Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

Cape Cod

Posts Tagged ‘doctor’

Smaller, As Time Becomes Shorter

This weekend was spent in Chicago at the annual meeting of men and women with whom I share my day job. As I noted in “Sunday musings…” I’ve been suffering a bit from some sort of degenerative issue in my hip. Traversing the longest indoor “bridge” outside of the Providence airport rental car connector, my discomfort made me think of my Dad and the back pain that grew to consume him as he aged. Mind you, my discomfort is minimal in comparison, and my particular problem is quite amenable to a surgical fix with a high success rate. Still, it made me feel older, and it made me think of my Dad, gone these 3 years.

Below is what I wrote some years ago when I started to notice the changes in Dad.

 

When did my Dad get so small? Close your eyes. Think of your Dad. What does he look like? How old is he with your eyes closed? He’s younger, isn’t he? And bigger. MUCH bigger.

I spend most of every day in the company of people decades my senior. I’ve watched some of them age over 20 years or so. There are a few with whom I’ve bonded, who I remember and can conjure up an image if asked. I never appreciate the change in size in them, though.

It’s a strange phenomenon. It’s uncomfortable, no? There really IS a physical change that occurs as we age; we really DO shrink physically. No, it’s more than that when you look at your Dad, more than the physical decrease in size, the loss of vigor and all that goes along with it, the stuff I might actually notice in my patients. What makes it so striking when it’s your Dad is that it’s more than just physical, but a diminution in all dimensions and domains including the one inside your head.

He WAS strength when I was a kid. Literally, a rock. Immovable and unshakeable at all times. Unmoved by excuses or explanations when he knew he was right, or if he MIGHT be right. The final arbiter of discipline (“wait ’til your FATHER gets home…”) in a very traditional family, every thing about the guy was just huge.

When did he get so small? It’s almost scary, you know. He was the guy who stood between me and everything that might be dangerous, at least figuratively. At least in my mind. It’s hard to reconcile the guy I just put on a plane back to RI with my Mom, and the guy who’s there–right in front of me–when I close my eyes. So small now, almost frail. That classic love/fear thing now replaced with something more like love/protect. Does he see it, too? How small?

Will I see it, when I’ve become small?

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.

 

Sunday musings 10/14/18

Sunday musings…

1) Feral. Abbie the Wonder Dog was feral for the first 6 or 9 months of her life. I can’t remember exactly. She was live-trapped and rehabilitated by a Border Collie rescue organization in north central Ohio. When she frustrates me it is always helpful to remember this.

Having a formerly feral creature living in our midst is also a very good counter to the frustrations of modern life. I try to remember how far I am from true privation whenever I find myself railing agains the insanity and inherent indifference that the world clearly has toward my existence.

A quick thought of my clever (read: sneaky) pup is usually all it takes to quell my urge to explode when I encounter the tragedy of a poor internet connection…while hurtling through a mountain pass in a car going 80 MPH.

2) Test. Some 10 years ago or so I proposed that a true measurement of health should be possible. Something that combined the most basic of classic medical knowledge (weight, %BW fat, BP, Cholesterol, etc.) and the breakthrough notion that physical fitness could be measured and tracked. My theory included the necessity of including some sort of measurement of “well-being”, a mandate that was initially openly mocked but seems to have been rather meekly accepted as both logical and necessary.

Creation and launch of such a value, call it “Total Health” or something along that line, has fizzled due to the lack of consensus–nay, even interest–in coming up with a way to measure Fitness. Imagine, in a place like CrossFit where the very definition of Fitness was created, no one save me and a tiny group of equal obsessives has so much as let fly a tiny trial balloon. The original owners of CrossFit LA were the first to use a standard entry test. 500M Row/40 Squats/30 Sit-Ups/20 Push-Ups/10 Pull-ups. I suggested pulling from both traditional sources (The President’s Fitness Test) as well as CrossFit and the larger endurance communities: 2:00 each of PU/Push-Up/Sit-Up/Squat, 1RM Deadlift, 1 mile Run. We ran a competition once called the “Fittest Eye Doc” using this.

What is necessary is a test that is a) doable by the general public, and b) capable of creating a single value that can be measured and tracked. Once that is done mathematicians and statisticians can be let loose with the various factors and given the task of coming up with a formula that includes all three categories. Why bring this here, again, when thus far my previous dozen or so postings have been met with crickets? With the pivot to health and the rapid build-up of a cadre of physicians who are at least superficially interested in using high intensity exercise for the purpose of increasing health, I am hopeful of a broader dialogue that comes to an agreement on a test.

