Founders Keepers

There is a term in population genetics called the founder’s effect and I have caught myself thinking about it a lot lately.

Basically, in a founder’s effect a small subset of a population is isolated from the larger population. For instance, maybe seven people went on a three hour boat tour but instead ended up stranded on a deserted island. The Professor and Mary Ann mate and reproduce, as people are wont to do, and several generations later the resulting population on that island looks very different from the larger population that it originated from. There is a loss of genetic variation and certain traits get reproduced at a greater rate than you would find elsewhere. Sometimes this is benign, like with a greater proportion of blue eyes or brown hair. Sometimes it is bad, like when you have a higher predisposition to develop colon cancer or maybe a higher rate of growing an extra leg out of your backside…

EPIC is one of the largest electronic health record in the US. It is highly customizable. Therein lies its power AND its weakness.

Keep in mind that I have only a small part of the picture and I am making certain assumptions, but here is what I have gathered:

When a healthcare system decides to go with EPIC there is a build out, or personalization, that occurs. The EHR that I see is very different from the one used by a physician in another healthcare system across town or in one across the country even though they are all called EPIC. 

From that initial build out, there are changes made as the product is tweaked. For instance, when we went live, we had to enter our password to log in but then had to enter it again with each and every note we signed, every single order we placed. Hundreds of times a day I was typing in my password. Now? I only type it in to log on. Good thing, too, as I was at risk of destroying expensive equipment.

I have staff in my clinic who have worked for three other major hospital systems in the area who also use EPIC. What they describe is much, much easier to use than what we have currently. In fact, they regularly threaten to leave and go back to those other organizations so they can feel at peace again.

How does that happen? 

How do they have such different products? 

Because they are all starting with a basic product. It is thrown out onto a deserted island with a few people making decisions and then everyone waits to see what you get down the road. 

The founder’s effect.

No one from the other hospital systems is sharing what works for them from what I can tell. There is no collaboration. So each one has parts that work well and other areas not so much. Why can’t we help each other?

THEN you have smaller islands. We are a small clinic in a huge system. We did not get support staff who came out to help us after going live until the following week and then only for two days. The bigger clinics? They had trainers there on day one. Some clinics never got anyone. Training classes done before had very little to do with the reality of the EPIC we were presented with on day one. So we have muddled through figuring out our own work arounds. Some good. Some bad. We need an infusion of fresh genetic material to correct our problems. 

That only works well when you have someone visiting your island to add to your gene pool and that only works if that person is genetically diverse themselves. Getting people to leave their islands is difficult. Distance to travel, time constraints, don’t know how to swim, etc… 

So we get this perpetuation of problems and errors… fractured systems. It has been really interesting to watch from my vantage point at the bottom, looking up. I wonder what this will look like in six months.


Boy making ripples in water of pond with a stick

Last week a physician shadowed me to see if there is anything I or my staff can do differently with my work flow with this new EHR. I was looking forward to having a forum to vent my complaints with the system and hopefully to have a way to fix it but nervous at the same time, not knowing what to expect, worried that they would have suggestions that would make me look a fool.

The physician who happened to come was one that had a hand in writing some of the new EHR templates. I was so disappointed in those templates that between you and me I actually cried in frustration in the first few weeks of our changeover. How could we be expected to do what we needed to do when these were the tools we were given to do it with? I told him that I did not like the templates, that I thought they S-U-C-K-E-D. 

Yes, I used the word sucked and I cringe even now at the recollection. With that one word I dismissed all of the considerable time and effort he had poured into those templates. 

Have you ever been so frustrated and nervous that unreasonable things just flow out of your mouth? 

Of course you have. 

Ever been on the receiving end of someone else’s frustration, as they vented like that? 

Sure you have…

At times, when I feel passionately about something, my filter just ups and disappears. After listening to him tell me that I should hire a staff member to approve or reject all of my refills instead of doing it myself, after having him say that my desire to take and enter my own past medical and surgical histories was a waste of time, after being lectured that writing a narrative history of present illness was silly that I should be clicking buttons instead… I was no longer really hearing his words to me or my own responses back to him. 

But I LIKE doing those things! Interacting with my patients is what makes medicine fun and rewarding for me.

It was not until days later that a realization hit me. He believes this stuff just as passionately as I believe that he is wrong. My response was not just unprofessional, it was mean. I try to have compassion and respect for all of my patients, even the difficult ones, but where was my compassion for him?

You need to be flexible. Medicine isn’t what it used to be. You have to adapt.

I don’t want him to be right. 

I hate that he might be right. 

And so I have spent this past week after reading his write up of our interaction licking my wounds, pondering the next step. What do I do from here?

The first thing, I believe, is to apologize. I don’t know that it will matter to him, but I need to apologize for me. I don’t want to be *that* person, the one who believes their rude behavior is justified.

