen and papyrus way was hindering both present and future care, and indeed might be contributing to harmful care, the era was ripe for any or all of these presumably noble, altruistic non-profit institutions to answer the call.

When American healthcare was ready to look to any of these institutions to lead us into the digital information age, each and every one of them abdicated. The leaders of these and other great institutions had the chance to develop a true medical record in digital form that was first and foremost a tool to be used to improve the care that was provided in their institutions. They had the resources. Any one of them could have taken a leadership role in its development, not unlike the kind of leadership many of them have taken as the first institution in on cutting edge medical care such as organ transplantation or new generation cancer care.

Instead, both early and late, the leaders of each one of these major institutions chose a path with an eye not toward how the EMR would engage in the care of a patient, but in how it would engage with accounts receivable. Each institution opted to prioritize the growth of revenue over improved care. Everything is about maximizing the income of the institution, while at the same time minimizing the risk associated with billing.

J’accuse.

Think about that second part for a moment. EMR’s are not designed to promote the safety of an individual patient as she goes through her care experience (despite what the marketing brochures may tell you); for safety they are designed to limit the likelihood that a payer audit will find a lack of documentation that supports the charges. The bigger the company making the program, the greater is this emphasis. In the early 00′s any one of the above institutions (and Texas, and Ohio State, and Dartmouth, and…) could have launched a program that met all of the MEDICAL criteria for a good record. If they wanted to make a profit they could have sold the rights to use it.

Why don’t EMR’s communicate with one another? Were you aware that even institutions that run software from the same vendor do not have the ability to simply put notes from one another into a universal chart? Crazy, huh? Frankly I’m not really all that sure who is to blame for that particular bit of nonsense, but the obvious answer as to why your Epic chart can’t communicate with, say, Nextgen lies with that abdication of responsibility I spoke of above.

By not taking control of the process of EMR development at the outset all of our major medical institutions learned that 1) they never really bought an EMR, they just rent it which means that 2) they no longer really own their own information. What better way to remain in control if you are Epic than to prevent The Cleveland Clinic from banding together with The University of Pennsylvania as a bargaining unit than to prevent them from sharing patient information ON THE SAME DAMN PLATFORM?

J’accuse.

To their collective shame our most prestigious medical institutions and their leaders sold their souls by prioritizing their role as commercial entities rather than as leaders in medical care on behalf of patients. In the process they allowed themselves to be enslaved by the commercial interests that now control the medical record. Worse than that they created an additional barrier between a patient and his own medical record.

There has to be a bright spot, right? Some shining beacon, a last bastion, someone willing to stand against toute le monde and defend the honor of academia, to not become the next rhinoceros?  Certainly some institution was willing to stand up and do the right thing by saying “screw it”, we’re gonna make a killer EMR that does everything that Larry Weed said it should do first, and then figure out the billing crap later, right? Perhaps the medium sized Intermountain Health in Utah is on the right track, but all of the really big institutions turned belly up to submit to the demands of payers, hoping for a treat and a  belly rub. Surely UVM, the home of Larry Weed didn’t cave, right? The University of Vermont must surely have been driven by its early entry into the world of digital information management and created its own EMR that both houses information in a clinically relevant way, as well as allowing for computer-guided decision making, right? RIGHT?

Nope. Sorry. The University of Vermont runs on Epic.

 

 

Adventures in EMR Vol 2 Epilogue: May We Please Have…?

“The essence of Medicine is story—finding the right story….Healthcare, on the other hand, deconstructs story into thousands of tiny pieces…for which no one is responsible.” –Victoria Sweet, M.D.

Being forced out of your comfort zone in any endeavor is always painful. In my experience it is also conducive to learning something new, and at least in my case it is a catalyst for creative thought. What, then, have I learned from our forced-march, point-of-a-bayonet transition from one EMR system to a new one? Are there any lessons to be learned on a broader scale, beyond the walls of SkyVision? Can I take this bowl of lemons and create lemonade that can be passed around the much larger table that encompasses the broad landscape of American medicine?

First off, our collective experience with our transition reinforced my long-held contention that you simply can’t effect change in a system of any type without either being a functional unit in that system, or shadowing those who work in the system you wish to improve. Imagine designing the cockpit of the next generation fighter jet without ever actually either flying one or sitting next to someone while they fly it. Take a look back at my essay “EMR and Underpants”; our information ecosystem was designed by engineers far, far away from the point of care delivery. It’s roughly the same as giving someone the job of choosing what underpants to deliver for your daily wear without ever having seen what you look like or talking with you about how you wear your clothes.

After all of our struggles there does appear to be one, huge 30,000 foot lesson in all of this that should, by rights, become the foundation of the next wave of innovation in EMRs: the spoken word is the goal. What made our traditional scribe process so successful in both efficiency and accuracy was the development of charting based on a spoken narrative. The doctor would dictate exam findings. The scribe would then intuit the various diagnoses from the conversation occurring between the doctor and the patient. While the doctor then went on to outline the plan of action this, too, was transcribed into the medical record. It was a natural and familiar way for all of the players in the room to communicate.