Challenge: create a test of fitness that is broadly accessible in all ways (scalable) that can be included in a definition of health. 3-2-1…Go.

3) 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 its historical recipients. Today 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 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. 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.

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.

And so we mourn the end of the Age of Volunteerism. We wait with equal parts sadness and fear for arrival of what follows.

I’ll see you next week…

–bingo

 

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.

 

When “Team Player” Means It’s All You

“It’s better to full-ass one something than to half-ass a bunch of things.” Anonymous

Soon enough I will be living another week of on-call coverage for one of the largest hospitals in Ohio. When asked recently by colleagues why I still do hospital coverage I had to admit that I really didn’t have an answer. I don’t really have to do it, and yet it doesn’t really seem like it feels right not to. There’s a kind of “pay it forward” debt to the giants who came before me that still lingers, I suppose. That debt’s been paid, with a bundle of interest, many times over, and it may be time to close the ledger.

Why now? Well, it has very little to do with the work itself because that hasn’t really changed all that too very much over the years. No, it’s more about the work that’s NOT being done by others, work that they own and are responsible for and don’t do, that will ultimately drive me away from this part of my day job. It’s really no different than any other job or workplace anywhere. The lazy and the shiftless, the incompetent and the entitled all see it as just fine to kick the can downstream to whomever they can get away with kicking it to.

I’ll bet you just had a dozen images of this from your own life flash by, right?

Boy, there are a thousand reasons you will hear to explain and rationalize why they feel it’s perfectly reasonable to get you to do their work. After awhile it gets really old. The first thing you should do when you encounter this is to look within and make sure that YOU aren’t doing this anywhere to anyone else. Gotta make sure that your virtue is intact before you saddle up the high horse! Once you’ve ascertained that all is right and proper with your own work ethic you then have a bit of a choice to make: rock the boat or sail along. Sadly, though you know the consequences of the latter (you continue to do that slacker’s work), be prepared for the possibility of not being thanked for pointing out reality to bosses and co-workers. It’s entirely possible that you will be the one criticized. Totally fair, right?

In the end there is no best answer to this dilemma. All you can do is use the feelings generated in you by being on the receiving end of this work-shifting to make yourself a better worker, no matter who it is you do that work for. If you do, indeed, reach that point where you just can’t look at yourself in the mirror any more because the injustice is simply too much to accept, it’s OK to call it as you see it. That’s where I am today, and that’s what I’ll be doing while on call. To be sure, all of that “pay it forward” I’ve done will get me an audience, though it may not mean I will be able to effect change. Other than workload, that is. In this tiny part of my day job, I will continue doing the very best job I possibly can, as I always do, for each of my patients each time I see them.

What I won’t be doing is picking up the other half an ass that someone else missed before I full-ass my part of the job.

Offloading info/Work

Why do I write? Why do I sit down and use time that could otherwise be put to use in the gym, or in the office, or even just hanging with the Man Cub? As a long-standing lover of language I am always on the lookout for the best vocabulary to explain concepts I sometimes struggle with. Offloading is a term that is used in this case to describe what it is that humans do with information that they do not need to keep on hand in “useful memory” space.

This is what I do with ideas when my “wetware” memory is full.

This is hardly new. Indeed, the sturm und drang associated with the mega-trends in education, etc. associated with our massive information/recall apparatus that is the internet actually has its origin in the Greek era of Socrates and the transition from an oral tradition to one in which teachings were written. (HT to Frank Wilczek). Prominent adherents to the oral tradition such as Socrates and Simonides argued forcefully that the advent of the written transfer of information would weaken the mind and produce an inferior type of intelligence. In a fascinating and delicious ironic twist, all we know of either of these men we know because someone else wrote down what they recalled hearing.

In my day job we are still encased in a paradigm in which information is transferred from teacher to student and then tested to see if that information has been committed to memory. Imagine, with the explosion of data now available in the world of medicine we test (and test, and test…) both new doctors and established ones to see if they remember a certain percentage of facts, regardless of how often those facts come into play in the act of practicing medicine. The CrossFit analogy is to test a trainer on the precise moment that the obturator engages in the deadlift. One neither needs to know this to teach the deadlift, nor does one need to have memorized this in order to have it on hand in the gym. So, too, in medicine.