And then? What then?

There is the question. 



I used to be an author.

Every day I wrote two dozen or more short stories. 

Some were comedies:

“The pain in the right knee started after a snowboarding accident in Aspen two months ago during a spring break trip with friends. He swears that a tree suddenly jumped into his path and evasive maneuvers failed.”

Some were tragedies:

“The patient states that she learned last night that her husband has had a two year long affair with a coworker. She would like STD testing and something to help her sleep for a few days.”

Now I am supposed to point and click predetermined text to generate my note. It comes out something like this:

“The episode started two months ago. Pain is in the right knee. It is worse with movement. It is better with nothing.”

Where is the patient in that? Gone.

Then it is followed by a long list of smart text that generates an office note so full of crap that it is impossible to get to the meat of things quickly. I routinely get 4 page notes from specialists. I read the first paragraph and then the last page to hopefully figure out what is going on. The rest is meaningless drivel that is tacked on for billing purposes. I scan through hundreds of pages of documents every day. You know how I can read so many blog posts so quickly? Years of practice…

We are losing our humanity. 

Change the human body from a person to a machine.

Change the healthcare providers into automatons.

It is inevitable, isn’t it? Dehumanize the patient. Dehumanize the doctor. Dehumanize the nurses and medical assistants and other providers. Do it little bit by little bit. If you do it in one fell swoop, there will be rebellion. Whittle away at it in small bites so it is easy to swallow and then one day we will all look up in horror at what we have become but by then it will be too late.

Once you have done it to healthcare, do it to every other aspect of our lives. 

Little bit by little bit. 

I think, perhaps, it is already too late.

Homework assignment! Ask to read what your doctor writes about you next time you go in…. 


Fall foliage on the river

I hate CME.

No, that isn’t true. Not entirely. I love learning. I adore it, in fact, so I like a lot of the continuing medical education (CME) that I end up doing. BUT I hate, nay loath, the maintenance of certification hoops that I have to jump through in order to maintain my Family Practice board certification. 

Every year I say I will start it early, I won’t wait until the last minute. But what happens? I wake up one morning and realize it’s now crunch time. I can no longer simply say, “I can do it tomorrow.” Oh, no. There IS no more tomorrow left.

Crunch time also happens to hit during the holidays AND the busy time at work when everyone is trying to get their physicals in before their deductibles start over again or falling ill to all manner of miserable communicable diseases. And then there is that pesky new EHR. I’d like to meet the person who thought October would be a fine time to introduce a new electronic health record. Why not the spring when it is slow, hmmmm? Instead, they must capitalize on the misery and my tendencies toward procrastination…

I just want to beat my head against the wall. My tolerance for this kind of stuff has gotten worse with all of the other stupid crap I have to do for my job and for Medicare. Let’s just dump tons more crap on the doctors, why don’t we? Turns me crabby!

Hell, I cannot even keep up on blogging. If I missed your post, I’m so sorry. I cannot see my real life friends. My kids are lucky they have another parent involved in their lives because some days it feels like I am dead to them. Yesterday I only ate some nuts and an apple all day. Good thing I didn’t get to drink any fluids aside from my morning coffee because I didn’t have time to stop and pee anyways. 

The reality is that medicine is complex and changing every day. Gone are the days of merely treating a heart attack with a prayer and an aspirin. We have to work hard to stay current. But answering questions on pain management that have not been edited since 2007 to prove that I deserve to be board certified is such a friggin’ waste of time when there are other, more important things I need to be doing… like moving to Canada!

This rant is brought to you by the U.S. Election Day, 2016… and by board approved “knowledge assessments”!

Virtual Perfection


My new electronic health record (EHR) likes to be helpful. Very helpful. It is full of all sorts of suggestions to ensure that my care is better than best.

For instance:

When I prescribe a birth control pill, a warning flashes up in the form of a red and yellow pop-up to remind me that it is contraindicated in pregnancy. Um. Duh? The patient isn’t pregnant. Not yet anyway. 

Similarly it wants me to know that metoprolol, a medication used for blood pressure and the heart, is contraindicated in chest pain. Well, Ok…

Dozens of commonly used medications have absurd warnings. What I am most afraid of is getting to the point where my brain blocks out all warning pop-ups because at some point I am going to get alerted about an allergy that I forgot about. I don’t want to automatically click through that alert. It would help if the medication allergies were listed on the same screen as the order entry screen. Wishful thinking, I guess.

The EHR wants me to add “Morbid Obesity” to everyone with a BMI over 30 and “Overweight” to everyone with a BMI over 25. For many of my patients, rubbing their noses in their weight is counter productive AND the bigger question would be is being overweight by BMI standards really a medical condition? I don’t think so. THEN it wants to suggest that I send the patient for nutrition guidance. That would be all well and good but when was that ever covered by a patient’s insurance company? Almost never. Even for diabetics, thank you very much. I have yet to have a patient volunteer to pay $1,500 for nutritional guidance with a dietician. I sure as hell wouldn’t.