Why can’t I do that with any of the EMRs available on the market? Why is it that I can’t talk to an EMR and have my verbal encounter become what we would all recognize as a progress note? Heck, I’d be thrilled if there was an interim step in which all of the BS clicking we are doing to check all of those boxes could turn into something that looked more like spoken English (although our new EMR is OK and getting a bit better on this). With all of the hundreds of millions of dollars being raked in by EMR behemoths like Epic you mean to tell me they can’t find the resources to make this happen? Please.

You see, the essence of every healthcare interaction is the spoken word. When you have to stop talking or listening you have devalued time. Think for a minute from the patient’s point of view: it doesn’t matter whether it is a doctor of some other kind of worker in the room, once attention is shifted from the patient to the screen quality plummets. Make me a poor man’s AI interface that I can cue verbally to let it know what I’m doing and put it in the right box so that Uncle Sam won’t ding me for being a poor data entry clerk. I’d even be willing to talk to Mrs. Pistolacklioni about her smoking at every 3 month follow-up for her severe glaucoma (a disease that has no increased risk if you smoked, by the way).

While I’m at it, and as long as we are talking about communicating (cue Paul Newman in Cool Hand Luke), may we please find a way for the real medical record to be freely available on every platform? Seriously, how did this one escape the cloistered engineers and double-blinded underwear salespeople? Your Samsung cell phone can call your buddies iPhone and vice versa. An airman flying a MIG 22 can communicate with an inverted Tom Cruise in a 3g dive because there is a single standard for radio transmission and reception. Come on. This is basic stuff, the equivalent of declaring the gage of railroad tracks. You mean to tell me that the same people who think they know so much about how things must be that they have an opinion on the shape of operating room hats somehow missed this? Again. please.

I’m not kidding about the OR hats by the way; some DA administrators simply declared that bouffant hats were safer because they think so and won’t come off that even in the face of randomized control studies to the contrary.

Seriously, go all the way back to Dr. Larry Weed at UVM in the 1980′s and return to his beloved premises. There is too much information to be contained in any one doctor’s head, and doctors cannot avoid their biases and frame of reference when making medical decisions. Having true interoperability across all platforms would allow the free movement of information at the direction of the patient, the person who should be in control of that information after all. (Note: Carbon Health is on to something)

As a society we’ve allowed ourselves to remain captives of the trial bar’s defense of the status quo when it comes to malpractice lawsuits. This, in turn, has prevented us from examining repeating errors to determine if there might be a common thread that could be altered and thereby reduce their frequency. Interoperability would allow just the sort of root cause analysis that is needed, and because it would be done using anonymous information no actionable disclosure would be necessary from the doctors involved. As a bonus this would probably allow us to create true, vetted care protocols for the majority of patients with the majority of problems, and this evidence based care would then have to be admissible in court. All that would be necessary would be for doctors to explain in their chart why they decided to deviate in an individual case if that came up. Bingo, a data-driven solution to defensive medicine, all from better communication.

My new vendor is unaware that I am writing this, but interestingly has invited me to consider joining their advisory board and to speak at their annual convention. Who knows if those invitations will continue to be extended once they read this, but if they are I will have two very simple, very basic messages. This whole medical record thing should be about communication, just like it’s always been from the days of Hippocrates. That, and that Larry Weed was right. Before we go any further forward go back and read Larry Weed.

All we need is a little electronic SOAP to clean up this mess.

 

Adventures in EMR Vol. 2 Chapter 3: Jogging in Quicksand

Being an eye doctor in 2018 means that you will take care of patients whose care is covered by a government program of some sort. In order to be able to get paid for your labors you need to record your work in an electronic medical or health record (EMR), and that EMR must be able to comply with  certain diagnosis and quality reporting standards. Failure to comply with these requirements does not mean you can’t take care of these patients, nor does it mean that you won’t get paid for doing so. It just means you will eventually get paid roughly 22% less for that work than someone who has an EMR that does comply.

15 months of effort to get our legacy system into compliance led to 3 months of research culminating in the purchase of a new EMR with a very sophisticated, dedicated ophthalmology/eye care format. With our purchase came on site training (with overtime pay for staff) and literally hundreds of man-hours of preparation work (on the clock) performed by both staff and doctors before we went “live”. The entire adventure was nothing less than a series of “OMG, you have GOT to be kidding” surprises for each one of us, starting with this killer: I would have to pay to retain access to the information SkyVision had gathered on our patients over 13 years. Yup. You heard that right. Even though we would never enter another electron of information into our old system, in one way or another I was going to have to ransom my own medical records.

As embarrassing as it is to admit it, I probably own that particular surprise. Really shoulda seen that coming.

What I also didn’t see coming, indeed what none of us saw coming, was just how different it is to practice medicine in the age of EMR. From Hippocrates through Osler and on to Marcus Welby and whatever the name of the doc played by George Clooney in “ER” was, medical care proceeded in the same orderly fashion. Once again we have Dr. Larry Weed to thank for codifying this process in the form of the SOAP note. Subjective -> Objective -> Assessment -> Plan. You listen to your patient’s story, cataloguing her symptoms and their salient characteristics (onset, severity, duration, etc.). Next comes the collection of data including your exam findings and any test results you may have. From this accumulated knowledge you make a diagnosis, or at least assemble a differential diagnosis, either of which launches a plan of action. The flow is so obvious that it’s somewhat astonishing that it took Dr. Weed to publish this as a process breakthrough.