Please don’t get me wrong, I still enjoy knowing a bunch of stuff and being able to call up that stuff without needing to use my Google-Fu. The reality is that we have made a move from memory in written form to memory in digital form that is just as profound and disruptive as that from oral to written. We have only to remember where it is we have stored our memories, our books and our music and our musings.

And our passwords. We still need to remember our passwords.

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.

 

Adventures in EMR Vol 2 Chapter 2: The War of the Roses

Unsportsmanlike conduct, piling on should have been the call, but alas, no flags were thrown. After roughly 15 months of crossing our fingers and hoping that our original EMR vendor would be able to guarantee our compliance with the twin pitchforks of ICD-10 and quality attesting it became clear to us that we could no longer afford our “spend and pray” strategy. We felt forced to initiate divorce proceedings with our legacy software and begin the search for a new program that would ensure our compliance, and in so doing allow SkyVision Centers to survive as an independent entity.

Well, that’s what we thought we were doing anyway.

Our original search for an EMR program in 2004 was undertaken from a position of strength in the skinniest of markets. There were only a few vendors who made a product suitable for eye care, and we were making a “want” buy rather than a “need” buy. In this position we had the luxury of working with the ultimate game plan: we could play to win. By this I mean we could clearly state what our objectives were and lay out in clear terms how we expected our new EMR to enhance our business. I mean enhance in every single manner, most definitely including the bottom line. Our search was meant to bring in technology that would not defend against loss but to help us bring in more revenue, to help us win.

SkyVision Centers entered the eye care market with a single, borderline maniacal focus on enhancing a patient’s experience in the office. Face it, there is no way that any but the most sophisticated patients are going to be able to differentiate between doctors and practices based on quality measures having to do with outcomes and safety. Our medical world is quite opaque in ways both inadvertent and purposeful. Discussing “bad doctors” or “bad hospitals” just isn’t done. By the same token, touting better outcomes or safer care is considered borderline slander by other doctors and institutions. Hence we simply considered all of this–quality, safety, etc.–to be the “table stake”, an assumption that each patient made, and we decided to set ourselves apart by our focus on how each patient FELT during their care.

If you think about this, we should also  be able to make all of these assumptions about something as basic as an EMR, right? That it should enhance both the doctor’s and the patient’s experience during care, or at least not have the opposite effect. Our original EMR was quick and efficient, was adaptable to our existing care and process protocols rather than the other way around, and allowed us to maintain eye contact with our patients for >90% of any care experience in the office. This, more than anything else, explains why I hung on for so long after any objective outsider would have already jumped ship to a new, regulatory compliant program.

It took precisely 90 seconds to realize that our patient-centered ideal was going to take a hit by changing our EMR. That’s how long I had to listen to the consensus best patient/doctor interface among the “modern”, compliant programs. Every single program arrives with a pre-set protocol, an indelible and unalterable set of mandatory processes that you WILL implement into your practice. Another 90 seconds spent reading the front page marketing pitch of this new batch of EMR candidates makes it clear that you are not looking at a program designed from the doctor/patient interface out to the billing office on its way to the payer. Every single product now sold that will comply with the various and sundry “quality” and reporting requirements is built from the billing interface back to your exam.

That’s an awfully tough pill to swallow.

Let me take just a minute to address the subject of scribes, staff members whose job it is to transfer the data that a doctor obtains and put it into the medical record. The solution to all of the problems created by EMRs is supposed to be solved by using scribes. Many (most?) doctors who are new to EMR are also new to the concept of using a scribe. Not so, though, in ophthalmology, at least at the level that I have practiced since I left residency training. For the most part I have had a scribe in the exam room with me from my very first day of practice. Our scribes were not just Carol Burnett Show era secretaries but highly trained technicians who simply rotated through their turn writing exam findings, diagnoses and plans with a pen on paper. I’ve always had this, and we utilized scribes in EMR v1.0 as well. Part of the unfairness was that I anticipated the need to hire MORE scribes simply to tend to the software’s protocols, so we were losing before the game even started.