Are you coming in for strep? Well, the computer wants to remind me that you also need your tetanus booster. Except that I already gave you a tetanus booster two years ago. You are good for another eight years, technically. In fact, the computer has that immunization in the shot record, it just isn’t giving you credit for it. Or me credit for it, apparently. I have to go through a complicated series of maneuvers to “properly” record that you had the vaccination. It cannot be easy. Oh, no.

Oh! I have patients that are finding their records merged with old records from when they saw an unrelated doctor in another part of the state over fifteen years ago. Kinda fun, except that their name is now reverting back to their maiden name or some other nonsense and I have to delete those ancient meds off of their current med list before anyone gets confused.

Speaking of the magical appearance of meds, do you have something you don’t want your PCP to find out about? TOO BAD! If you fill an antibiotic or any other medication at a pharmacy from another provider, I’m gonna find out. That has made for some awkward conversations with patients about their over utilization of teledoc services… I hate it when they cheat on me with another physician!

The EHR fills in quantity and refills on many of the meds I order automatically, except it often isn’t correct. For instance, a Z-pack (azithromycin) that it says to take two pills on the first day and then one pill every day thereafter, auto fills a quantity of two rather than six. Or amoxicillin three times a day for ten days sometimes auto fills a quantity of 20 rather than 30.

It is still early. We will see how this continues to shape up as I get more proficient.

Dark Days

pond before a rainstorm

So how was it? The first day of the new EHR?

If you really want to know… It was a cluster F**K with a capital “F”.

I don’t want to bore you with all of the gory details but suffice it to say some clinics had staff so frustrated they were just walking out, quitting on the spot. 

My staff is all coming back tomorrow. I think. I’d like to believe that pizza and slushies and chocolate helped but I am not sure there was anything that really could have made it better short of an electrical fire. A devastating electrical fire….


There’s always tomorrow.

The End and The Beginning

Yesterday was the last day I had to use our old electronic health record. I hate that thing. Loathe it. In fact, I am not quite sure there is a word in the English language that would adequately convey the depth of my negative feelings about that thing. If I could physically place that EHR behind the wheel of my truck and roll over it back and forth until it was pulverized, it would be very gratifying.

However, as I closed it out for the last time, my virtual desktop completely empty, I felt an odd sadness that I had not expected. I spent nine years learning how to play that game. I knew how to navigate the system, work around its weaknesses. It was familiar to me. I was comfortable because I knew what to expect. I knew how many clicks X, Y, and Z required. If I couldn’t print, I knew I needed to log out and try to get hooked up to a new server. I knew how to phenangle clicks to get credit for preventive care, even if it was laborious. I knew lab orders and imaging orders could get lost, how we needed to utilize a back up plan. I knew that no matter how much I complained about the screen blanking out periodically, or the eprescribe function sometimes not working, the help desk would always say that it was a “known problem” and there was no ETA on when it would be fixed, if ever.

On Monday, I will log into a completely different system. A better system. As I drove home yesterday I realized that I now felt more professional, more grown up, more like a “real” doctor. I felt taller in my seat, somehow.

Now I have a grown up EHR. 

Then a black cat sauntered across the street in front of me at a stop sign, mocking with his bright green eyes….

Seriously. It was eerie.

The reality is that I don’t know what the hell I am doing in the new system. The training sucked as all EHR training does. I don’t know what to expect. I don’t know where the holes are or how the work arounds need to function. I don’t know how to get credit for preventive care. Heck, I’m not even sure I can construct a coherent office note and we will be taking a hit financially due to the switch since the new system is more expensive and we have had to operate at reduced capacity due training requirements.

What is the future going to be like in my virtual world going forward? 


Black cats aren’t really bad luck, are they?

Leaning to the Left

Chicago skyline from a boat in Lake Michigan

“They denied it again.”


I had, no joke, completed various permutations of that paperwork half a dozen times and I was done. DONE, I tell you. The faxed rejection notice included two pages of suggested changes to be completed before resubmission, all things I had already taken care of.

Four months of this back and forth. I was trying to get diapers, pads, wipes, and barrier skin cream for a patient with cerebral palsy via Medicaid.

Initially, I had completed the form just as I had for years. However, I found through subsequent denials that I could not use just cerebral palsy as the diagnosis code. Nor could I just use the code for incontenance or neurogenic bladder. I had to use ALL of them together. But that was still denied.

Then I wrote a letter of medical necessity, as Medicaid said the paperwork forms were not enough. The letter I wrote said, “This patient has cerebral palsy and incontenance and needs diapers, pads, wipes, and skin cream.” Seriously, it was exactly the same thing the forms themselves conveyed, only I wrote it in sentence format on a letterhead.

