A Country Doctor Writes:

An overweight man with high blood pressure asked me about Ozempic the other day. He and his wife have different insurances. She is on Ozempic with a low co-pay. It would be high enough to be difficult for my male patient to afford.

So I asked him: “What does it feel like to be hungry?”

“I don’t know”, he answered. “I can work all day without even eating breakfast and feel fine but then once I start eating, I just go on and on. I’m not much of a snacker, I just eat big meals.”

“I have a large hiatal hernia with spontaneous reflux even standing up”, I started. “If I go too long between meals, I get acid reflux and pain in my upper belly. And sometimes I get cranky and confused”, I explained.

“I don’t feel any of those things”, he said.

My response was instant like a divine flash of lightning from the sky: “Why don’t you let your wife plate your food, just the size portion that she is eating?”

He smiled and raised his eyebrows.

“Because you don’t feel hungry, you just have an appetite. Doing this would save you a lot of money and avoid piling more medication on top of what you’re already taking. It might be worth a try”, I said.

“Let your wife be your Ozempic”, I added. “And if you haven’t lost any weight when you come back to see what this new blood pressure pill is doing for you, we can talk Ozempic and other options if you’re still interested!”

https://badgut.org/information-centre/a-z-digestive-topics/hunger-and-appetite/

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.