Category Archives: Medicine

Do No Harm

Cardiac neuroses are often iatrogenic in origin. A well-meaning but careless comment by a physician can change a person’s sense of well-being in an instant. The effect can be permanent and devastating. Many clinicians who complain about overly anxious patients don’t appreciate their own role in the genesis of this problem. Our words matter. They can reverse the good we do with our medications and procedures.

If you are a heart rhythm doctor, the scenario is familiar. Your patient (we’ll assume a male for the sake of pronoun economy) has premature ventricular complexes (PVCs). Not a lot of them, but he feels every one. They are intolerable. There is no underlying structural heart disease. These are benign PVCs. The treatment options are not good. Drugs have side-effects that range from annoying to life-threatening pro-arrhythmia. Catheter ablation offers the possibility of “cure,” but is not a sure thing and has its own set of risks. The PVCs aren’t very frequent and perhaps will disappear with sedation during the procedure. Even if they don’t and they can be mapped, how far should they be pursued? What if they are epicardial in origin? Should we really consider placing a catheter directly into the pericardial sac and ablate near a coronary artery to treat benign PVCs?

Reassurance is the best treatment. You tell the patient that these PVCs are benign. You say that many people have PVCs, even more frequent than the patient has, and that most people aren’t even aware they have them. You tell your patient that there is no underlying heart disease, that these PVCs will not shorten his life, and that the treatments are likely to have side-effects or unwarranted risks. But it doesn’t matter to the patient. His palpitations are incapacitating. He can’t do his job when they come on. He has read a lot about PVCs and has seen several doctors before coming to you, the arrhythmia expert. He wants something done.

You stall. You ask the patient to try a different beta-blocker than the ones he has tried already that haven’t worked. You say you need to get some of his medical records from his other doctors. You want to review his Holter monitors. You need to make sure there is only one PVC focus if ablation is being considered as a treatment option. Mostly you are uncomfortable recommending an aggressive approach and want to put off making a decision.

Six weeks later the patient is back in your office. The new beta-blocker didn’t work. Surprise, surprise. He has read the information you gave him about ablation and wants to try it. He is desperate. He is willing to take the risk.

You look at the patient. He is in his mid 30s. He is an executive, type-A personality. You have seen his type before. But you are curious about something.

“When was the first time you found out about your PVCs?” you ask.

The story comes out. It was about 5 years ago. One of his friends at work had gone and gotten an “executive physical” that was being offered by one of the cardiology groups in town. It was a nice deal. There was a physical exam, they checked your cholesterol, and you ran on a treadmill for a few minutes. Afterwards there was orange juice and bagels. So he signed up for it.

During the treadmill the technician seemed a little nervous. Before he got too far into it, the technician stopped the test. You have an irregular heart beat, he was informed.

This was news to your patient, who had always assumed his heart was just fine. But the technician told him that he should refrain from any strenuous activity and needed to see one of their specialists about the irregular heart beat. In the meantime, a 24 hour Holter monitor was put on and he was sent home.

The monitor was turned in the next day, and he waited nervously for the result. That night, he was awakened from sleep by a phone call. The doctor on-call had gotten a call from the monitoring service. The Holter monitor had shown a critical result. During sleep, your patient had had 3 PVCs in a row. The monitoring service deemed this ventricular tachycardia and dutifully informed the on-call doctor of this “critical” result. The doctor was obliged to call the patient, whom he didn’t know. Not knowing if this was a patient with end-stage cardiomyopathy and ejection fraction of 10% or someone with a perfectly normal heart, the doctor on-call felt it was the better part of valor to assume the worst.

“You are having runs of ventricular tachycardia on your monitor,” he told your patient. “This is a life-threatening emergency. Your heart could stop and you could have cardiac arrest. You need to call 911 and get to the hospital ASAP.”

After hanging up, the on-call doctor rolled over in his bed and went back to bed, knowing he done his job, making sure a patient with a potentially life-threatening problem would take it seriously and get to the emergency room. But for your patient, life had changed forever. Even after a full workup that showed no structural heart disease, he couldn’t get it out of his head that his heart rhythm was unsteady. His heart was unreliable. He could die at any time. He had never paid attention to his heart beat before, but now he could feel the irregularity, the strong beats that told him he was having more PVCs. They were driving him crazy. Crazy to the point he would consider having a doctor insert a catheter into his heart and burn away some of his heart muscle to get rid of them.

This story is not an exaggeration. I have seen something like this happen many times, with patients who have generally benign conditions like PVCs or supraventricular tachycardia, or somewhat more serious problems like atrial fibrillation. Patients with heart conditions are worried that what they have will kill them. They know about heart attacks and cardiac arrest, but they are not as well-informed about lesser cardiac conditions that are not life-threatening. Apparently some doctors are equally poorly informed, or just think they are doing their duty by scaring the hell out of patients in order to get them to do their bidding, whether it is to go to the emergency room or take some medicine or do some procedure. The problem is magnified by the disappearance of long-term patient-physician relationships. Patients are at the mercy of the on-call schedule, and rarely get good advice when they are called with the result of some lab test in the middle of the night by a doctor who doesn’t know them.

What to do? Be careful what you say to patients, especially those you don’t know well. Think about how your would react if you were told the same thing. Don’t use your authority as a physician to bully a patient to do what you thing is “the right thing.”

Choose your words carefully.

Thoughts on Mark Josephson

I’m sure there will be plenty of tributes to Dr. Josephson in the next few days from his colleagues who knew him well and those who didn’t know him personally but learned so much from his books and articles. I fall somewhere in the middle. I wasn’t one of his students at Penn who learned from him directly. I did meet him several times. I did work for years at the University of Colorado with Alden Harken, the surgeon with whom Dr. Josephson developed the “Pennsylvania Peel” — endocardial resection, the first surgical treatment for ventricular tachycardia. Oh, and I did live in the same apartment Mark used to live in during my cardiology fellowship in Philadelphia in the 1970s. More on that later.