After the letter, they said they would cover everything except the skin cream. 

Take a guess why.

Because I had to say the skin cream was to be used as a barrier.

I rewrote the letter, adding the phrase “for barrier to prevent skin breakdown” after the skin cream mention.

Finally, it was approved. 

Two months later everything had expired. So I meticulously rewrote the forms and the letter with the exact same codes and phraseology. I even placed the periods and signature flourishes in exactly the same places.

It was denied.

You know what? I will play whatever damn game they want me to play but I need to know the rules. Changing the rules randomly without warning and without explanation is absurd. Sure, it wastes my time, but the real issue here is the patient needs the covered supplies and the state is doing its darndest to make sure that doesn’t happen. Not on their dime, at least.

These are the games we play.

Meanwhile, skin breakdown and ulcerations….

Kerfe at Method Two Madness asked, “Do you have a solution for remaking the way medicine is practiced in the United States? I know our politicians don’t consult either doctors or patients when they write their laws. But let’s pretend they will listen and do the right thing…what would you suggest?”

My list of biggest desires is this:

1. A simple EHR and an end to the litany of stupid ways that I have to prove to the government that I am using it *wisely* or demonstrating that I am providing a “patient centered medical home” or any other inane acronym/phrase they come up with.

2. No more silly game changes like the paperwork situation above. There would be a simple rule book that does not change on someone’s whim without notice.

3. Controls on the costs of medications.

4. Universal healthcare coverage that is shared by all politicians. This scares me because I have seen the government muck up almost everything it gets its hands on and healthcare is too important to screw up any more than it already is, but I don’t know how else to do it. I have watched as even people with insurance cannot afford needed care with the high deductible plans now provided by employers. It is a sad state of affairs.

5. A salary cap for healthcare, insurance, and pharmaceutical company CEOs.

6. Better security for the IT part of healthcare. I have read that stealing healthcare data is much more valuable than stealing a credit card number. I don’t doubt it. We have rushed into the technology without adequate safeguards. 

To be honest, though, I am probably the last person who should be fixing things. I have very little knowledge in the areas of politics, policy, and government finance. If you relied on me to take care of things, we would probably have a collapse of our economy… 


Taylor, a high school student thinking about medical school, asked some questions on my It’s All An Act post about six weeks ago. I had been saving these because I wanted to think about them for a bit.

How did you choose your specialty?

I chose family medicine so that I would not get bored. I get to see patients diaper to diaper and everything in between. In truth, I had it narrowed down to surgery, psychiatry, and family medicine. Surgery was a lifestyle I was not sure I could cope with in the end, despite how much I loved it. Psychiatry… that deserves its own post, but after doing a few extra rotations I was disheartened by what I saw. That left family medicine. I still think I picked the right one, despite my grumblings about the various frustrations of primary care.

If you had the chance to change anything about your career, what would it be?

The EHR. I will rant more about this later. I don’t understand why we cannot have a simple, straightforward system that is intuitive. This is 2016, for crying out loud. We put man on the moon decades ago! This is not rocket science.

Is medicine worth the 20 years of education/sacrifice in your twenties?

Yes. I have a placard that hangs over the door in my office, so I can see it every time I step out to see a patient. “One shoe can change your life. -Cinderella” That may seem cheesy and trite but I have done more, see more, accomplished more than I ever thought possible. Medicine is my shoe. It is an honor and privilege to get to practice medicine every day.

Do you have any advice for aspiring physicians?

There is no substitute for hard work. This sounds simplistic but there it is. You have to be smart, sure, but without hard work, smart is meaningless. 


“Accept that some days you are the pigeon, and some days you are the statue.” Scott Adams

Our electronic health record (EHR) went down for almost an entire afternoon. Mayhem. Panic. Paper. 

You know what, though? It struck me, as I was handwriting a prescription for the first time in months, MONTHS, that we have made the EHR the center of medical care. 

We are missing the point. 

Now, I know this is not a new, revolutionary concept. I have been hollering variations of this, as have others, for quite some time.

It was refreshing, though, to make actual sustained eye contact and not have to worry if I clicked the button to “prove” that I reviewed their medications or the button that says they declined their flu vaccination or the button to “prove” that we did “pre visit planning” or the button to print the patient summary that will never get read. I didn’t have to harass them about whether or not they were signed up for the crappy patient portal system, either. And I had enough advanced notice that the system was going down that I could print a chart summary with current meds and such, like having an abbreviated paper chart!

What could I accomplish without an EHR?

A whole hellava lot, I thought. I revelled in the fantasy, the freedom. I felt downright giddy with glee.

Maybe the EHR will stay down? Forever?

Then, a pharmacy called about one of my handwritten prescriptions. They couldn’t read my handwriting….

So much for that.