Needled 

Door of St. Patrick's Cathedral in New York City

“Your mammogram shows an area the radiologist is recommending that we biopsy. I am going to put in a referral for you to see a breast specialist to get that done.”

“Um. I already have the biopsy scheduled. The radiologist said they could do it. It has been approved by my insurance and everything.”

I glanced at the time stamp on the mammogram report. She’d had the mammogram done just that morning. The report summary said “suspicious calcifications concerning for malignancy….”

“I would really rather we get you hooked up with a breast specialist to do this.” 

Silence.

Who do they think they are, scheduling my patients for procedures that I have not even authorized yet?

“I’d rather just get it done. It’s already scheduled for next week.”

“Look, I can get you in with the specialist in just a few days. This is not going to delay care in any way.”

Suspicion began to creep into her voice. “I really don’t want to,” she said firmly. What exactly had they said to her? 

How do you say, “I think you might have cancer,” without causing panic? How do you remain professional when you are seething inside?

If it were me, if it were my mother, I would want to have the biopsy done by a breast specialist, not a radiologist. They have surgical training but more importantly, they know what to do if god-forbid-it-turns-out-to-be-cancer. Instead of waiting to see someone that can take the next step, I would be already plugged in. I have seen it too often. The panic, fear… the rage… 

My patients deserve the same care I would get, the same care I would demand for my loved ones.

I knew how it was going to go, though:

“If you don’t stop doing this, I am going to stop sending my patients there for mammograms.”

The manager laughed at me through the phone. “You have to send patients to our facilities. We are in the same system. You know they track that sort of thing.” 

And she’s right….

The suit squinted at me from across the table.

“So, in analyzing the data from your mammogram referrals we see that you are sending about 52% of your patients to outside facilities. Care to elaborate on why that is?”

“Is it required that I send patients to only system facilities?”

“Oh, no. No. It’s not required.” 

That would be illegal.

“So why are you here talking to me about this again?” I could feel the pricks of anger rising under my skin.

“We can’t require you to do that but in the interest of managing costs for patients…” He trailed off. 

In the interest of keeping more money in the system…

I held back a laugh. 

It was an interesting thing, how much more frequently my patients getting mammos at system facilities seemed to end up getting biopsies compared to those facilities outside the system that did not do biopsies as part of their services. Did they track that, I wondered? Was my perception about this correct or merely a projection, tainted by the animosity I felt? I resolved to start keeping a tally.

“While we are on the subject, your referrals to system specialists is below the system average for primary care. Why?”

“The why depends on the patient. Some prefer to stay in the area. Driving downtown is a hardship for a lot of them, not to mention the cost of parking. Some need a physician with a certain set of skills or a certain personality. Some have experience with a physician through a family member or have been seeing this specialist for years and need a referral each year because of their insurance.” 

Why am I justifying this to you?

A month ago they added a button on external referral orders that requires me to provide an excuse so they can better track such things. If there was a “bite me” option on the choice list, I would use that. 

Previously they had only loaded the contact info for physicians within the system. If they were not a system specialist they had to be loaded manually by filling out a form that went to the practice manager then to a practice administrator and then to a VP and then to someone to add them in. It took weeks.

Provide us with a list of the specialists you would like to use and we will contact them to try to get them to join the system.”

“I’m not doing that. I’m not letting you use my name to convince them to join anything. If they want to join, they can look you up. Meanwhile, I will continue to refer in a way that keeps the best interests of my patients as a priority.”

Technically they could pull those names from electronic health record. Maybe they already had.

“Oh, we always want you to keep the interests of your patients as a priority. We would never ask you to do otherwise.”

Except that is not how it feels…

Advertisements

Tall and Skinny, No Whip

The Empire State Building

“Your patient is on social media Tweeting about it.”

“Tweeting about what?”

“The weight thing that prints out on the after visit summary for the patients.”

Come to find out she had also called and spoken to my office manager and my practice administrator. 

Good for her.

When we first moved to this electronic health record last fall one of the most annoying things was that on everyone that the program deemed “overweight” or “obese” got a large bright yellow box on the screen that alerted to me to the fact that I needed to add weight loss to their goals. 

I always hit the ignore button but it annoyed me that now I had to click an extra button because it stood between me and each patient’s active problem list. Not everyone needs to have “obesity” on their problem list and I would argue that NO ONE should have “overweight” as an official diagnosis. People who are “overweight” and  “obese” know good and well where they fall. They certainly do not need a computer “diagnosing” them with it, too.

I growled inside each time I saw that yellow box.

Then sometime in March I noticed that all of my “overweight” and “obese” patients were getting detailed weight loss instructions printed on their end of visit paperwork. It was going so far as to tell them exactly how much weight they needed to lose to reach a BMI of 25.

WHAT? I didn’t tell it to do that!

It was autopropagating. Someone flipped a switch somewhere which meant a good many other someones approved the change.

What were they thinking?

Shouldn’t I have control over that? Shouldn’t I be the one to decide? I am the doctor. I know the patient. 

I complained.

Nothing happened.

I mentioned it again.

Still nothing happened.

Some of my patients have eating disorders. A number of my patients have serious emotional issues wrapped up in their obesity. These people for sure should not end up with that kind of stuff on their handouts.

I messed around with the program for a while and discovered that I could manually remove it from the print outs if I clicked an obscure “X” box on the wrap up page at the end of the visit. I have to scroll down to the bottom of the screen to find it. That meant that on every patient I see every day I would have to scroll down to that area and click a box to remove weight from their goals.

I should not have to do that. There are literally 30 million other clicks I have to remember on each patient at each visit. Give me a busy day and things will slip through the cracks. This is something where the cost of human error is too great in my opinion.

For this patient, I was running 30 minutes behind. On hers I forgot to click the button. The print out told her she needed to loose over 30 pounds and detailed the diet and exercise changes she needed to make to get that accomplished. So she went to social media with it.

Suddenly, everyone downtown started scrambling. There will be a meeting now to discuss this.

And I am so very angry.

But not at her.

What does it say about a system that responds to social media pressure before it listens to its own physicians? And why would you ever pick a BMI of 25 and set it as the automatic weight loss goal for every single patient? What about the studies that show that people who are in “normal” BMI range do not live as long as those in the overweight range? That a decrease in life expectancy does not occur in obesity except for the extreme morbid obesity range?

Obesity isn’t killing people. Diabetes is. Cardiovascular disease is. We have put such a focus on weight that we have sabotaged the patients who are most vulnerable and as far as I am concerned we are killing them.

“I can’t lose weight so what’s the point of exercising and eating healthy?” 

I hear this every day.

Weight is not the point. It should not be the point. Healthy lifestyle is. But rather than use those things as the goals they made weight loss THE goal.

Fine.

Maybe I cannot change their mind. Maybe I cannot change yours. But do NOT force me to participate in a game that I do not want to play.

Next time I see that woman I am going to give her a great big hug and a high five.

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.

Wavering

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. 

Embellished

img_3987

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…. 

Starvation

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

img_2856

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….

Hmmmm.

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? 

Hmmm…

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.”

“WHAT?”

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…