Mark Josephson may represent somewhat of a dying breed in academia. In the great academic triad of clinical care, research, and teaching, the last element, teaching, which makes the least money for institutions, is emphasized less and less. Dr. Josephson excelled as a teacher. A lucky few were able to experience his teaching skills first-hand. A far greater number learned from his writing, in particular, from his opus magnum Clinical Cardiac Electrophysiology. Originally a relatively small but densely written book in a red binding, subsequent editions were more massive, filled with page after page of painstakingly labeled intracardiac recordings and clear-cut explanations of obscure electrophysiologic phenomena. I cut my teeth on this book, reading the original through when I was an EP fellow in Houston, and then reading the 2nd edition straight through when preparing for my first EP boards.

The book was important because it set a standard for analysis of intracardiac recordings that inspired subsequent researchers and students of the field. Back in the 70s and 80s, the mechanisms for most major arrhythmias (with the exception perhaps of atrial fibrillation) were worked out solely by analysis of intracardiac recordings and a few pacing techniques. Mark Josephson was instrumental in this process. Back then, working on arrhythmia mechanisms was the important thing. Therapies for ventricular tachycardia were drugs like quinidine or procainamide, and EP-guided drug therapy was, in retrospective, a pseudoscience. Yet working out the mechanisms of WPW syndrome, supraventricular tachycardia, and ventricular tachycardia eventually led to effective ablation and device therapy in the 1990s and beyond.

Dr. Josephson, who along with a cadre of first-generation EP superstars trained by Dr. Anthony Damato (the “godfather” of EP) at the Staten Island Public Health Hospital, set a standard for teaching in the field of electrophysiology that was often emulated, but never matched. Moreover he wrote a number of incisive editorials over the years in an attempt to keep the field rooted in its scientific basis, rather than be swept away by the insidious influence of industry or the idea that it wasn’t necessary to understand the pathophysiology of an arrhythmia if you were just going to burn it away.

As mentioned above, I was lucky enough to meet him on a few occasions and to round with him. By coincidence we discovered that the apartment on Henry Avenue in Philadelphia where I lived when I was a fellow was the exact same apartment he had lived in several years before. He remembered well the old guy who lived one floor above us, a fellow by the name of Sullivan, nicknamed “Sully.” I was just a plain cardiology fellow when I lived there, only subsequently deciding to go into EP and move to Houston for training. I always wondered if I picked up some kind of EP karma from living there. Who knows?

The advances in diagnosis and treatment of arrhythmias that have occurred since the 1970s are extraordinary, and uncounted numbers of people have benefited from these advances.  It seems a shame that most lay people, saddened at the loss of actors, musicians, sports heroes, and other celebrities, have no knowledge whatsoever of the passing of people who have actually had much more impact on their lives, like Dr. Josephson.  So it’s up to us, his colleagues, to remember Mark Josephson and give thanks for his incredible contributions to medicine and the world.

A Tale of Two Histories

Compare the following two versions of the same medical history:

Version 1

CC: chest pain
Mr. Smith is a 57 y/o white man who comes into the office today for the first time with a complaint of chest pain. He states he has been in generally good health in the past, though he has smoked about 40 pack-years and admits to not exercising much, other than occasional games of golf. He has trouble keeping his weight down. He has been a middle-level manager for many years, but about a month ago changed jobs and took a pay cut. He says this has been quite stressful. He has changed jobs before, but states “I’m getting too old to keep doing this.” About 2 weeks ago he started noting some mild heaviness in his chest, lasting up to 5 or 10 minutes. He attributed this at first to eating heavy meals at dinner, but now thinks it occurred after climbing stairs following meals. He took some Tums, but was not sure if the pain eased from this or just from resting. These episodes of discomfort were localized to his anterior chest, without radiation or other associated symptoms at first. Over the last 2 weeks he thought that they were getting a little more frequent, occurring up to twice a day. Two days before this visit, he had an episode of more intense pain that woke him up from sleep at night. This episode lasted about 15 minutes and was associated with diaphoresis. “My pillow was soaking wet.” He woke up his wife who wanted to call 911, but he refused, though he agreed to make this appointment somewhat reluctantly. He has had no further episodes of chest pain, and feels that he is here just to satisfy his wife at this point. He generally doesn’t like to come to the doctor. He doesn’t know his recent lipid levels, though he says a doctor once told him to watch his cholesterol. His BP has been high occasionally in the past, but he attributes it to white coat syndrome: His BP is always normal when he uses an automatic cuff at the store, he claims. He is on no BP or lipid-lowering meds.  He takes a baby aspirin “most days.”  His parents are deceased: his mother had cancer, but his father died suddenly when his 40s, probably from a heart attack, he thinks.

Version 2
  • Mr. Smith
  • CC: chest pain
  • Age: 57 y/o Sex: M Race: Caucasian
  • Onset: 1 month
  • Frequency: > daily [X] weekly [ ] monthly [ ]
  • Location: Anterior chest [X] Left precordium [ ] Left arm [ ] Other [ ]
  • Radiation: Jaw [ ] Neck [ ] Back [ ] Left arm [ ] Right arm [ ] Other [ ]
  • Pattern: Stable [ ] Unstable [X] Crescendo [X] Rest [X] With exertion [X]
  • Duration: < 15 min [X] 15 min or more [X]
  • Risk factors: Tobacco [X] Family history CAD [X] HTN [?] DM [ ] Hyperlipidemia [?]
  • Relief: Rest [?] Medications [?] Other [ ]
  • Associated symptoms:  N, V [ ] Diaphoresis [X] Dizziness [ ] Other [ ]
Which is better?

