A Country Doctor Writes:

Archive Page 135

Medicine is a Love that Finds Us

Published March 14, 2017 Progress Notes Leave a Comment

Medicine is a love that finds us wherever we happen to be.

It snatched me, a quiet four year old boy, almost sixty years ago. I don’t know how it happened. I remember being in the hospital and having stomach X-rays and I have also been told we had a family doctor who made house calls. I couldn’t have seen doctors on TV, because television was only introduced in Sweden when I was three and I saw my first program at age 5, a show about an infantile doll named “Andy Pandy”.

At age four I simply announced that I was going to become a doctor and I never hesitated after that. It seems everything I did from that moment on prepared me for what I do now: Being a Boy scout who made do with what I had on hand; learning discipline as a military recruit in basic training; working as a substitute teacher for fifth to ninth grade students; spending a summer as the pastor’s assistant with confirmation students and in his parish, and traveling the world to interview people from other cultures.

In my day to day work I always look for the story behind each patient’s symptom and even behind their laboratory values. I often find myself circling around the concept of Narrative Medicine.

The other day I happened to read the Swedish journal for general medicine (Allmän Medicin). A doctor, who seemed to be about my age, had written about his experiences with Narrative Medicine and the tension he used to feel between it and today’s Evidence Based Medicine.

The writer’s name was Christer Petersson, and he looked and wrote as if he was someone I had known from High School. I Googled his name and found another article he had written, in 2009, in the Swedish Medical Journal, Läkartidningen.

That article was titled “I worked as a Doctor for 20 Years. Then I Became a Doctor”.

I did a quick double take and continued to read, finding exactly what the title suggested: He had studied medicine because the science interested him and it seemed like a good thing to do. He was a young man with big thoughts and big ideas. But he felt uninspired by learning about the digestive system and was uncomfortable with the notion of treating mundane things like bleeding, boils and open wounds.

He writes:

“It took about 10 years and quite a bit of agonizing before I discovered that I was exactly where I was supposed to be, and it took another 10 years to understand that I actually was a doctor and didn’t just work as one. During that time I learned that man is more than his digestive system and the most important events in life often happen in the seemingly uninteresting space where blood flows, boils burst and wounds heal.”

And then, he paraphrases Hippocrates’ first aphorism:

“And I saw that it is equal parts suffering and joy to deal with all this as a doctor: to cure sometimes, treat more often and comfort the best you can.

It doesn’t get any better than that, does it?”

Different journeys to the same destination.

EMRs Should Be Like Rental Cars

Published March 2, 2017 Reflections 5 Comments

When a new doctor joined our clinic, she spent a week learning our electronic medical record. She had used two other systems before, so she was no stranger to EMRs, but that’s how different they can be.

That’s crazy.

EMRs should be like cars, which range from the likes of Smart to Mercedes Maybach from Daimler, Mini to Rolls Royce from BMW or Skoda to Porsche from the Volkswagen group of companies. They range from simple to sophisticated, from nimble city cars to opulent highway cruisers.

There are occasional differences like type of fuel, battery, ethanol or gasoline powered, steering wheel shift paddles or voice controlled entertainment systems, and the driving experience varies wildly between marques but you could probably pick up just about any car as a rental vehicle, learn the basics and safely be on the road within just a few minutes.

For example, one country doctor, who shall remain unnamed, worked for over a year with an EMR which he explained to his patients wouldn’t tell him if any new reports had come in since they were in last. One day, by accident, he discovered a tab on the right hand panel of the computer screen, labeled DRTLA, that does just that – Diagnostic imaging, Referrals, Telephone calls, Labs and Actions, plus other incoming documents, neatly arranged. Somehow the implementation process skipped over that feature. That is just one of many functionalities of my particular EMR a new user wouldn’t be able to figure out very easily on their own.

A rental car would be considered dangerous if the shifter didn’t look somewhat like shifters in other cars, or if the windshield washer fluid and coolant caps weren’t easily distinguishable.

Similarly, a car would be considered unsafe and illegal if the windshield was only a few inches wide, and if drivers had to press a button or two in order to see the whole road in front of them. But that is how each lab report, like a Complete Blood Count, shows up on that same EMR.

And, now I know this, of course, but why is the “send” button on my prescription module marked “fax”, with a drop down menu choice of electronic prescription, which is the way we have to send prescriptions to comply with Meaningful Use? To confuse clinicians? I can think of no other reason.

A child, or a middle aged physician, can pick up an iPhone and quickly work the basic features by intuition, and wouldn’t be completely lost if suddenly handed an Android phone instead.

And, truth be known, my iPhone does some things better and faster than my million dollar EMR. And some inexpensive cars are more reliable than high prized exotics.

“Did You Read My Chart?”

Published February 28, 2017 Progress Notes 3 Comments

The patient, I surmised, was the one in the wheelchair, with nasal oxygen and an unhealthy red color of her cheeks. The younger woman in the room with her looked like she might be a daughter.

