When the Narrative Isn’t

With the advent of the AHR I frequently get notes from referring physicians are ERs that look like this:

 

HISTORY
Chief Complaint
Patient presents with
• Dizziness
• Syncope
Patient states he passed out x3 prior to coming to the ED. Per patient, I fainted three times at home. The last time my wife called an ambulance and they brought me here
Patient is a 32 yo male presenting with: syncope
History provided by: Patient
Language interpreter: no
Syncope
Episode history: Multiple
Most recent episode: Today (Patient states he fainted x3 this morning)
Duration: 20 seconds
Timing: Intermittent
Progression: Worsening
Chronicity: exertion and standing up
Witnessed: yes
Relieved by: Lying down
Worsened by: Nothing tried
Associated symptoms: Difficulty breathing and Dizziness
Risk Factors: coronary artery disease

I find templated text difficult to read. Does the version above tell the patient’s story?  Since I’m not a computer, it’s easier for me to encompass the story when it’s written in a true narrative form:

     Patient presents to the emergency room following three distinct episodes of fainting. The first one occurred in bed while he was lying down. His wife noticed he had stopped talking, shook him and he seem to be back to normal. The next episode occurred when he was walking into the bathroom and his wife heard him fall. The final episode occurred on the stairs. Each episode was only a few seconds  in time and there was no loss of bowel or bladder function with them. He did not appear confused following the spells. All episodes occurred within the space of about 30 minutes. EMS was called and they did an EKG and were concerned that he might be having a heart attack (patient has a left bundle branch block that is not new). He was mildly short of breath and a little dizzy prior to the third episode. He denies chest pain. Nothing clearly made it better or worse. He has no prior history of fainting or passing out. He does have a prior history of heart stents for coronary artery disease.

Perhaps I’m old-fashioned. Maybe the templated writing is just as effective, or maybe more so when understanding what happened to the patient. I’d love to get your opinion. Please write in the comments below.

 

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Brief Observation on “Med Reconciliation”

Patient is seen by her nephrologist and there is documentation in her Plan of Treatment: AVOID ALL NSAIDs. The physician never noticed in the med list that the patient is taking an NSAID (and has been for years). The only reason I picked up on it was because the patient told me she hadn’t been able to get her Celebrex approved by insurance so the orthopedist changed her to meloxicam. Having read the nephrologist’s note right before the patient came in, we have the following exchange:

Me:”But you’re not supposed to take an NSAID like meloxicam”

Patient: “I’ve been taking celebrex for years. Nobody told me to stop”

Me: “OK, I’m telling you to stop”

Patient: “So I can use advil every once in a while for pain? Tylenol doesn’t help”

We have an extended conversation about what NSAIDs are.

What IS it about EHRs that make straight-forward information difficult to see?

 

 

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Thoughts on Turning 60–What’s with that?

Sixty is a formidable number. Different from 30, 40, 50. One of those “decade” numbers that stops you in your tracks. Fifty was a bit intimidating but ultimately the approach and the finish of 50 turned out not to be a big deal. However, I’ve been thinking about 60 for a year now and I suspect I’m going to continue to ponder it for a while throughout the next several months. It is the top of some distant hill that I’ve reached, huffing and puffing along. Turning to look behind there are so many great memories but looking forward seems mirkier than other hills climbed in the past. Darker and a little frightening.

Why is that? Mortality is closer. Fears of morbidity arise. I’m a little stiffer and a little heavier than I’ve ever been. Getting pounds off is so much harder than it used to be and I’m less willing to put in the work to do so. What’s with that? I’ve always been a very goal-directed individual and now I find myself wanting to sit quietly, enjoy the moments and draw more often than choosing the next thing to accomplish. What’s with that?

I considered getting a master’s in something—Informatics being the most likely candidate. All my peers seem to be doing that—no longer is “just” an MD satisfactory. You need a Master’s in something—an MBA or an MPH (public health) or Informatics. So I did some research on pursuing that. I enjoy learning, why not? Well primarily because I wouldn’t have time to do any of the other things I am enjoying—traveling, drawing, spending time with friends and family. And what would a master’s get me—another frame on the wall and an opportunity to work harder? What’s with that?

IMG_9005

The drive to become something else is gone. Been there, done that–mother, doctor, wife, blogger, geek–check, check, check, check, check. My children are grown and successful, my marriage is happy, my career cemented. After years of ambitious productive activity it dawns on me–finally, I can do what I enjoy doing—drawing, writing, seeing patients, tinkering with Apple products–and saying no to ambition.

 

At 60, I get to choose just being better at the things I do now. I can quit dabbling.

 

And I am so OK with that.

 

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Why Doctors Call It Meaningless Use

In the last week I have received three documents from hospitals that illustrate what physicians find so frustrating about the MU (Meaningful Use) program.

Example #1: Patient’s wife calls me for an appointment regarding three episodes of passing out. On obtaining the emergency room records there is no mention that the patient lost consciousness. In fact, there is no story whatsoever regarding the patient’s presentation or symptoms. All that is in the document is lab values. I can tell that the ER physician evaluated the patient for a heart attack which is not a typical workup for passing out.