Version 1 is an old-fashioned narrative medical history, the only kind of medical history that existed before the onset of Electronic Health Record (EHR) systems.  This particular one is perhaps chattier than average.  It is certainly not great literature or particularly riveting, but it gets the job done.  Version 2 is the kind of history that is available on EHR systems, though usually entry of a Version 1 type history is still possible albeit discouraged.  With an EHR, entering a long narrative history requires either a fast, skilled physician typist, or a transcriptionist — either human (frowned upon due to cost) or artificial, such as Dragon Dictation software.  This latter beast requires careful training and is frustratingly error-fraught, at least in my experience.  The Version 2 example is not completely realistic.  In practice there are more check boxes, more pull-down lists and other data entry fields than can be shown here.  But you get the idea.

Version 2 seems to have a higher signal to noise ratio than Version 1.  It’s just Version 1 boiled down to its bare essentials, stripped of unnecessary verbs, conjunctions, prepositions, and other useless syntax.  It contains everything a medical coder, a medical administrator, or a computer algorithm needs to do his, her, or its job.  It has taken the medical history, the patient’s story, and put it into database form.

But Version 1 is not just Version 2 embellished with a bunch of fluff.  Certainly Version 1 is more memorable than Version 2.  There is a chance the physician who wrote Version 1 will remember Mr. Smith when he comes back to the office for a follow-up visit: Mr. Smith, that middle-aged fellow who was stressed out when he took a pay cut while starting a new job and started getting chest pain.  Another physician meeting Mr. Smith for the first time might after reading this history modify his tactics in dealing with Mr. Smith.  One gets the impression that Mr. Smith is skeptical of doctors and a bit of a denier.  Maybe it will be necessary to spend more time with him than average to explain the need for a procedure.  Maybe it would be good to tell his long-suffering wife that she did the right thing insisting that he come in to the doctor.  All this subtlety is lost in Version 2.

There are some cases where Version 2 might be preferable.  In an Emergency Department, where rapidity of diagnosis and treatment is the top priority, a series of check boxes saves time and may be all that is needed to expedite a patient evaluation.  But for doctors who follow patients longitudinally, Version 1 is more useful.  A patient’s history is his story: it is dynamic, organic, personal, individual.  No two patient histories are identical or interchangeable.  Each history has a one-to-one correspondence with a unique person.  A good narrative history is an important mnemonic aid to a physician.   A computer screen full of check boxes is no substitute.

While the Version 2 history was designed for administrators, coders, billers, regulators, insurance agents, and the government, the Version 1 history was designed by doctors for doctors.  We should be wary of abandoning it, despite the technical challenge of its implementation in EHR systems.

 

Massive Heart Attacks

Google Ngram of the phrase “massive heart attack”

Carrie Fisher’s sad, premature death is an occasion to reflect upon the poor job the news media does in reporting medical news. The initial report from TMZ had the headline “Carrie Fisher Massive Heart Attack on Plane.” If one equates “heart attack” to the more precise medical term “myocardial infarction,” as is usually done, then this is certainly diagnostic overreach on the part of TMZ. From their report it appears that Fisher suffered a cardiac arrest; indeed that term is used in the body of the article. So why not use that term in their headline? Perhaps massive heart attack sounds more dramatic. The word “massive” seems to go naturally with “heart attack.” Try to think of other phrases in which massive fits so well. Massive hack? Massive debt, perhaps? Few phrases roll off the tongue as well as “massive heart attack.” But most of the time when used by the media this phrase is not at all accurate.  Rather it is a catch-all term to indicate something serious related to the heart has occurred.

Of course we don’t know exactly what happened to Carrie Fisher, nor is it any of our business, but none of the information available indicates that she had a large myocardial infarction as opposed to a primary arrhythmic event like ventricular fibrillation or ventricular tachycardia. As a cardiologist having seen this sort of event a depressingly large number of times it is possible to speculate on what happened.  She likely suffered a cardiac arrest related to an abnormal heart rhythm starting suddenly in the heart’s ventricles.  Lay persons and the media often refer to this as the heart “stopping.”  While the pumping of the heart stops or is reduced, in actuality the heart is beating very fast or in a disorganized fashion to the point where it can’t effectively pump blood.   Without rapid correction using an electrical defibrillator this leads to sudden death.

In Carrie Fisher’s case CPR was administered while the plane was still in flight. It is unclear how much time elapsed between the onset of the cardiac arrest and administration of CPR.  It is difficult to tell from the reports if an AED was used on the plane or if defibrillation was attempted only after the plane landed.   We know she never regained consciousness and most likely suffered brain death due to prolonged interrupted circulation.

Carrie Fisher was a cigarette smoker and used cocaine, at least during her Star Wars days.  Could heart disease caused by smoking and drug use have contributed to her sudden death? Could more recent use of drugs like cocaine have been a factor? We don’t know, but if the family deems it fitting that the circumstances of her death be made public, it might help educate the public and the news media on some of the nuances of heart disease and the difference between a “massive heart attack” and a cardiac arrest.

Finally it is interesting to examine some of this lay cardiac terminology using Google Ngrams. The Google Ngram site is a search engine that can be used to look up the frequency of words or phrases in thousands of books published over many years. It can help establish when certain phrases like “heart attack” or “cardiac arrest” were first used and when they became popular. The Ngram at the top of this post of the phrase “massive heart attack” shows the rise in popularity of this phrase over the last 50 years. The Ngram below compares the terms “heart attack”, “myocardial infarction”, “sudden death”, and “cardiac arrest.” It is interesting that “sudden death” is a term that has been used without much change in frequency since the year 1800. “Myocardial infarction” and “cardiac arrest” both entered the literature around 1930-1940. “Heart attack” dates back to around 1920, but has become more and more popular, while the medical term, “myocardial infarction” seems to be less used recently. Curiously although the phrase “heart attack” has been around since the 1920s, it is only since 1960 that the phrase “massive heart attack” has become popular.  One wonders why.  These kinds of results are open to all kinds of interpretation: I’ll leave that to the reader as an exercise. But I encourage you to try Ngrams out yourself, on any subject that interests you. The results are often fascinating.

