Saturday, November 18, 2017

When Electronic Medical Records Crash

The computerized era has introduced all of us to a genre of errors that never existed during the archaic pen and paper era.   The paper medical chart I used during most of my career never ‘crashed’.  Now, when our electronic medical records (EMR) freezes, malfunctions, or simply goes on strike, our office is paralyzed.  Although I appear to the patients as a breathing and willing medical practitioner, I might as well be a storefront mannequin who appears lifelike, but cannot function.  We cannot access the patients’ records, write a prescription or enter a new office visit. 

Mannequins appear lifelife but don't function well.

Of course, like any business who faces this crisis, we expect instantaneous rescue from our IT professionals, as if we are their only client and they are permanently stationed in our waiting room just waiting for us to sound the alarm.

This is among one of the most frustrating aspects of EMR for medical professionals.   We simply don’t have the time or psychic reserve to absorb unexpected loss of computer service.  We are not playing computer games (although sometimes it feels as if we are.)  We have a live patient facing us as we face a blank screen.  It is frustrating and awkward.   The patients understand this reality as he undoubtedly has endured similar frustrations in his own life.  But, he has come to the office with a reasonable expectation that may not be realized.

Yes, we resort to writing a note in longhand and scanning it into the EMR later, but this is problematic.  First, a scanned document cannot be ‘read’ by our EMR as this document is not ‘part of the family’.  It can’t be tracked, as we do routinely with laboratory and x-ray data.  More importantly, I will be offering medical advice without any access to the prior medical record, which may span years.  If the patient has a complex, chronic condition with a history of extensive testing and medication changes, moving blindly could lead me into a blind alley or through a trap door.

I propose no solution to all of this.  No technological system can perform perfectly.  It’s another example of our ever increasing reliance and dependency on technology – more than we really need, in my view.  I have no choice but to accept EMR in my professional life.  But, there are opportunities when we can stand up and push technology back.

Do we really need Alexa to turn on our lights?

Sunday, November 12, 2017

Why Curbside Consults are Dangerous

One of the skills and stresses about being a doctor, is giving advice to or about patients we have never seen.  If readers think these are rare events, it happens nearly every day.  Often during weekend or evening hours when I am on call, my partners’ patients will call with questions on their condition or about their medications.  Radiology departments contact me during off hours with abnormal CAT scan results of patients I do not know.  Or, a doctor may call me during the day for some informal advice about one of his patients.  These physician-to-physician inquiries are called ‘curbside consults’, which are appropriate for simple questions that do not require a formal face to face consultations.

Physicians must be cautious when providing a curbside opinion on a patient he has not seen as even informal advice could result in legal exposure if the patient later files a medical malpractice claim.  Consider this hypothetical example.

An internist contacts a gastroenterologist for a curbside opinion on an elderly patient who had some mild rectal bleeding.  The internist suspects hemorrhoids and doesn’t want to refer the patient for a colonoscopy as the patient had one 3 years ago at which time hemorrhoids were discovered.  The gastroenterologist reassures the physician that the bleeding is probably from hemorrhoids, which is a very rationale conjecture.  But, it may be wrong.  The bleeding now may be from a colon cancer that was either missed on the last colonoscopy or has developed since.  The cancer won’t be discovered for another year.  Is the 'curbside' gastroenterologist responsible here?

I think so because, even though he hasn’t seen the patient, he has rendered medical advice directed toward a specific patient, rather than simply offer generic comments.  Indeed, the internist may have told the patient and his family that the 'curbside' gastroenterologist agreed that no testing was necessary.  Had the gastroenterologist pushed back against the internist and insisted on arranging for a colonoscopy or seeing the patient in the office, then the outcome may have been different.

Had I been asked for a curbside opinion regarding above inquiry, I would have been much more circumspect with my response, and ideally, I would have entered a chart note in my electronic medical records.  Memories of physicians and patients can fade over time.  I would feel more secure if my chart note recorded that I recommended that the patient be sent to me for an office consultation.

Some questions should never be answered ‘from the curb’.  I would not, for example, give informal advice to an internist about changing his patient’s medications for Crohn’s disease.

If I have any discomfort in responding to an inquiry on the phone, then I recommend an office visit when I can provide a thoughtful and informed opinion. 

Some inquiries are so innocuous that I respond readily even without entering a chart note.  These generic questions do not directly connect me to an actual patient.  To clarify, I will list a few examples.

