A Country Doctor Writes:

The arguments about nominating a new Supreme Court justice have illustrated how relative everything really is around here.

Since our Constitution is still being reinterpreted after all this time and since Roe v Wade may be reversed, depending on one 48-year-old woman’s opinion, is there any wonder why not all doctors think and act alike?

There may be laws of physics, although I don’t think all of them are immutable anymore, but there are hardly any laws in medicine. All we have to go on are data and differing interpretations of what to make of it.

It should be obvious that much of what we do in medicine is far from straightforward or universal. All we have are broad stroke images, rough ideas, of how our bodies and biomes work. Right now, as we struggle to understand how one virus differs from another, we look back and realize that some patients with Covid were dying because they were put on ventilators – and there we were, thinking we wouldn’t have enough of them.

Medicine is like a society without sophisticated laws; a culture, clan or cadre of practitioners with scientific training, intellectual curiosity and open-mindedness as well as a required amount of humility, because we are constantly navigating in uncharted and ever-changing waters. And this society is built on just a few principles, perhaps outlined best—but certainly not legislated—in the Hippocratic oath.

We face two obvious dangers: trusting our own knowledge too much and trusting conventional wisdom too blindly.

Most people think you need to be very smart and experienced to sit on the Supreme Court—or any other bench for that matter—even though the laws of the land may seem like they should be self-explanatory. Imagine how challenging it is to always be an effective physician. But is that how my profession is viewed right now?

No, we are portrayed as followers, rather than interpreters, of the science. But the truth is, we often face unique situations where there are neither laws nor good science to guide us.

And as the physicians treating our ailing president seem to be making unusual or even inexplicable treatment decisions, it should be obvious how inexact the art of treating individual patients really is.

Interviewing celebrities can make you a celebrity yourself, and it can make you very rich. So there’s got to be something to it or it would be a commodity. The world of media certainly recognizes the special skill it takes to get people to reveal their true selves. 

At the other end of the spectrum of human communication lies our ability to explain and also our ability to influence. These three aspects of what we do—elicit, explain and influence—are far from trivial, and in my opinion quite fundamental aspects of practicing medicine.

….

The problem with our work environment is that all the technology and all the well meaning efforts we are subjected to have, ironically, conspired to distance us from our patients and made us less effective than we could be.
— Read on thehealthcareblog.com/blog/2020/10/02/physicians-communication-skills-are-overlooked-and-undervalued/

Kevin MD is running a piece today that I wrote a while back and had a lot of fun with, comparing the practice of medicine to childhood games like where’s Waldo and whack-a-mole.

After reviewing this one office note, my brain was exhausted. I had not expected the chart review to be so much more like Where’s Waldo than Who Dunnit.
— Read on www.kevinmd.com/blog/2020/09/wheres-waldo-finding-whats-important-in-the-medical-record.html

” I can’t help reflecting on how focused we are in medicine on the subject matter and how little we speak about the delivery of subject information. The business world seems to talk more about how to sell something than how to produce it. I think as physicians or scientists, we look down on that, thinking that a cup of coffee is a cup of coffee, so why are all these people devoting their lives to how to sell that cup of coffee?

We need to get off our high horses and take a look at how we present information about what we “sell” because what we try and hope to sell may have a greater impact on our “customers” future health than which brand of coffee they choose to drink.”

— Read on www.kevinmd.com/blog/2020/09/we-need-to-give-more-thought-to-informed-consent.html

I wrote about this three years ago, which is long enough to make a cell phone outdated, if not downright obsolete. From what I can see, nothing has changed in terms of what EMRs look like. In one of my practices we have a new (?!) EMR that’s even clunkier than its predecessor from the same company (Greenway, you know who you are: Why do you make me SCROLL down Every Blood Test Known To Man instead of starting to type in a search box???).

Doctors are still mostly charting on laptops or even desktops. Haven’t the EMR companies heard of iPads? eCW has a fair app, but with bugs that haven’t gone away in the last three years and new ones that are appearing. Nobody has an interface that works like a doctor thinks, and nobody has the user interface simplicity of the technically sophisticated games my grandson plays on his Xbox. Actually, video games allow you to do everything without awkward commands or click boxes. And they go back to the early 90’s (see post script below).

If I open a patient’s “chart” today and try to prescribe a drug, the software asks what day’s encounter and what type of encounter I want this to be under. Excuse me: It’s today and I’m sending in a script. Why do I have to tell my multimillion dollar system that?

The technical unsophistication of EHRs is mind boggling, but even more appaling is the worse-than-DOS-era interfaces we have to deal with. My nurse gets a paper depression questionnaire from my patient. It is abnormal. She enters the details and the score in the computer. I don’t get a pop-up. Instead, I have to remember to click FORMS-Nurse Work Flow-Screening-PHQ9 and then see the score and click one of the boxes to document my action. How sad, how nerdy, is that?

I would like to know what the excuse is for the fact that children’s games have better interfaces than EMRs. And don’t tell me that medical records are more complex. They are not, at least not yet. I can mark a patient as allergic to iodine and having stage 3 or 4 kidney disease but many systems would still let me order a CT scan with iodine contrast. Someone (many of them) is making indecent amounts of money selling indefensibly inadequate, incompetent software to the nation’s health care providers. And laughing all the way to the bank.

P.S. Historical footnote: My Brooklin home was once owned by Mark Lesser, who was the programmer behind NHL 94, one of the most famous video hockey games of all time. His office on the third floor of the barn was my “man cave” for several years.