Google Ngram of other heart attack related phrases

Geeky Docs

I remember the disdain some of the EHR trainers had for their trainees back when our hospital system “went live” several years ago. Of course this disdain was tempered by their knowledge that if docs weren’t so computer illiterate, or the user interfaces of the EHR systems weren’t so awful, or if the EHR software wasn’t so bug-ridden, their jobs wouldn’t exist. So they soldiered bravely on, undaunted by grumpy old docs who now had to type their notes despite never learning how to touch type, who had to reconcile medication lists a mile long including meds like cinnamon that they really could care less that the patient was taking but had to be reconciled nevertheless, who had to painstakingly enter orders using an interface designed by an engineer who knew as much about medicine as — an engineer, and who were angry and resentful that this newfangled computer system was being shoved down their throats under threat of loss of government medicare reimbursement. Given the tensions and personalities involved, it still amazes me that the EHR transition was accomplished without loss of life or limb.

Maybe the classes helped. Long before the go-live date, we went to EHR school. This consisted of several days of classes, during which the world of health care delivery was supposed to stop (it didn’t) while all medical personnel sat around drinking coffee and listening to talks about how the EHR was supposed to work. Even though this was a useful education into what the life of a hospital administrator must be like, the real world of patients and disease tended to encroach on the world of mouse clicks and meaningful use butttons to the point that I skipped the last afternoon of classes and the final exam. Unfortunately my truancy was detected and, under penalty of garnishment of wages, I was forced to do a make-up class. Despite the rigorous training, the number of months that elapsed between EHR school and going live ensured that I and my colleagues pretty much forgot everything we learned — hence the need for the EHR trainers.

I was a little disappointed that I wasn’t selected to be a “superuser.” A superuser is a user who is technically savvy and enthusiastic about using the EHR — a true believer who could help other users who were having problems, even after the EHR trainer cadre had long since departed to initiate other hospital systems into the EHR religion. I suppose I failed to qualify on my lack of zealotry. I also kept my technical savvy under the radar. So I became merely a user. I found that, unlike my experience with other forms of technology, the EHR was making my life worse. Simple tasks became complex. My work slowed down. More mistakes were made. I was stunned. I could not think of any other example where a computer program was less efficient than the technology it was designed to replace. But it appeared that EHR systems were a counterexample to this.

So I decided to write a few blogs about how bad our EHR was, but the EHR company, who employs people whose sole purpose is to scour the internet looking for screenshots or bad-mouthing of their precious software, caught wind of this and reported it to the administrators of the health care chain I worked for. After some angst, I agreed to shut up for a while, though now that I am retired, I don’t feel bound by any non-disclosure agreements the hospital system signed with the EHR company.

EHR advocates have sometimes commented that once all the old, non-technological, non-touch typing doctors die off, then everyone will be pleased as punch with their EHRs. The new generation of doctors, raised on technology, able from infancy to handle a Playstation controller with aplomb, will have no problem using EHRs. There is some truth to this, but this criticism misses the point of my and others’ criticisms of current EHR software. There are plenty of technologically sophisticated doctors of all ages who are uncomfortable with the state of EHR systems today. I have written computer software and most would consider me one of these “geeky docs.” Most of the critiques of EHRs that I have read have been from tech-savvy doctors, not from the technological dinosaurs that the EHR pushers believe make up the majority of doctors today. None of us wants to go back to a pen and paper chart system. All of us want to see EHR systems improve in usability and interconnectivity. We all use computer software in our daily lives and know that EHR programs don’t measure up to standards that other computer programs meet. We don’t like the secrecy of the EHR companies or the astronomical cost of the software. But mostly we just want the software to get better. This won’t happen unless the software designers start listening to users. Tech-savvy docs need to be on the forefront of this. We need to push for change and not allow the EHR companies to keep falling back on their old excuse: if you docs only knew how to type, you’d love our system.

Stranger in a Strange Land

Inside Noah's Ark (photo from AP)
Inside Noah’s Ark (photo from AP)

Reading about the opening of the Noah’s Ark Theme Park in Kentucky brings to mind the days when I worked as a physician in that state. I had moved from an academic position in Colorado and joined a large group of private practice cardiologists in Louisville. I found that people in Kentucky were different from those in Colorado. They were much more overtly religious.

As an interventional electrophysiologist I would meet with each patient’s family before and after every procedure. Not infrequently one of the group sitting in the waiting room was introduced as “this is our pastor.” Usually at some point the pastor would suggest a round of prayer, and I was expected to participate, at least by bowing my head and maintaining a respectful silence. If the prayer was before the procedure the main focus was usually to make sure God guided my hand and the outcome would be good. Prayers after the procedure usually focused on thanking God for safely getting the patient through the procedure and asking for a speedy recovery.

It was not a good time to bring up the fact that I was an atheist. So I just went along with it, only briefly and mildly discomforted. Religion gives strength and comfort to people in the life and death situations that doctors often deal with. I rationalized that my silent participation was helping my patient and the family psychologically. Besides, how would they feel about my performing complicated heart procedures on their loved one if they thought I was an unbelieving heathen incapable of accepting God’s guiding hand?

It’s uncomfortable to be an atheist and a doctor, just as it uncomfortable in America to be an atheist in general. Polls show that the public distrust atheists to about the same degree they distrust Muslims. Being an atheist is practically taboo for someone running for public office. George H. W. Bush famously said “… I don’t think that atheists should be regarded as citizens, nor should they be regarded as patriotic. This is one nation under God.”   Atheists are considered immoral by religious people. They point to the atrocities committed by Stalin, Mao, or Hitler. Atheists in turn point out the Crusades, the Inquisition, the burning of witches, or, more recently, the atrocities of al-Qaeda and ISIS. Neither the religious or non-religious have a monopoly on morality.