What’s the proper schedule for the hepatitis B vaccine?
Is the generic for Nexium equally effective?
Are ulcers caused by stress?

There’s a skill set physicians need when we are advising strangers.  Sometimes, the skill is knowing when to remain silent or when to push back.  If you're not careful, it's easy to trip over the curb.

Sunday, November 5, 2017

Polypharmacy in the Elderly: Who's Responsible?

There's a common affliction that's rampant in my practice, but it's not a gastrointestinal condition.  It's called polypharmacy, and it refers to patients who are receiving a pile of prescription and other medications.  I see this daily in the office and in the hospital.   It's common enough to see patients who are receiving 10 or more medications, usually from 3 or 4 medical specialists. 

Of course, every doctor feels that he is prescribing only what is truly necessary.  If an individual has an internist, a cardiologist, a gastroenterologist, a urologist and a dermatologist which is not unusual - and each prescribes only 2 or 3 essential medicines, then polypharmacy is created.  Each day, the patient swallows a chemistry set.

First of all, I don't know how these patients, who are often elderly, manage the logistics of taking various medicines throughout the day and evening, before meals, after meals and at bedtime.  Who can keep track of this?  Nurses in the hospital can barely manage this overwhelming schedule.  This has to negatively affect one's quality of life as the daily calendar of events is predominantly pill popping events.  

Keep in mind that the drugs we doctors prescribe are not that smart.  Does the Nexium I prescribe to hundreds of patients only act on just the right amount of stomach acid to relieve the patient's reflux?  Doesn't the drug reach every organ of the body having potentially deleterious effects that we might not be aware of?  Could Nexium be interacting with other medicines in an unfavorable manner?  While we are quick to demonize stomach acid as an enemy of mankind, isn't the acid that Nexium is reducing there for a reason?  Are we smarter than a few million years of natural selection?

I'm betting on Darwin's theory.

Extrapolate the Nexium example above to a situation when 10 or 12 drugs are cruising throughout the body on a Fantastic Voyage journey, colliding with each other and smashing into organs far away from the drugs' intended targets.  

We also function in a culture where every symptom demands a pharmaceutical response.  While depression, hyperactivity and insomnia are real illnesses, can anyone dispute that the medical community is over prescribing medicines for these conditions?

I wonder how many folks who are suffering from unexplained nausea, balance issues, confusion, dizziness, falls, bowel disturbances and abdominal pain are actually getting a taste of their own medicine.   When they present these symptoms to their doctor, they may end up with yet another prescription thrown onto the pile, when the solution is to diminish the pile which is causing side-effects.

Challenge your internist and your specialists to verify that every drug is truly needed. Insist on the lowest dose that will accomplish the mission.  Are the doctors on your team communicating adequately with each other?  Is someone in charge? 

In my experience, the biggest risk factor for polypharmacy is polydoctor.   More medicines and more physicians aren't better medicine.  Primum non nocere, first do no harm, still deserves to be the mantra of the medical profession.  In medicine, less is more.  On your next visit, ask your doctor to please do less for you. 

Sunday, October 29, 2017

Patient Navigators Climb Your Mountain of Medical Bills

To accomplish certain tasks, we need a little help from our friends.  No one can do it all, although many of us are more resourceful than others.  Some folks are adventurous and dive into a new arena with excitement.  They may be tinkerers who aren’t afraid to play with new gadgets.  Sure, they might break some china, but they are apt to widen their skill set and enrich their lives.  Others, eschew this dive bomb approach and prefer to wade cautiously into new experiences.  Their comfort zones are narrower.  They never break the china, but their personal growth is likely more stultified. 

For some activities, we should simply call upon the professionals straight away.  Here are some examples of jobs that we should pay others to do for us.
  • Cut down a huge dead tree on our front yard.         
  • Replace damaged roof shingles.
  • Investigate why smoke is seeping out of the hood of our car.
  • Prepare our last will and testament from or some similar website.

I realize that not everyone may agree with my examples above.  Many folks, for example, would have no hesitation to scamper up to the roof with a tool belt strapped on to do some reshingling.  Have at it.  If you ever spot a man on my roof, trust me, it’s not me.

If a job needs this tool, then keep your fingers and hire a pro.

There are some activities that we pay others to do, but we shouldn’t have to.  It’s not our fault.  Certain systems are so complex and byzantine that a normal individual simply isn’t equipped.  Why should most of us have to pay someone to figure out how much we owe the government in taxes?  I realize that this absurdity is employment security for the accounting and legal professions, but it indicates to me that the system is broken.  The system should be simple enough that we can calculate our obligations ourselves.