Example #2: Patient presented to the emergency room with shortness of breath. As far as I can tell she was given four nebulizers (breathing treatments) and sent home with no new medications or orders. What?

Example #3: This was a discharge summary following hospitalization. It lists the patient’s allergies, lab reports, radiology tests and medications but yet again, I don’t have the patient’s story or the other physicians’ thoughts on how treatment progressed and how the patient did, in other words, the narrative that physicians use to communicate with other physicians is completely missing.

After receiving those documents early in the week two more were faxed. Thankfully, these give me a Paul Harvey “rest of the story”.  So how is this meaningful?  The information I need to care for my patients was not contained in the first documents whose sole use is to fulfill meaningful use requirements. I am forced to look at two documents when one would not only suffice but actually be helpful. This wastes my time in an already time-stressed schedule. It is neither meaningful nor useful.

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Irritation #4

Patient brings in two sheets from Caremark. They recommend that she discuss blood tests with her doctor because of some meds she is on. One of the medications is a non-steroidal anti-inflammatory  (NSAID) and the PBM (pharmacy benefit manager) recommends that she have LIVER function tests checked by her physician. Now kidney function abnormalities are many times more worrisome and common than liver problems with the NSAIDs. I have multiple patients in my practice with significant kidney damage as a result of NSAID use and I have never seen, in many years of practice, liver damage, though I know it is theoretically possible.

Seriously…when can we get the insurers and the PBMs out of the exam room so I don’t have to spend more time discussing issues that are not a problem, instead of the issues that we need to talk about?

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Irritation #3

Patient goes to Walgreens to have her lipids and glucose check. The lab work is sent to me BURIED in a four page “EHR” note. So useful. It’s not discrete data so I can’t compare it to previous blood draws and it is difficult to find the labs. I have to click through and scroll multiple pages to find it.

THIS IS NOT INTEROPERABILITY! This is minimally useful. At least if the patient had come in my office the labs would be discrete and we could easily compare the data from year to year.

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Timely Inconveniences

Scrolling through my morning feed I happened upon this article about a physician’s suicide: Doctor’s Death an “inconvenience”for patients. Suicide has become an epidemic among physicians. Blog posts are rampant regarding this fact and most suspect that the loss of respect and control physicians have experienced in their careers over the last thirty years contributes mightily to the despair of practice.[1,2,3,4]

The callousness apparent in the article reminded me of less horrendous, but similar instances in my own practice and stories from other doctors who have taken vacation or had to reschedule patients due to unforeseen circumstances. I have been upbraided by patients who wanted to know why I had the audacity to spend time with my family or take a personal day when they needed to see me. This is amplified by my new contract which features “allowed time off” instead of “paid time off”. Not only do patients not value the time I need to replenish, but my system punishes me for doing so. If I never take time off, then I make more money for them and me. The importance of play in innovative thinking and better patient care is forgotten in the greed of corporate money-making.

As my daughter enters the arena of healthcare as a third year medical student, I hope the joy in patient care outweighs the sometimes callousness of corporate and patient expectations.

1. http://www.kevinmd.com/blog/2014/11/physician-suicide-101-secrets-lies-solutions.html

2. http://www.kevinmd.com/blog/2015/04/how-far-is-too-far-a-response-to-dr-fredric-brandts-suicide.html

3. http://www.kevinmd.com/blog/2014/02/doctors-commit-suicide.html

4. http://www.kevinmd.com/blog/2014/12/suicide-doctors-story.html

 

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Irritation #2

My ongoing regular posts regarding the daily aggravations and irritations of being a PCP.

Remember the Prior Authorization that I requested for my patient who had been on multiple anti-arrhythmics and saw a cardiologist who, after trying other medications, put her back on just digoxin and said to keep her on that? — Irritation #1– Well, Cigna decided, because apparently they know more about cardiology than the cardiologists and specifically they understand treatment of the individual better than a cardiologist who evaluated her, that she does not need the digoxin and refused the prior authorization.

REALLY? REALLY?  Now my staff and I have to try to get her an expedited appeal.

I am open-mouthed amazed.

 

 

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Irritation 1 – digoxin PA

It seems like every day some entity wants to question my medical judgement. I am not a perfect doctor but in the grand scheme of things, I know my patients’ health needs better than their  insurance company, the government, or their employers. The constant interruptions by individuals who want to believe their algorithms fit every patient does little to serve patient care and much to reduce my efficiency. To make a point of how often this occurs, I’ve decided to TRY to document each interruption, within the confines of my limited time. Here is todays irritation:

PBM (pharmacy benefit manager) requires a PA (prior authorization) to refill digoxin. Patient has been on digoxin forever. It is a med that is rarely used anymore, though was once commonly prescribed for congestive heart failure or rhythm control. Unfortunately it has some negative side effects and typically there are better drugs for the conditions it is used to treat. However, in this case, patient came to me on digoxin. I sent her to a cardiologist to see if she could substitute another drug. She was intolerant to other medications and ultimately the cardiologist felt that digoxin was the least risky choice and continued it. This was last checked as recently as two years ago.

Sigh. PA applied for.

 

 

 

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