I haven’t blogged for awhile. I haven’t been inspired. Now I have just finished my notes for Friday. It was a busy day and I left the office before I had finished all my documentation. That happens often. I get home and I spend another hour finishing notes. This is the way it is with many doctors. We want the record to reflect something of the patient encounter. Too often, it is just documenting for reimbursement. It’s about checking all the boxes necessary to meet certain core measures. This article in The Annals of Internal Medicine’s section On Being a Doctor captured the sense of an older physician’s struggle to take care of patients while teaching what medicine used to be like.
On Being a Doctor |6 December 2016
Coeur d’Alene
Richard B. Weinberg, MD
<!– –> Article, Author, and Disclosure Information
Author, Article, and Disclosure Information
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From Wake Forest School of Medicine, Winston-Salem, North Carolina.
Requests for Single Reprints: Richard B. Weinberg, MD, Wake Forest School of Medicine, One Medical Center Boulevard, Winston-Salem, NC 27157; e-mail, [email protected].
Published: Ann Intern Med. 2016;165(11):822-823.
Despite the fact that Colossus, our new electronic health record program, had a confusing interface of unintuitive icons, dead-end click paths, and unwanted functions that could only have been designed by a cabal of computer geeks and business administrators, I did my best to adapt it to the needs of my practice. But I immediately noted a distressing problem: Using Colossus to enter even the simplest note required more of my time—a lot more. Soon I was spending as much time tending to my charts as I was talking to my patients. And Colossus was monitoring my every click, the amount of time a chart stayed open, my billing codes. Every day, I was greeted by a Doctor’s Dashboard that rated my (subpar) performance and urged me to be faster. I did not need to be reminded that these data would be used to determine my compensation.
It intrigued me that these issues did not seem to bother our trainees. Born into the information age, familiar with computers and the Internet since infancy, they treated the installation of Colossus like the appearance of just another smartphone app and blithely clicked their way through their patient encounters with impressive speed. But it troubled me that their efficiency did not necessarily equate with delivering good medical care. Dr. Manning, the resident assigned to my clinic one Friday morning, was no different. Our first patient was a 54-year-old man referred for chronic diarrhea. Dr. Manning exited the examination room after a scant 10 minutes but was able to present a reasonable, if not generic, differential diagnosis and care plan. Upon visiting the patient, I concurred. “Let’s go see the next patient,” I said. “You can finish the encounter note later.”
“Oh, I’ve already finished the note.”
“How did you do that?”
“I used a disease-specific macro template that I programmed to autopopulate with patient data just before the visit, then I clicked in the history as I was talking to the patient, entered my orders, and closed out the note before I left the room.”
I looked over at my computer screen and saw that, indeed, his encounter note had already been forwarded to my inbox for authentication and signature—which, I reflected sadly, would probably take me more time than it took him to write it. I also noted that all of the meaningful use boxes had been checked and the patient information sheets and after-visit summary had been printed out. I reviewed his note; it read as follows:
CC: diarrhea
HPI: loose stools x6 mo; 4-6x/day; (+) postprandial, (±) nocturnal; (−) heme, fever
PMH, FH: on chart
ROS: all other systems (−)
PEx: {normal template}
DDx: Diarrhea, infectious v osmotic v secretory
Plan: stool for GI pathogens, C. diff, lactoferrin, osm, lytes; CBC, CMP, celiac serology panel; colonoscopy w/Bx; trial of Cipro; diarrhea info sheet
It was concise, efficient—and soulless.
“Where’s the social history?” I inquired.
“The nurses already asked him about tobacco and alcohol use.”
“There’s a bit more to the social history than that. Where was he born?”
He looked at me as if I had asked how many folds were in his patient’s cerebellum.
“I don’t know,” he replied in bewilderment.
“Is he married? Does he have any children?”
“That’s probably in the chart somewhere,” he offered lamely.
“What does he do for a living?”
“I’m sorry. I didn’t ask.”
“So, you don’t really know who this person is at all, do you?”
Dr. Manning looked down in dismay. Why was I asking such strange questions?
“Let me tell you the advice that my physical diagnosis teacher gave me over 40 years ago. Right off, ask every patient four questions: Where were you born? Are you married, and do you have children? Where did you go to school? What kind of work do you do? If you do this, it will be a rare patient with whom you don’t find some point of connection.”
He seemed very dubious but soldiered off to see our next patient, a 78-year-old woman referred for bloating and abdominal pain. After more than an hour he still had not emerged from the examination room. Perhaps he was trapped by a loquacious patient who had commandeered the interview, I mused. Just as I was about to go rescue him, he reappeared in the doctor’s work room, his face beaming with excitement.
“I asked the four questions,” he announced proudly. “My patient was born in Coeur d’Alene, Idaho!”
“Really? Not many Idahoans here in North Carolina.”
“Yes, but I’m one of them. I was born in Coeur d’Alene, too! And Dr. Weinberg—you’re not going to believe this—her sister was my first-grade teacher! We started talking about all the people we knew back home, and I almost forgot to ask about her problem. But then I asked if she was married, and she told me that her husband died suddenly last year from a stroke. Her brother lives in Charlotte—that’s why she moved here. She and her husband used to eat dinner together every single night for 60 years. She can’t bear to eat alone at home now, so she eats most of her meals at a K&W Cafeteria.”
A narrative story! In prose!
“I think I know what’s wrong,” he continued. “She’s been eating a lot of Southern food—biscuits, cream gravy, mashed potatoes, custard pies. There’s a lot of milk in those foods the way they make them here. I think she has lactose intolerance, and it’s her new diet that’s causing her bloating and cramps! All she needs is some lactase pills!”
We returned to the examination room, and I introduced myself to the white-haired lady who sat next to the consultation desk. “I hear it’s been old home week in here,” I joked.
“Yes. I think this fine young doctor has me figured out,” she replied. She reached out and took his hand. “Now, I know you’re an expert, Dr. Weinberg, and I mean no disrespect, but I would like Dr. Manning to be my doctor from now on. He knows where I’m from.”
Dr. Manning looked up at me sheepishly; I nodded back.
“I agree completely, Mrs. Sorenson. You’re in very good hands.”
Back in the doctor’s work room, I praised my resident. “Excellent job! Please keep me informed how she’s doing. Now, did you write all this down in your progress note?”
“No, not yet. I was too busy talking. I’ll finish the note later today. Uh—is that okay?”
“Yes, it most certainly is.”
“Thank you, Dr. Weinberg. No one has ever taught me something like this before.”
“You’re welcome. And thank you for showing me that autotext trick. Very cool.”
Dr. Manning departed for his noon conference, and I went to see my last two patients. By now, I was more than an hour behind schedule. The Dashboard was not going to be kind to me, but I didn’t care. I don’t need a computer to tell me how to be a doctor.