Similarly, shouldn’t understanding and paying medical bills be a simple process, similar to paying all of our other bills?  When I receive a plumber’s bill, leaving aside that his hourly rate might be higher than mine, I can easily understand the itemized services and how the total charge was calculated.  Not so with medical bills.  I’m a practicing physician and I cannot reliably understand my own medical bills. Medical bills occupy a unique universe, which is not governed by reason or logic.  I will assume that every reader has had similar experiences.

We need a modern day Rosetta Stone to decipher our encrypted medical bills.  Of course, we can always call our insurance company directly, which is guaranteed to be as relaxing and fun as undergoing a rigid sigmoidoscopy.  Also, don’t you love the musical phrase, “please listen carefully as our options have changed”?

Enter the new profession of Patient Navigators, an emerging occupation that helps the confused citizenry understand their medical bills.  We all know of many patients who have stacks of bills awaiting payment from physicians, hospitals, radiologists, pathologists, laboratories, emergency rooms, etc.,that would overwhelm the most rugged among us.  Grappling with medical billing is to tread onto a treacherous pool of quicksand with no bottom. Leaving aside the Herculean task of sorting through the morass, there is an inhumanity to expect sick or recovering patients to be forced into this maze of madness.

The existence and growth of the Patient Navigator profession is Exhibit A that medical billing needs to be reformed.  With all of the nonsensical ‘reforms’ that have been forced onto the medical profession, Obamacare missed a target that was overripe for real reform. 

Sunday, October 22, 2017

The Curse of Medical Records Documentation

Let me post a question that neither I nor readers can answer.
How much of what I do during the course of a day directly benefits patients?

Perhaps, I don’t want to really know as I would be dismayed at how much of my effort benefits no one. Ask a nurse who works on a hospital ward, how much of his or her effort is directly applied to patient care.  I would recommend that you have a double dose of antacid in hand – one dose for you and the other for the nurse. 

Just today, I was gently reproved by a hospital physician administrator for a lapse in one of my recent progress notes, which I write after seeing every hospital patient I consult on.  Which of the following transgressions do you think I was cited for?  Only one answer is correct.
  • I did not perform an adequate physical examination
  • I failed to address the results of an abnormal CAT scan
  • I neglected to write the time of day along with the date of the note.
  • I did not discuss the case with the patient’s family.
Just last week at our medical staff meeting, all physicians were told of the requirement to record the exact time, as well as the date, of our hospital visits.   This requirement, which is not new, is not to improve patient care.  It is a requirement imposed by the Joint Commission, which certifies that a hospital is complying with all rules and regulations.   I would like my readers to know that in over a quarter of a century of hospital practice, the visit times were recorded in 1-2% of all hospital notes of all physicians.  No physician has felt that the lack of recorded visit times negatively affected patient care.   Writing down the time may seem to readers to be just a minor irritant which takes only a few seconds.  It is, however, a symptom of documentation requirements that have run amok.

When the Joint Commission visits a hospital, the entire medical and administrative staff are on edge.  Why?  Because there are hundreds of requirements of dubious value that will be assessed  I support the Commission’s mission and recognize that many of the requirements are completely valid.  We want clean operating rooms, safe parking lots and a culture of respecting patients’ privacy.  But, trust me, many of the mandates from them can be trivial or absurd.

Colonoscopy Wildfire!

As an example, in our ambulatory surgery center where we do colonoscopies, we are required by the government to declare before every procedure if the patient is facing a fire risk.  Please do not ask me to explain this, as I am incapable.  Apparently, because we administer oxygen and use cautery, there is a flammability risk.

I want to reassure my current and future patients that to date our endoscopy center has been a flame free zone.  Moreover, the only instance where a firefighter was in our office was when he was getting a colonoscopy performed. 

The public would be shocked and outraged to learn how much of our time is spent racing on the hamster wheel, a difficult and timewasting exercise that yields no progress. 

Sunday, October 15, 2017

I'm Taking a Knee on Journalism

Thanks to NFL players, our national anthem is getting more attention than ever.  Keep in mind that many of us could not recite its words without error, and fewer of us have the range to sing it.  Even fewer can cite the historical event being described.  This is the latest, but not the last, example of a solvable issue that is being exploited to divide us.  I lament that so many of controversial issues ricocheting in the public square are similarly solvable, and yet remain combustible.