What then does it mean to be playing “not to lose” when choosing the next EMR? The very first premise is little more than trying not to lose money you’ve earned by receiving a penalty for inadequate fidelity to all of those reporting rules. After that it becomes something more like trying not to lose your soul. Which program would allow us to maintain as much of our substance and our style while allowing us to continue to take care of the same number of patients? I was willing to forgo growth (loss #2 before game time). How long would it take for us to transition between platforms? Was there a program that would let us go fast enough that our patients would forgive us the obvious change in what it felt like to be in the office, even if that change was a 25-50% longer experience? I mean AFTER the transition. 25-50% longer in the office AFTER we are good at the new program. That was the reality I encountered in my search.

I’m not gonna lie. My biggest fear was that I would choose the wrong program. Well, check that; my biggest fear was that I would choose a program that would hurt us more than another one I might have chosen. I did my homework. I reached out to colleagues who do what I do and had chosen an EMR in the last 3 years. I went into offices and watched staff members and doctors use the programs I looked at. It was unbelievably depressing in all honesty. The lack of eye contact with patients and the slavish attention demanded by the computers in the room was appalling, not to mention the drudgery. Death by a thousand clicks.

Check that. A million clicks.

A consensus arose among eye doctors, one that I agreed with, that there are two EMR products on the market that are better than all of the other options, and that it is essentially a toss-up between them. Every colleague I chatted with felt this way, including those who were content with their present programs; they would choose one of the two (and not their present program) if they were starting from scratch. After narrowing down my choice to two it was almost a coin toss to be truthful.

After pouring lots of money into that car I already had in the hope of returning it to functionality I was ready to buy a new car. To spend yet more money on one of the two choices before me. No matter which one I chose, I was choosing something that would mean an existential change in how we practiced medicine at SkyVision Centers. Because there were only two, no matter which one I chose I would forever be haunted by the question of whether life might have been just a bit less unpleasant if I’d chosen the other one.

Changing your EMR because you have to is like the War of the Roses: there is no winning or losing, there are only degrees of losing.

Next Chapter 3: Jogging in Quicksand (where only the “A” counts in SOAP)

Adventures in EMR* Vol 2 Chapter 1: Government Forces a Divorce

It’s hard for me to empathize with docs and medical organizations who as late as 2015 0r 2016 lamented the U.S. government’s irresistible demands to electrify the medical record and had not yet done so. Along with the other follies imposed on all quarters in healthcare, the Accountable Care Act (ACA) spawned in the early days of the Obama administration decreed that all care provided to patients covered (paid) in any way, shape, or form by the federal government must be recorded in electronic (computerized or digital) form. More than that, this digital health record (EMR) must conform to the nebulous and ever shape-shifting requirements known as “Meaningful Use” (MU). Armed with 30 pieces of silver on the front side and the promise of slow, withering financial ruin on the back, CMS went about the business of coercing organizations large and small to move from paper to electrons.

Why, you ask, if I am so obviously disdainful of this occurrence, do I find it hard to empathize with folks who’ve been harmed by this process? Well, our group SkyVision Centers (SVC) saw the value of using an EMR at the time of our founding in 2004, back when Mr. Obama was a very junior Senator from Illinois and about to be “discovered”. The concept of an EMR, with the medical record warehoused in a server rather than in a folder, was so obvious to us at the time that we never considered the use of a traditional chart as we developed our bleeding edge business plan. As a University of Vermont grad I had learned about medical information processing at the knee of the great Larry Weed. Indeed, my biggest frustration with the EMR’s available in 2004 (and still to a degree in 2018) was that they did not allow me to do the kind of information processing that I learned from Dr. Weed’s associate Dennis Plante, who taught me about computerized medical decision making in 1984.

Those doctors and those medical groups that were still using a traditional paper chart in 2015, 16, or 17 missed the boat by 10 years; their enhanced pain brought on by their inertia was self-inflicted. More than that, the larger among these groups (I’m looking at you, UPenn) essentially recused themselves from leadership positions that they could/should have taken. As an aside which I will explore in an epilogue to this series, very large early adopters (think Cleveland Clinic, The Mayo Clinic, and Harvard Pilgrim Health among others) bear a significant responsibility for the mess we now find ourselves in by abdicating their leadership role as medical institutions in favor of maximizing their return as business entities in the earliest days of EMR.