I introduced myself. I had been right about the other woman being her daughter.

It was Saturday clinic, urgent care at our country doctor practice, and the plastic holders with “express check-in” history forms and a scribble sheet for the doctor and the medical assistant were piling up in the pocket of my office door.

“So, what can I do for you today?” I asked.

The woman in the wheelchair gave me a sturdy look and said:

“Did you read my chart?”

My mind raced, thirty years into the past and back again.

As an intern and resident admitting patients to the hospital, I would routinely read up on the patient’s paper chart before entering the room. Each admission took as long as it needed, and the only time pressure I felt was usually my own. The emergency room doctors had already ordered the initial treatments each patient needed.

In practice before computers, I would glance at the problem list and flip through the last few notes, labs and imaging tests while pausing in my office or at the nurses desk, sometimes actually while walking toward the exam room.

Now, with computers that go black after just a few idle minutes, I’d have to log on in order to see any information, and the moments that takes feel like forever. Besides, I can’t very well sit in the last exam room I used and do this, since my nurse needs to room the next patient.

Also, now, with all the checklists we must complete in even the simplest visit, there really is no time during or in between visits to actually sit down and “read the chart”; our time is so pressured and the medical records have become so bloated that we end up just asking the patient, because the pertinent information drowns among the mandated minutia.

“No, there is seldom time to read the chart anymore”, I said.

My patient sighed and gestured to her daughter, who recited her medical history in a monotone voice as if she had done it too many times to count.

The woman had leg cramps, and it was probably because of low magnesium. Her exam was fairly similar to the last note by her own doctor. I did compare my findings and his.

So I prescribed magnesium and two days later we got a call that that had done the trick.

But I don’t think she will ever accept that when she sees a different physician, they will talk to her first, before deciding if it would be worthwhile to steal the time from someone else’s appointment to sit down and read her chart.

A Day in the Life of Sir William Osler

Published February 13, 2017 Progress Notes 1 Comment

Snowed in by a fierce Nor’easter, with our clinic as well as every other outpatient facility within 100 miles closed for the day, I stoked the fire in our wood stove, pulled up my high back chair and read for a couple of hours.

I returned to my treasured, signed copy of Harvey Cushing’s biography of Sir William Osler, the father of modern medicine. On page 431, under the subheading ’He Knew Not Idleness’, Cushing quotes a senior assistant’s account of Osler’s daily routine.

This description may be surprising to those who only know Osler by his famous quote, “Look wise, say nothing and grunt”:

“At 7 he rose; breakfast before 8. At a few minutes before nine he entered the hospital door. After a morning greeting to the superintendent, humming gaily, with arm passed through that of his assistant, he started with brisk, springing step down the corridor towards the wards. The other arm, if not waving gay or humorous greetings to the nurses or students as they passed, was thrown around the neck or passed through the arms of another colleague or assistant. One by one they gathered about him, and by the time the ward was reached, the little group had generally grown like a small avalanche.

The visit over, to the private ward. For the many convalescents, or the nervous invalid whose mind needed diversion from self, some lively, droll greeting or absurd remark or preposterous and puzzling invention, and away to the next in an explosion of merriment, often amid the laughing but vain appeals of the patient for an opportunity to retaliate. For those who were gravely ill, few words, but a charming and reassuring manner. Then, running the gauntlet of a group of friends or colleagues or students or assistants, all with problems to discuss, he escaped. How? Heaven only knows!

A cold luncheon, always ready, shortly after one. 20 minutes’ rest in his room; then his afternoon hours. At 4:30, in the parlor opposite his consulting room, the clans began to gather, graciously received by dear ’Mrs. Chief’, as lady Osler was affectionately known. Soon the chief entered with a familiar greeting for all. It was an anxious moment for those who had been waiting on for the word that they had been seeking with him. After five or 10 minutes he would rise, and perhaps beckon to the lucky man to follow him to his study. More often he slipped quietly from the room and in a minute reappeared at the door in his overcoat, hat in hand. A gay wave of the hand, ’Good-bye’, and he was off to his consultations.

Dinner at seven to which impartially and often, his assistants were invited. In the evening he did no set work, and retired early to his study where, his wife by the fire, he signed letters and cleared up the affairs of the day. Between 10 and 11 o’clock, to bed. Such were his days. Three mornings in the week he took at home for work. He utilized every minute of this time. Much of his summer vacation went to his studies. On railway, in cab, on his way to and from consultations, in tramway, and in the old ’bobtailed’ car that used to carry us to the hospital, book and pencil were ever in his hand, and wherever he was, the happy thought was caught on the wing and noted down. His ability at a glance to grasp and to remember the gist of the article that he read was extraordinary.