The media stokes these conflicts, in my view.  Listen critically to how CNN and other networks package and deliver the news.   Not only is the reportage suffused with editorial content and slant, but it sows overt division and partisanship by design.  

Consider the following two hypothetical questions from a TV reporter.  Which one would the network be likely to air?

“Senator, what is your plan for tax reform?”

“Senator, the leader of the opposing party attacked your tax policy as a cruel attack on working families.  Is he right?”

The 2nd example, in my opinion, improves television ratings at the expense of journalistic professionalism.   

Many cable ‘news’ broadcasts have become extended panel discussions where folks along the political spectrum talk over one another spewing forth predictable drivel in a rhetorical food fight.   Again, these performances may be spirited and entertaining, but they are actually a demonstration by the networks that conflict sells. 

Knees in the News!

The ‘take a knee’ issue has been morphed from its original intent to protest against racial injustice in the criminal justice system to venerating the anthem and the flag.  Of course, there was a pathway forward had calmer minds and listening ears prevailed.  Why solve a problem when conflict can advance your agenda?   Peoples’ positions can harden despite that they have lost sight of the actual issue before them.

Are NFL players who are ‘on the clock’ in uniform permitted to protest on the sidelines?  Although I am not an attorney, I am not certain that sideline player protesting is constitutionally protected, as would speech be in the public square.   Would owners be entitled to issue a restraining directive if the players' actions were driving away fans and profits?  Would a racist player be permitted to engage in a hateful gesture while in uniform on the sidelines?  Lawyers reading this post can enlighten us if an owner can lawfully require that all players stand respectfully during the anthem. 

 In our medical practice, if our staff all wore shirts with a message that stated, ‘I SUPPORT EUTHANASIA’, would the physician owners have a right to limit this speech?

Regardless of one’s view on the legality or propriety of taking a knee, this issue did not have to have sliced the country apart.   I am not hopeful in the short run. As long as our leaders profit from our divisions, and with the public’s insatiable appetite for conflict,  the end zone will remain far out of reach.

Sunday, October 8, 2017

Why Are You Seeing A Gastroenterologist?

I write to you now from the west side of Cleveland in a coffee shop with my legs perched upon a chair.  Just finished the last Op-Ed of interest in today’s New York Times.  Do I sound relaxed?

I rounded this morning at both of the community hospitals that we serve.  There is not a day that goes by that doesn’t have blogworthy moments.  If I had the time and the talent, I would post daily instead of weekly.   Read on for yet another true medical insider’s disclosure.

Gastroenterologists, as specialists, are called upon by other doctors to address digestive issues in their patients.  For example, our daily office schedule is filled with patients sent by primary care physicians who want our advice or our technical testing skills to evaluate individuals with abdominal pain, bowel issues, heartburn, rectal bleeding and various other symptoms.  The same process occurs when we are called to see hospital patients.   If a hospital admitting physician, who is usually a hospitalist, wants an opinion or a test that is beyond his knowledge or skill level, then we are called in to assist. 

The highest quality referring physicians are those who ask us a specific question after they have given the issue considerable thought.  Contrast the following 3 scenarios and decide which referring physician you would select as your own doctor.
  • “Dr. Gastro.  Just met this patient for the first time with a month of stomach aches.  Please evaluate.”
  • “Why did your doctor send you here?” queried Dr. Gastro to the patient.  “No idea,” responded the patient.
  • “Dr. Gastro, please evaluate my patient with upper abdominal pain. I thought it might be an ulcer, but the pain has not changed after a month of ulcer medication.  The pain is not typical of the usual abdominal conditions we see.  Do you think a CAT scan of the abdomen or a scope exam of the stomach would be the next step?  Open to your suggestions.”
Sometimes, we have to deduce the reason the patient is seeing us!
As readers can surmise, I favor primary care and referring physicians who give thought prior to consulting me.   There are many reasons today why primary care physicians pull the specialty consult trigger quickly.  Sometimes, busy internists simply don’t have the time available to deeply contemplate patients’ symptoms.   Physicians have also referred patients to specialists with the hope of gaining litigation protection by passing the patient up the chain, although the medical malpractice crusade has eased over the past few years.  Oftentimes, patients drive the specialty consultation process by asking to be sent to specialists. 

More often than you would think, we see patients in our office or in the hospital when neither the patient nor I have a clue why they are there.  This adds excitement to our task.  In addition to being diagnosticians, we must also serve as detectives, divining the reason that the patient is before us!

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