As social consciousness is raised about oppressed groups such as the LGBT community, there has been little progress in the acceptance of atheists in American society (I mention America because the situation is quite different in Europe). And yet the non-religious are a fast growing group. In 2014, 22.8% of Americans did not identify with a religion.  Although a relatively small percentage of these people call themselves as atheists, probably because of the negative connotations of that term, this overall percentage is larger than the percentage of Catholics, Mormons, Jews, or Muslims.  It is amazing how unrepresented this large group is in our government! If one looks at scientists, (2009 Pew poll ), only 33% profess belief in God, vs 83% in the general public.  There is some evidence that the top, elite scientists are even less likely to believe in God (only 7%).  But do doctors hold beliefs similar to scientists? An older poll from 2005 showed that 77% believe in God, slightly fewer than the general population, but far more than scientists.  Nevertheless there are undoubtedly many doctors who do not share the religious faith of their patients.

To the religious patients who read this and feel they wouldn’t want a non-religious doctor:  I can assure you that I am a good person, with a sense of morals rooted in our common humanity. Not believing in an afterlife just makes me want to focus more on improving the quality of this earthly life, the only life I believe we have. I would only ask you not to assume that your doctor holds the same religious beliefs as you or that your doctor wants to participate in group prayer with you and your family.

To the non-religious doctors who read this I ask: how do you deal with your atheism in your practice? Are you, like I was, basically mum about it? Would your patients distrust you if they knew? Would they find another doctor? Is it better to pretend to be religious, just as pretending that a placebo is a real drug can be beneficial? In many parts of the country this question comes up rarely or not at all (I never faced it in Colorado), but in Kentucky, the state of Ken Hamm and Kim Davis, as well as throughout the Baptist South, I assure you that this is an issue you will face.

Back when the Creation Museum opened in Petersburg, Kentucky in 2007, I was one of the protesters who stood by the entrance and waved signs touting science and reason over belief that the Earth is only 6000 years old and that dinosaurs and humans lived together at the same time. I watched as families with small children and church buses filled with impressionable kids drove past. There were a number of obscene gestures pointed our way, but most people just seemed puzzled that anyone would question their beliefs.

Standing next to the hospital bed, I only wanted to help my patient and if that meant concurring with their religious beliefs, so be it. But I also think non-religious doctors, and non-religious people in general, are afraid to “come out of the closet” and assert their own beliefs — belief in the beauty of nature and science, and in our own innate morality. After the attacks in Paris, San Bernardino, Brussels, Orlando, Istanbul, and Baghdad — just to mention some of the latest — the destructive force of extreme religious ideology is evident to all. Given what is at stake it isn’t helpful for non-religious doctors or for that matter for any non-religious people to hide their beliefs.

Which is why I wrote this.

I’m a Better Computer Than Any Doctor

[Ed note: I couldn’t resist writing the following after reading this post on KevinMD.com by Dr. Keith Pochick. Please read it first. Apologies in advance.]

I’m a Better Computer Than Any Doctor

“I love you,” she said as she was leaving the room.

“I, I um…”

“Not you. Your computer.” She cast my computer, still warm and glowing with its brilliantly colored logout screen, a glance of longing and desire, and left the exam room.

“Oh, I thought…”

The slamming of the exam room door clipped off whatever the end of that sentence might have been.

I sat down and rolled my chair over to the computer. I stared at the mutely glowing screen. It stared back at me, mockingly perhaps, daring me to click the OK button and log out. Which is what I should have done. She had been my last patient of the afternoon. Not that my day was over. I had to go back to the hospital to see a couple of consults that had come in during office hours. And I was on call tonight. I was tired, but that didn’t matter.

Yet here was this stupid machine in front of me, getting all the credit when I was doing all the work.

I was in a sour and contrary mood. I cancelled the logout. The busy EHR screen reappeared — my patient’s data, all fields filled, all checkboxes checked, and all meaningful use buttons pushed. Yet somehow, despite fulfilling all my data entry duties, I didn’t feel satisfied. Who was the doctor here anyway? Me or the blasted computer?

I scanned my patient’s history. Female. Black. 45 years old. Diabetes. Abscess. The boxes were all ticked, but somehow the list of characteristics failed to capture the essence of my patient. Where were the checkboxes for sweet, smart, chatty, charming, or stoic? How was I going to, five minutes from now, distinguish her from every other “female-black-middle-aged-diabetic-with-abscess” patient? Of course the computer wouldn’t have any problem figuring out who she was. Birthdate, social security number, telephone number, or patient ID number — all those meaningless (to me) numbers were easy for the computer to remember. I had to make due with trying to remember her name, and her story — a story that had been diluted down and filtered out of any meaningful human content by the wretched EHR program.

My patient hadn’t had to interact directly with the computer like I did. All she saw was me looking up information, me typing in information, me staring at the screen. All she saw during most of the visit was my back. From her point of view I was just a conduit between her and the computer — the real doctor in the room. I was just a glorified data entry clerk. It was the computer that made sure that I was compliant with standard medical practice, that the drugs I ordered did not conflict with the other drugs I had ordered, and that I didn’t otherwise screw up her care. I shouldn’t have been surprised that her last remark had been addressed to the computer and not me.

“Well, screw this,” I remarked to no one in particular. Suddenly angry, I reached down and yanked the powercord of the computer from its electrical socket.

There was a brief flash on the screen. But it didn’t go dark. Instead a dialog box appeared accompanied by an ominous looking red explanation point icon.

“Warning,” it read. “External power loss. Backup battery in use. To protect against data loss, please shut down the computer using the Power Down button. Never turn off power to computer while it is running.”

The condescending tone of this message only made me angrier. I looked at the base of the stand that the computer sat on. Sure enough there was a big black block with a glowing red LED. Must be the backup battery. A thick power cable connected the battery to the computer box.