His power to hold the mastery of his time was remarkable. He escaped as by magic, so graciously, so engagingly that, despair though one might, one could hardly be irritated. No one could speak consecutively to Osler against his will. How did he do it? I know not.”

(W.S. Thayer, ‘Osler’. The Nation, N.Y., Jan. 24, 1920.)

It makes me reflect:

Time, my old arch enemy, is always on my mind. Over the years, I have managed to adopt a somewhat Oslerian persona, which tries to make every minute, and every brief encounter, count in the mind of my patients and in my own pursuit of forward movement in each clinical case I encounter.

But most days I don’t know that I am anywhere nearly as skillful as the old master in navigating through it.

He probably capitalized on his larger-than-life reputation and position in the world of medicine. I have only a local reputation and the position that career longevity and mature appearance bestows me, like my silver haired temples and my wrinkled hands and face.

But the one thing I know and sense every day in the clinic is: If for a single moment my love of my profession or the connection I feel with my patients and my coworkers is clouded or briefly forgotten, the pace of my workday becomes almost unbearable.

It is only when I am carried by the momentum of my greater purpose that I can make every one of my brief encounters with my fellow human beings count and be healing in any sort of way.

Dropping the SOAP Note

Published February 4, 2017 Opinions 5 Comments

The SOAP Note isn’t what it used to be, and what it has become needs to be scrapped, because it has made the office practice of medicine cumbersome and unsafe.

In simpler times, when medical records were written by and for doctors, the SOAP Note represented a significant leap forward in terms of expanding and organizing office notes, and also notes from emergency rooms and walk-in clinics. Prior to that, notes sometimes only documented the diagnosis and the treatment, not how those were arrived at.

With S for Subjective, O for Objective, A for Assessment and P for Plan, the reader could instantly find exactly what he or she needed to know from a colleague’s medical record entries.

These days, medical records contain a lot of data that is mandated by outside parties – CMS, ACOs, PCMH/NCQA, the Joint Commission, and now even local states, like Maine.

EMR vendors have inserted these mandated items in sometimes very illogical places in the medical record, and they have also infused bookkeeping items where they probably work best for billing purposes, but definitely not to document clinical thinking.

Some examples:

I see many ER notes that don’t clearly state the patients “Chief Complaint”. I see that they got there by private vehicle, gave the history themselves, didn’t need an interpreter, had already had all their baby shots and were not yet ready to quit smoking, but I’ll be darned if I can figure out what brought them out in the middle of a snowstorm to see somebody in the emergency room.

In the SOAP Note, anything observed during the visit instead of told to us, such as vital signs, heart sounds, blood tests and in-house X-ray findings would go under Objective. Tests ordered but not expected back until later went under Plan.

In the EMR I work with (or under?), there is no Objective and no Plan. There is Exam and Treatment.

That difference isn’t subtle.

The tests I do in-house are ordered and resulted under Treatment, after I have already stated under Assessment what the diagnosis is. That makes no sense. A chest X-ray doesn’t treat anything. The antibiotic I prescribe goes there, too, so at least that makes sense. But essentially, the logical and chronological order of my notes has been hijacked by non-clinicians.

More static items like past medical history, family and social history used to go on the inside left of paper records, where they could be referenced and updated on the fly. Now, just like in a hospital admission note where the patient is presented as if they had never been seen before, they are prominently displayed in every single office note.

That is one of the fundamental differences between a paper office note and an EMR note; the former is pertinent and the second is comprehensive, because the note presumably has to document that the doctor mentally went back over known historical facts and considered their possible relevance for the problem at hand with the speed of expertly trained thought and hard earned experience.

It didn’t seem enough to keep the background data separate and simply state “I considered the Past Medical, Surgical, Social and Family history in handling the patient’s issues in today’s visit”.

Even if someone I stitched up ten days earlier just comes back to have the stitches removed, the second office note reads as if a stranger just walked through my clinic door.

In such a case, a visit that lasts less than five minutes from the doctor’s point of view requires verification of all the data that isn’t likely to have changed in ten days, and the office note is just as long as the original note about the chainsaw cut or their first get-established visit – seven pages of 99% irrelevancy for a simple suture removal.

The mandated add-ons’ presence in every single office note has created a clear and ever-present danger that time-pressured clinical staff and physicians will miss critical information and put patients at risk for clinically incomplete care, even though I’m sure the non-clinicians’ intent at some point was to ensure the opposite.

All these additions have inflated and cluttered up the SOAP note to the point where I think it is high time we reclaim a space, however small, inside the office note for strictly medical documentation that is immediately pertinent.

This nugget notation needs to be near the top of our computer screen, so we don’t have to scroll, even to get from the beginning to the end of it.

We must accept that the office note serves the needs of many people and bureaucracies, but if we don’t make it serve us better, we’ll drive ourselves into the ground and at least some of our patients into their graves because we might miss critical things in the overinflated medical records of today.

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