Friday, September 1, 2017
Happy Labor Day VI
I missed my Labor Day message last year for some reason. I must have been too burned out. Burnout has been a big theme in the physician community in the last several years. It is almost like it is a new discovery or another new epidemic. Now we have detailed comparisons of degree of burnout by medical specialty and even some country to country comparisons. The curious phenomenon about burnout is how physicians are blamed for it. The typical intervention is to have a "course" on how to "handle" burnout. You know mindfulness, meditation, yoga, and time management. There is never any focus on the fact that physicians just work too hard because they have to work free for so many people. Managed care companies, pharmaceutical benefit managers, government bureaucrats at various levels, and their own employers have come to expect that American physicians have nothing better to do than devote their time and energy to the betterment of those collective businesses. By that metric physicians are the most exploited employees in the USA. There is no other group expected to work for so many businesses for free.
Don't get me wrong. I am not saying that physicians are not paid well. I am saying that according to the studies I read they are being paid for anywhere between 50-75% of the time they work. Even the time that they are being paid for is deeply discounted. What other group of professionals in the USA is expected to work on an arbitrary productivity scale that varies greatly from payer to payer and has a superimposed global budget and federal incentives and penalties superimposed on top of that? Only physicians work in that environment. Only physicians are expected to teach future medical professionals for free. Another one of those cases where the the term "professionalism" can be marched out and used against you. An example: "You can just pick up this course for the medical students or residents. It should not take much time and I know you like to teach. They want you to teach." The next several weekends (whether you are on call seeing patients or not) will be devoted to to coming up with PowerPoints. Lectures and seminars in medicine these days don't happen without the ritualistic exchange of PowerPoints. In the process PowerPoints get blamed. I actually like PowerPoints if they are done correctly. I think they are unfairly blamed when the burden to suddenly produce them is displaced onto the medium rather than the process.
But the focus of my missive today is not burnout or the root cause of excessive uncompensated work. It is one of the sources of uncompensated work and that the the electronic health record (EHR). The attitude toward the EHR has shifted in a direction that I have promoted for over a decade. When the group I was working for was presented with the EHR and trained on it, I knew it was a problem from the start. We were moving from a hospital wide system that was basically for entry of medication orders by health unit coordinators, vital signs, labs, and nursing notes. All of the progress notes were dictated or hand entered. At the end of the day I printed out the MAR (record of medications given) for each of my patients and double checked all of the medications they were getting. The MAR was a single page table showing all of the medications in the left margin and day columns to the right with times of administration. It was all dot matrix printing - so not as stylish as modern printouts.
Back at the time when politicians were overhyping the EHR and how it would save the health care system hundreds of billions of dollars - I did a little experiment with one of my new hospital admissions. I decided to read all of the outpatient medical notes to see how many significant medical diagnoses were being carried over in the EHR. At the time we were online with the new system for about 8 years. It took me 4 hours to find and read all of the notes from Internal Medicine, Endocrinology, and Cardiology. There were 236 notes in all. But in the end I noticed that 10 significant diagnoses had been dropped somewhere along the line. Nobody ever seems to want to acknowledge the complexity in medicine. As people get older they accumulate an incredible number of medical problems and in some cases the only indication is a very long list of medications that they are taking. They have been seeing an equally long list of physicians truncating that list of diagnoses because of time constraints. In the EHR you eventually end up looking at a very short list and need to reproduce a comprehensive evaluation from scratch. So much for the time savings of the EHR. Even the politicians are quiet on that one for now.
A more recent EHR experiment happened to me just recently. I still treat medically complex patients and often receive them from acute care hospitals where they may have been in intensive care units. Since many of them were taking various psychiatric medications, I felt obligated to see what the intensivists, cardiologists, pulmonologists, and gastroenterologists all had to say about these medications and whether they complicated critical care or ongoing care of the chronic medical problems. I want to see the results of ECGs, labs and imaging studies. I want to know if the patient received any of their usual medications when they were in the ICU or general hospital. Before there was an EHR all of this information was contained in about 10 very readable pages consisting of the admission note, discharge summary, MAR, and a couple of sheets including the actual ECG tracing and lab reports.
For the event in question I read through the EHR printout. It was 48 pages long. It contained limited data. Blood pressure trends and readings were not printed even though that was one of the critical parameters being followed. The physician notes were jumbled paragraphs considerably less that traditional reports. The bulk of those notes consisted of checklists and imported data in different fonts and margins. The appearance was chaotic. Who uses 14 point Courier font in documents these days? I haven't seen that since the days of the telegraph. In that entire 48 page document there were about 6 lines in a cardiologist's note that made sense so I locked onto those for my report.
I was less optimistic about Phase Two. I have been working in my current position for about 7 years and during that time I have requested MARs on hospitalized patients about 50 times. I have received exactly zero. In this case for some reason it went through. I received a 60 page fax that was the MAR. The patient was critically ill and delirious at one point, so there were five different infusions used in intensive care spread out across many of the pages. The composition of the solutions were listed and the specific rates of infusion. If I wanted to know the exact amounts that the patient received - it was up to me to figure it out. Two critical factors from the MAR that were not evident from the EHR printout. First, the patient was much more critically ill than described in the EHR printout. Second, none of the maintenance psychiatric medications were given. Total time to figure all of this out - 60 minutes. In addition to the read of the EHR printout and interview - total time for the evaluation and report was 2.5 hours.
It is impossible for physicians to do a good job of patient care without all of the material I reviewed in this case. On the other hand, there are few places in the USA where the physician has 2.5 hours for each new evaluation. That is how you end up with truncated problem lists, partial medical care, and physicians staying in clinic 3 hours after everyone else has left. Without the data there is not enough information for the physician to have a decent informed consent based discussion with the patient on the new set of risks associated with a critical illness.
The real culprit here is the fact that physicians have lost control of their profession. We have had an overhyped, inefficient, ridiculously high-priced piece of software foisted upon us by politicians and the businesses that they support. It is really no better than personal database software that I was using in the 1990s and that software produced a more readable and coherent report. The only reason the software works at all is because there are a million physicians out there with work arounds and doing the uncompensated hard work necessary to keep it afloat.
There is no better topic to comment on this Labor Day. This is my wish to all of my colleagues trying to avoid repetitive stress injuries from the mouse clicks and typing necessary to support EHRs everywhere (I had to switch to my left hand about ten years ago).
Happy Labor Day!
George Dawson, MD, DFAPA
Picture is Titian's work Sisyphus in the Public Domain from Wikimedia Commons at https://commons.wikimedia.org/wiki/File%3APunishment_sisyph.jpg