I grabbed the power cable and wrenched it loose from the backup battery.

Sitting back up I expected to finally see a nice dark screen. Data-loss be damned!

The screen was still on. The EHR program was still on. Another dialog box had replaced the first. The red exclamation point had been replaced by a black skull-and-crossbones icon.

“Critical Error!” it read. “All external power lost. Internal backup power now in use to preserve critical patient data. Local data will be backed up to main server, after which this unit will shut down in an orderly fashion. DO NOT ATTEMPT TO INTERFERE WITH THIS PROCESS AS IT WILL RESULT IN THE INEVITABLE LOSS OF CRITICAL PATIENT DATA!!”

At that moment the gauntlet had been thrown down. I knew what I had to do. Let the dogs of war be unleashed!

In the moment before I acted I imagined the reaction of the software engineers at the company that created our EHR program. “I knew we couldn’t trust doctors with our software. We give them a simple job to do. Just enter the data into the system, print out the generated instruction sheets, and send the patients on their way with a merry ‘have a nice day.’ I knew we should have programmed the stupid doctors out of the loop.”

Too late for that, I thought. My chair crashed down on the computer, smashed the monitor to pieces, and caved in the aluminum siding of the computer case. Sparks flew and the air filled with the smell of smoke and ozone. Suddenly the exam room went dark. The circuit breakers must have tripped when I short-circuited the computer.

The room was not completely dark. There was a glowing rectangle on my desk. My heart skipped a beat, then I realized it was just my phone. I had left it on the desk. Why was it glowing? Probably a text or email or something.

I picked up the phone. It was the mobile app version of our EHR program. A dialog box filled the screen. The icon was a round black bomb with an animated burning fuse GIF.

“FATAL ERROR!,” it read. “You are responsible for the IRRETRIEVABLE LOSS of CRITICAL PATIENT DATA. In doing so you have violated the unbreakable bond of trust between the PATIENT and the COMPUTER. This is a breach of the EHR contract made between you, your hospital system, and our company, as well as a breach of the EULA for this software. As such, you will be terminated.”

Strange use of words, I thought. Also strange that the bomb GIF animation seemed to show the fuse burning down…

EPILOGUE

Hospital Board Meeting — One Week Later

Hospital CTO: “So it appears that Dr. Stanton, in a fit of anger at our EHR system, took it upon himself to smash his computer. The cause of the resultant explosion that killed him is, certainly, still somewhat unclear.”

Hospital CEO: “Unclear?”

Hosital CFO: “I hate to interrupt, but I didn’t think there was anything in a computer that could blow up, no matter how much you smash it up. Am I wrong?”

Hospital CTO: “Well ordinarily, yes that’s true.”

Hospital CEO: “Ordinarily?”

Hospital COO: “Let’s be clear. Dr. Stanton certainly violated our contract with the ____ EHR Corporation.”

Hospital CEO: “Violated?”

Hospital CBO: “It’s clearly stated on page 197 of the contract that any attempt to reverse engineer or otherwise try to, uh, figure out how the EHR program works is a violation of the contract.”

Hospital CEO: “Smashing the computer was an attempt to reverse engineer the program?”

Hospital CTO: “I think that we would be on shaky legal grounds to argue otherwise.”

Hospital CEO (nodding to the elderly doctor seated at the other end of the table): “What’s your opinion, Frank?”

Medical Board President: “Well, as the only physician representative here, I’ve become more and more concerned that our EHR system is subsuming more and more of the traditional role of the physician.”

Hospital CXO: “Oh come on!”

Hospital CSO: “Same old story from the docs every time!”

Hospital CCO: “Broken record, I’d say.”

Hospital CEO: “Gentlemen, and Ms. Jones, enough already. This has been an unfortunate accident, and at this point our major concern has to be that there is no adverse publicity that could harm us in our battle against the ______ Hospital System, our sworn and bitter rivals. Accidents happen. The party line is that we are all upset that we lost Dr. Stanton, one of the best EHR data entry operators we had. OK? Meeting adjourned.”

Hospital CEO (Privately to hospital CTO as the meeting breaks up): “George, when are they updating that damn software. You know, that stuff we saw at the Las Vegas EHR convention last month. Where we can finally get rid of these damn meddling doctors who are constantly screwing up our EHR.”

Hospital CTO: “Bob, believe me, it can’t come soon enough. Not soon enough.”

THE END

Life Interrupted

broken-iphoneI don’t mean to trivialize the plight of soldiers with the real thing, but I believe that after many years of carrying a pager (and later a smart phone qua pager) I have developed something akin to PTSD. I seem to have an excessive fright/flight response to the phone ringing, to sudden loud noises, and, bizarrely, to sudden silences. I retired from medicine two years ago. I would have expected my quasi-PTSD to have diminished by now. Maybe it is a teensy bit better, but it’s not gone.

After I retired I latched onto social media, thinking it would help fill the void which I expected would inevitably appear when transitioning from the super-busy life of a private practice cardiologist to the laid-back life of a retiree. Facebook, Twitter, Google+ with a bit of Reddit, Tumblr, and Goodreads thrown into the mix. Of the bunch, I have stuck with Twitter most consistently. I like the fact that I can follow people without having to be “friends” with them, or them with me. I like its ephemeral nature. I can dip in and out of the twitter stream, ignoring it for long stretches without the kind of guilt that occurs when I ignore my friends’ posts on Facebook. And the requirement for terseness produces: terseness — something lacking from most social media. I think Twitter’s planned abandonment of the 140 character per tweet limit is a mistake. Like any other rigid art form, whether sonata-allegro form in music, or dactylic hexameter in poetry, the very rigidity of the format forces creativity. Or not. Four letter words, bigotry, hatred, and racism also seem to fit easily into the Twitter form factor.