Back in those UVM days Dr. Weed built his case from two very specific premises: there is simply too much medical information for any doctor to be able to house it in his/her brain, and decision making based on the data available for any one patient is too easily influenced by a doctor’s frame of reference and biases. Sounds familiar, especially if you spend any time on Twitter and follow folks like Vinay Prasad, Saurabh Jha, and Amitabh Chandra. Dr. Weed clearly envisioned a universe of connected records (mind you, this was well before anyone outside of the government  had heard of the internet) that would allow the free interaction of multiple doctors with all of the information available on any patient. Without using the word Dr. Weed described “interoperability” perfectly. (Note that UVM had all testing results–radiology, lab, etc–available on computers in the 80′s. Sister hospital Maine Medical Center one-upped them with computerized order entry in 1983.)

Mind you, most of this was not really available in 2004 when SVC was looking for its EMR. We just assumed that it would eventually be programmed into a larger system as more doctors and practices saw the light. Our rationale for implementing an EMR at this early time in history was driven by the obvious advantages that it would give us when it came to providing the best possible patient experience when we were taking care of patients with eye problems. Utilizing an EMR allowed us to maximize our efficiency so as to minimize the amount of minutes wasted over the course of a care visit to SVC, fulfilling with our pocket book our mission statement to provide “The Best Experience in Eye Care”. Our specific EMR choice fit seamlessly into our Toyota manufacturing-derived system of workflow and enabled us to vastly exceed our patient’s expectations when it came to the office experience.

We were on the cutting edge. So what happened? Well, in short, Obamacare with all of its regulatory burdens happened. Onerous “quality” measures came and went in the early days of the ACA. My professional organizations as well as the owners of the EMR we’d chosen lobbied vociferously against the implementation of what would have been disastrous burdens on the field of eye care (among other specialties). Back at home we doubled down on our market advantage as the best office experience for our patients and slow-rolled along with our EMR provider as it did the minimum necessary to remain compliant. In hindsight I was clearly choosing efficiency and the maximization of the patient interface with the practice over Larry Weed and the information interface.

We probably could have continued this way if not for ICD-10, the coding change that increased the number and complexity of mandatory diagnosis reporting when billing. For reasons that remain unclear to me our EMR provider could not accommodate the change to ICD-10 in a way that allowed us to properly document our charges for very specific, common eye problems. This is a problem, you see, for eye doctors of any stripe take care of patients who are covered by government-funded programs. Failure to comply now meant penalties that would ramp up to 22% of payments in an industry that routinely runs a profit margin of 25-30%. Each slow step in the right direction was followed by multiple steps backwards and sideways.

We as a group never felt that our concerns and clear business needs were being adequately addressed. Have you ever owned a car that had a serious problem? One that seemed as though it was fixable, at least at the onset? Maybe it was a car that you loved, or maybe it was just a car that was paid for and did the job for you. You put money into the car to fix it and it’s not better, so you spend some more, and then you spend some more. At a certain point you realize that no matter how much money you put into fixing that car you just can’t lose the thought that it’s not going to be enough. You just can’t shake the worry that despite all of that money you are still going to end up on the side of the road at midnight in the middle of nowhere. After months of expensive upgrades that were late in coming it became clear that we could not be guaranteed that the EMR we’d been using since our creation would be able to carry us forward in a financially safe manner by meeting the government’s regulatory demand.

In effect, the U.S. government, through the regulatory demands of the ACA, forced us to initiate divorce proceedings with our EMR. To survive it became clear that SVC would need to buy and implement an entirely new EMR.

Again, you might ask, why can I not empathize with those who are late to the EMR game and suffering the pains of implementing a new EMR into their organizations if we are now in those same, exact shoes? I think it’s a fairness thing, and I fully acknowledge the irony that I am a guy who routinely quotes Scar’s great line “Life’s not faaaiiirrr.” You see, in my mind, we did the right thing way before we had to by spending money we really didn’t have in 2004 on an EMR way before it was mandatory. And we spent. And we spent. As anyone who has ever worked with mandatory software knows, your key critical programs are the gifts that keep giving…to your vendor. For our commitment to providing a better experience for our patients (and admittedly more business for the practice) we would now be rewarded by having the privilege of paying for a whole new system.

And as I will discuss next, paying for the “right” to see all of the information we’d already paid for.

Next Chapter 2: The War of the Roses

 

*Like all good reporting where one hopes to discuss global issues rather than very granular, product-specific issues, this series will not name any products that we have previously or are now using.