A Country Doctor Writes:

It should be no secret by now that this rural family physician is pretty much unimpressed by today’s EMRs.

There are many little things that range from annoying to dangerous, but which don’t have a global impact on how I get through my day.

For example, in my Epic, the date when a blood test was ordered displays much more prominently than when it was actually drawn. This makes perfect sense for accountants, who keep track of when the order was received or when the bill went out. They have no idea that in medicine, it makes a difference whether the panic value reflects the patient’s status before they went to the emergency room last week or after they started their new potassium replacement.

More dangerous is when controlled substance prescriptions have an automatic stop date inserted if the provider follows the prompt and enters a numeric duration. What then happens is that a pain or anxiety patient who takes fewer pills some days when they feel better falls victim to having their medicine removed from their list on the day that is supposed to be the minimum time the drug is supposed to last, not the maximum (although Epic displays “up to X days”). Then, either my covering provider will refuse to refill a prescription because it is no longer on the patient’s list or that provider or I will need to re-create the medication from memory of another screen we have to visit, because you can’t “restart” an expired medicine in many EMRs. I have at least once prescribed the wrong potency of a pain pill that had fallen off the list. I caught myself because I had a funny feeling, and jumped through several hoops to retrieve the information from the old prescription.

But my absolute major gripe with today’s EMR’s is how much more difficult it is to glance at a report and get the gist of it. I don’t know if it is a generational thing, but I can glance at a report that follows the format of an 8 1/2 x 11” printed or faxed report and instantly get the essence of it and often even find the typos (for my readers outside this country, that’s approximately an A4 page). Even in my personal life, on my iPhone 13 mini, I can just take my myopic glasses off my nose and read a PDF of such a page and instantly understand what it means. Scrolling through screens that occupy maybe 20% of my laptop screen is slow and annoying and increases my screen time by many multiples.

Very seriously, if I get an emergency room report from my hospital, I only want to see the last page because that’s where the key information is. With the other hospital in the area, I only need to read the first page. But with an electronic medical record it’s not that easy to skip between the pages.

So, yours truly is a speed reader only if the page looks like a page. Maybe I should put up a poll: Page view or screen scroll preference by age?

If we only had the tools and the administrative support that just about every one of us has been asking for, there wouldn’t be a doctor shortage.

The quote here is from 7 years ago and things have gotten even worse since then.

Major league baseball players don’t handle the scoring and the statistics of their games. They just play ball.

Somehow, when the practice of medicine became a corporate and government business, more data was needed in order to measure productivity and quality (or at least compliance with guidelines). And somehow, for reasons I don’t completely understand and most definitely don’t agree with, the doctors were asked not only to continue treating our patients, but also to more than double our workload by documenting more things than we ourselves actually needed in order to care for our patients. Even though we were therefore becoming data collectors for research, public health and public policy, we were not given either the tools or the time to make this possible – at least not without shortchanging our patients or burning ourselves out.

We didn’t sign up to do all this, we signed up to care for our patients. And we were given awkward tools to work with that in many ways have made it harder to document and share with our colleagues what our clinical impressions and thinking are.

It takes a lot of years to become a doctor, and sometimes many more years to become a good one. I don’t know whose harebrained idea it was to require us to do all the data entry to serve those other purposes that were never part of practicing medicine before. It has been said that seeing two more patients per day will pay for an assistant/scribe or whatever is needed.

So… Why is this not happening? In my own personal experience, we survived 15 minute visits with a previous EMR. With our new one (Epic, the probable industry leader), that is simply not possible. What’s wrong with this picture?

With clerical support, there wouldn’t be a doctor shortage and the burnout epidemic would not have the proportions it now has.

Let the doctors do the doctoring and leave the bookkeeping to someone else, at least until the EMR technology catches up and speeds us up instead of slowing us down!

I have a patient who lives in a house with black mold. He had modest symptoms but wanted to know if they were related to the mold in his home.

I cultured his nose and some skin lesions he had. The skin scrapings showed nothing, but the nasal culture showed growth of penicillium.

Up-to-date, which I spend $500 a year of my own money on, is usually a reliable source of medical information. They stated that people with systemic penicillium infection have a 97% mortality rate or something crazy like that. There was no comment on what to do if you find it in a nasal culture. My patient is feeling fine. He did his own Internet search and came to the conclusion that penicillium is one of the common black molds. A regular Google search tells you that penicillium is harmless to people with intact immune systems.

Good thing I didn’t trust up-to-date blindly in this particular case.

I worry about over-reliance on computers (and especially not-yet-ready-for-prime-time AI) and under-reliance on common sense.

(After a whole month of radio silence, I am writing here again. I have built my Substack site and I have taken care of some things in my life, most recently the task of making room for the last of my furniture from Sweden. I feel like I am starting a new chapter of my life in a few weeks when I turn 70, still hard at work doing what I set out to do at age four, but looking at it a little differently.)

This week’s JAMA has an essay in its series, A Piece of My Mind, titled The Stories We Tell Ourselves. The author, palliative care physician Danielle Chammas, MD, writes about the importance of the words we choose when we speak and our task as physicians to help our patients view their circumstances in the best possible light and to rewrite their stories.

She Writes:

Stories allow for the integration of loss, fear, and suffering into one’s life. They become the vehicle through which clinicians can help patients redefine what it is they are hoping for (rather than lose touch with hope all together).

Is somebody a patient, a victim, a survivor, a burden? What does it mean to be a fighter? To do everything? Did we give up on a loved one, or did we honor their dignity? Did we choose to not resuscitate, or did we choose to allow a natural death? Whether intentional or not, clinicians are often an important source of vocabulary that these writers draw from. With each choice of words, clinicians affect narratives, and some words wield particular power. Just, for example, has the power to diminish. How boxed in does one feel when their identity slips into just a patient, just a diagnosis; when hospice becomes just about dying rather than living one’s final days to the fullest?

Dr. Chammas’ essay touches at the essence of being a healer. Our duty as clinicians is not only to treat the disease but also the patient — to ease suffering and help our patients move beyond the present, to wherever their abilities and circumstances allow them to go. We don’t “get over” losses, be that the death of a loved one or the loss of our own health or abilities, we will always remember and live with our losses. We must integrate them in a way that somehow makes sense in order to be able to carry on. This really sank in with me when I attended a Harvard course in the Catskills titled The shadow of the Object, which I blogged about back in 2009:

The title of the course was “The Shadow of the Object”, which is a quote from an enigmatic passage in “Mourning and Melancholia” by Freud. It was held in an old, slightly run-down family resort in the Catskills in upstate New York, very similar to the setting of the movie “Dirty Dancing”. In its heyday, this resort was a summer haven for middle class families from New York City – a chance to experience nature and participate in organized activities while mingling with people of their own kind.

The central idea of the conference was that we never “get over” loss or trauma – we just have to find ways to carry it with us in a fashion that makes sense for us. It is a simple notion, but it has profoundly affected how I have counseled patients from that moment on. There is such a tendency in our society to focus on the “positive”, to downplay the importance of sadness in a healthy and balanced life.

One particular thought we brought with us from “The Shadow of the Object” is the concept of moving through grief by finding ways to honor the legacy of the lost loved one. I have found that to be one of the most healing things you can teach those left behind after someone they respect and love passes away.

Helping patients rewrite their stories, which don’t have to be written, I just mean how they explain things to themselves (and perhaps others), is a big task that can take time over several encounters. But choosing our own words very carefully is something we do, or should do, in every visit, every day.

I wrote about this, too, in 2009:

The Power of Words