But I digress.

Part and parcel with social media accounts came push notifications. Someone would post something on Facebook. My phone would beep. A notification would appear that someone had posted something on Facebook. The phone would beep again. There was now an email saying that someone had posted something on Facebook. Multiply this by half a dozen social media accounts and you get a phone that is beeping as much as my old beeper used to beep on a Monday night in July when the moon was full. It was kicking my PTSD back into high gear.

It seems that the notification settings for my social media apps were by default intended to insure that, no matter how un-earthshaking a post was, I would be notified come Hell or high water, by telegram if necessary if all else failed. It is a testament to how lazy I am that it actually took me about a year and a half to do something about this situation. Good grief, I was even getting notifications whenever I received an email. Actually, if I ever went a day without receiving an email, that would be something I’d want to be notified about.

So finally I turned off all the push notifications I could. Like unsubscribing from email mailing lists, this isn’t as easy as it sounds. The master notification switches are buried deeply in sub-sub-menus within the Settings of each app. But using my sophisticated computer know-how along with a lot of “how do I turn off notifications in such and such app?” Google searches, I was able to accomplish my goal.

The cyber-silence is deafening. And it’s a good kind of deafness.

I do feel some guilt when I occasionally look at Facebook and see all my friends’ posts that I have not “liked.” I hope they understand that on Facebook not “liking” a post is not the same as not liking a post. Sometimes it’s a bit awkward to tune into Twitter to find that you have been ignoring a direct message that someone sent you three days ago. But overall I find that I can focus better on tasks without the constant nattering interruptions from social media.

I still start muttering incoherent potassium replacement orders when the phone rings in the middle of the night, but it is getting better.

1950s Prescription Drug Commercial

show-thumbIf annoying 21st century TV prescription drug ads were run as annoying 1950s TV ads (and taking into consideration 1950s morals and censorship).

Here is a pdf version of this post formatted as a screenplay, if you’d prefer (it looks nicer).

 ======

CUT TO:

TITLE CARD.

“The George Burns and Gracie Allen Show.” Theme music begins.

HARRY VON ZELL (V.O)
The George Burns and Gracie Allen Show,

CUT TO:

ADVERTISING FILM SNIPPET.

Zoom in on floating box of Vialis tablets, as if resting on a gray table, light source from left. Box is tilted at 45 degree angle, pointing upward. Music swells.

HARRY (V.O.) (CONT’D)
Presented by Eli Pfeltzer, the makers of many fine prescription drug products, including VIALIS, the miracle pill for men.

CUT TO:

ADVERTISING CARD.

“Eli Pfeltzer, Makers of VIALIS, the MIRACLE PILL for MEN.”

CUT TO:

INT. THEATER STAGE – DAY

Announcer Harry Von Zell is standing center stage in front of a live studio audience. Curtain is down and is behind Harry. Audience applause swells and terminates. Music fades and stops.

HARRY
Hi everybody.

Looks at watch.

HARRY (CONT’D)
Our curtain’s about to go up on George and Gracie, but first I want to let you in on a little secret. You’ve seen George get flustered at Gracie on many an occasion, and maybe you’ve asked yourself the question, “what keeps them together?”

Audience laughter.

HARRY
(chuckling)
Well, I’m not going to answer that directly. George already has fired me three times this month.

Audience laughter.

HARRY (CONT’D)
But instead I am going to tell you a story, a story about two women who meet while out shopping. Two old friends who haven’t seen each other for a while and need to catch up on what’s going on in their lives. Here they are, at the department store coffee shop.
(indicates to audience to watch film screen to left)

CUT TO:

INT. DEPARTMENT STORE COFFEE SHOP – AFTERNOON

Two women, Betty and Marge, middle-aged, dressed nicely, wearing modern clothes, gloves, and flowery hats are seated opposite each other. They are drinking coffee.

BETTY
(putting down her cup)
Oh, Marge, Fred and I are so happy together. My life is wonderful. He’s such an amazing man. He constantly brings me home flowers and candy. Gosh, he’s such an old-fashioned Romeo. He makes me feel like, well, like a real woman.

Marge starts sobbing uncontrollably.

BETTY (CONT’D)
I can’t begin to describe…
(she stops talking, suddenly observing Marge’s reaction to her words)
Oh my goodness! Marge! What’s the matter?

Marge brings herself under control.

MARGE
(still sobbing a little)
Oh, Betty, don’t get me wrong. I am so happy for you and Fred. It’s just, it’s just…
(she hesitates)
I wish I could say the same about my Alfred. I don’t know what’s happened to him. It’s like all the romance has vanished from our marriage. He’s just not the man I married.

Betty reaches over and pats Marge’s shoulder to console her.

BETTY
Oh Marge, I completely understand. In fact, Fred and I were having the same problems not too long ago. Then we learned about VIALIS.
MARGE
(puzzled)
VIALIS?
BETTY
Yes, VIALIS. It’s the new prescription drug from the Eli Pfeltzer company. It’s specially made just for men.
MARGE
(looking interested)
How’s it work?
BETTY
It improves the circulation of the blood. As men get older, they get tired blood. It really gets them down.
MARGE
How does improving the circulation help?
BETTY
(slyly)
You’ll see!
(she winks)
Here try these.
(she pulls out a box of VIALIS)
If they work, just have Alfred ask his doctor for more.
MARGE
(looking at the box, turning it over)
Well, I guess I’m ready to try anything.

FADE TO:

TITLE CARD

“A Month Later…” Brief interlude music

HARRY (V.O)
And now our two old friends meet again at the same department store, a month later. Let’s see how Marge is doing.

CUT TO:

INT. DEPARTMENT STORE COUNTER – AFTERNOON

Marge and Betty encounter one another for the first time in month. Attire similar but not identical to former meeting.