From the minute we sat down with our laptops and tablets in front of us to learn how to use our new EMR, every single SkyVision staff member fell through the looking glass into a world gone, at best, sideways. Charting to billing, documenting everything that goes into taking care of a patient from the primary point of view of the payers, renders the SOAP model moot. Everything begins and ends with the diagnosis, the Assessment in SOAP-speak. What you plan to do comes next, and you now have to justify what that will be by demonstrating that the diagnosis can be found in the data. Your patient’s complaints have to be explained by your findings. Our tidy little straight line progression handed down from Hippocrates has been scrabbled. SOAP has become APOS.

How perfect is that?

Everyone is aware of how time consuming it is to enter data into a compliant EMR. There is just an endless number of boxes to click, even if you ignore the nonsensical sections that apply to worthless quality measures (childhood vaccine history review at the dermatologist? Smoking cessation at every eye doctor visit?). Even with the pre-loading and on-the-fly development of protocols that “pre-fill” all of the boxes for very common evaluations (e.g. cataract surgery in my world), it just takes a boatload of time to enter all of the information that is demanded. I hear those clicks in my sleep.

Remember, I already used scribes to enter information; if they are slowed down patient flow slows down, too. If I stay and enter information myself my schedule backs up downstream. If the scribe stays with the patient in the room after I’ve gone on to another patient there is no place to put the next patient in line. Leaving the charts “open” so that they can be “finalized” later is an option, of course, but one with three penalties. The practice gets socked with overtime expenses, the staff is overworked and can’t be home, and believe it or not that open chart is “timed” as a quality measure as if the patient was there waiting all that time. Doing a better job ends up dinging your quality score. Merde.

So what did we do and how did it go? We started 5 months ago with 3 charts in the new system per doctor per 1/2 day session. Sounds pretty reasonable, huh? Ease your way into it. Try not to upset the whole apple cart. Maybe just bruise an apple or two. The plan was to slowly increase the number of charts filled in the new system each week by slowly expanding the type of visits we recorded. You know, post-ops before massive, complex pre-op evaluations. New patients who didn’t have any data in the old system. It sounded pretty good when our trainer suggested it. Naturally, as soon as we expanded our universe of new EMR patients we crashed the entire office flow. What had been a finely tuned machine that seldom ran even five minutes behind on a single patient became a battlefield filled with folks waiting 30, 40, even 60 minutes for their exams within an hour of the opening bell.

It was like jogging in quicksand.

I’d really love to tell you that 5+ months in it’s all unicorns and rainbows. That we are now up and humming along, seeing the same number of patients we always have and running on time like we used to.  I’ll admit to occasionally coming across a random footprint that might have been left by a unicorn, and every now and again we catch flashes of color, a rainbow seemingly just out view. We had to hire a part-time tech to assume the task of “pre-populating” the new EMR charts with information from the old system. Every staff member has had to drop parts of their duties to take on the tasks of entering patient information on the front side or finalizing the chart entry so that it is consistent with our billing on the back. I will have to buy access to my old records in the old format, at least temporarily, so that we don’t get slowed down learning a new way to look at old data.

The best way to describe where we are after 5+ months is that we are now running rather than jogging in that quicksand. Exams that once kept a patient in our office for a maximum of 67 minutes now take closer to 90 (we really do track that kind of stuff). Where we rarely had a single patient more than 15 minutes behind schedule we now routinely have  5 or 6 who run an hour late every single day. A couple of week ago I was worried that this one change was going to drive us out of business because of the increased costs, and what I assumed would be mounting ill will from patients who were disappointed in their wait times and stopped coming to see us. Not gonna lie, it didn’t look very good.

A funny thing happened on that road to ruin paved in quicksand: my staff and my patients collectively said “no way.” Crazy as it sounds, two groups of folks who were suffering alongside me looked at the alternative and said “no”. Oh sure, there were certainly patients who trashed us on rating sites because we ran late on a single visit, including some who’d given us straight 5 out of 5 stars for years. But most of them read our “Under Construction, Pardon Our Dust” signs, gritted their teeth, and basically said that we’d earned their patience. Staff is coming in early and staying late. They are huddling and brainstorming ways to restore our flow. Our charting is no better than before but we do send out better letters. Some day we may even be able to do some of those things that Larry Weed talked about when it comes to managing large amounts of information and making complex decisions.

But for now it’s still nothing but pain. It’s hard and the hardship is slow to abate. We all feel the sense of unfairness, that we were forced into this position, and that what we have now does not make our patients any better off than they were before. I would not have chosen this path, not for any reason, had I not been forced to do so. I have no idea, and I will never know if it would have been easier had I picked the other option. Beware all ye who travel here. You are about to embark on a journey where each step is taken in quicksand. It will be a long, long time before you are cleansed of the residue.

Remember, your SOAP has been replace by APOS.

 

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