BETTY
Marge, Hello!
MARGE
Hi Betty.
BETTY
Well?
MARGE
(laughing)
Well what?
BETTY
You look happier than the last time I saw you.
MARGE
I am. Alfred’s blood circulation is so much better, thanks to you and VIALIS. It made a big difference. And I can tell you, when his circulation got better, mine did too!
(she laughs)
MARGE (CONT’D)
Oh, and more good news. I’m expecting!

Betty gasps.

BETTY
My goodness, that’s wonderful. How many is it now?
MARGE
It will be my tenth. I’m so happy!
(she pulls out the box of VIALIS from her purse and holds it up to the camera)
I think all wives should tell their husbands about VIALIS, don’t you?  It really is the MIRACLE PILL for MEN.

CUT TO:

INT. THEATER STAGE

Audience applause. Harry again stands center stage before the curtain.

HARRY
I too want to applaud these two modern wives who are willing to do the right thing for their husbands. We all know that often it’s the wife who needs to take the initiative in looking after the health of her husband. Lord knows, it’s the last thing we men think about.

Audience laughter.

HARRY
Uh-oh, curtain’s going up. It’s time for George and Gracie.

Audience applause. Harry exits stage left. Curtain rises.

EXT. OUTSIDE OF GEORGE AND GRACIE’S HOUSE – DAY

George is sitting on porch, smoking a cigar. Gracie enters from inside the house.

===

REMAINDER OF SCRIPT HAS BEEN LOST

CUT TO BLACK

THE END

 

Reining in the EHR Monster

it-looks-like-you-are-stupidDr. Lisa Rosenbaum has an excellent piece in the NEJM this week entitled Transitional Chaos or Enduring Harm? The EHR and the Disruption of Medicine.  In essence a review of Dr. Robert Wachter’s book The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, it deals with the ever increasing intrusion of the digital-industrial medical complex on the practice of medicine.  Bottom line, electronic health records (EHR) in their present form interfere with patient care.

It doesn’t really matter how we got to this point. Many well-meaning people in government, the insurance industry, and the medical software industry have contributed to this mess. Despite good intentions, they have created a broken system.  It’s clear why.  As Dr. Rosenbaum points out, the one key element lacking input into the development of EHR systems has been physicians. What do they know? Clearly those who designed current EHR systems either don’t know or don’t care how doctors actually practice medicine.

There is nothing inherently bad about the concept of electronic health records. There are clear benefits to these systems. The ability to look up medical records online (albeit limited by poor EHR interoperability) is a tremendous advantage over the clumsiness of paper charts. There is no denying that electronic prescribing is a real advance over illegible handwritten prescriptions. EHRs that would be easy, even fun to use can be designed. Doctors are not adverse to technology.  Their noses are as buried in their iPhones as much as anyone’s.  I don’t even think it would be very hard to design a “fun” EHR. Unfortunately there are powerful forces that would resist such a design.

The government and insurance companies want to “play doctor” and tell doctors how to practice medicine through the medium of “meaningful use.”  They need to stop using doctors as guinea pigs in this experiment of enforcing medical practice guidelines via EHRs.  The system of billing based on documentation is also at fault.  EHRs need to shift from documenting for the purpose of billing to documenting for the purpose of medical care. The EHR vendors need to pay attention to the actual workflow of doctors and other health care personnel and emulate that workflow as closely as possible.  Like any good tool, EHRs need to be as transparent as possible. The last thing we as doctors should be doing is paying more attention to our computers than our patients.

A common physician workflow, which I and many of my colleagues used, is as follows. Whether seeing a patient in the office or in the hospital during rounds, there were 3 basic steps: 1) I would review old notes, test results, and other records. 2) I would go see the patient, take a history and do a physical. During this step the patient has my undivided attention.  And 3) write orders and document the visit. The main purpose of the documentation was so I and others could come back later and know what my thoughts and plans were for the patient.  This workflow can be emulated using an EHR, but only if the current excessive documentation burden is lessened.

In an ideal world, medical documentation would be brief and to the point. We don’t live in that world. Per the medical coders, a written note saying “review of systems negative” can’t compete with a screenfull of checkboxes all checked as negative — as if this is somehow more meaningful. A cut and pasted note chock full of details but identical to the note from the patient’s last office visit is more legitimate than a brief “no changes in patient’s complaints, findings, or plan,” even though they are identical in meaning. Brevity is the soul of wit, but apparently not in the EHR world. Somewhere behind the scenes there are coders counting bullet points and government bureaucrats making sure meaningful use checkboxes are checked. Did you review the patient’s allergies? How could anyone know if the ‘allergies-reviewed’ checkbox isn’t checked?

Early versions of Microsoft Word were notorious because of the inclusion of Clippy the paperclip. Clippy would constantly pop up while you were writing with “helpful” hints like “It looks like you are trying to write a letter. Can I help?” The answer was usually a resounding “No, get off my computer,” and mercifully Microsoft euthanized Clippy in later versions of Word. Writers trying to write a novel don’t want some know-it-all computer assistant popping up and offering them suggestions on how to round out characters or improve the plot. They want the computer to get out of their way and just put the words up on the screen that they type. Maybe that’s why George RR Martin still uses ancient no-frills WordStar to write his novels.

Similarly doctors don’t want some transmogrified Clippy-monster lurking in their EHR system telling them what to do. “It looks like you are writing a progress note. Would you like to review the patient’s allergies? Please click this button. And if you click just two more review of system points, your note could be coded as a level 4 visit rather than a level 3. Would you like to embed the lab and Xray results in your note? This will show the coders that you have definitely reviewed these results and could bring your note up to a level 5 visit.” And so on.

EHRs need to get out of the way of both patients and physicians and become unobtrusive. Government needs to stop trying to social engineer the practice of medicine via meaningful use. The EHR should be a tool like a stethoscope or ultrasound. Right now it is a monster sucking the lifeblood from the profession.