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Leftism Is Heartless
I was a third-year medical student (otherwise known as a scut-monkey – responsible for every job in the hospital that no one else wants to do) when we had a 96-year-old woman come in with pneumonia. The resident in charge of me told me to get her old hospital records. I asked the patient if she’d ever been in the hospital, and she said that she had, just once, in this very hospital. Great, I thought – that makes it much easier. No records transfers. This was the early 1990s, and we still had paper charts, which were archived in the basement after six months. So I was hoping her hospitalization was recent.
I asked her when her hospitalization was. She answered, “When I was four years old. Maybe five. I really don’t remember it very well.” I just stared at her. That would be around the year 1897. Maybe 1898 or 1899. That won’t be on the front rack. It was 11 p.m. My hopes for sleep that night were fading fast. So I trudge down to the basement, walk past endless racks of charts, and start digging through boxes back by the heating and air equipment.
One advantage I had was that no one had disturbed these boxes in some time. So unlike the more recent charts, everything was about where you’d expect it to be. And sure enough, I found her chart. I sat down on a box and started reading.
She had gotten very sick very quickly, and her father had carried her into the hospital. She couldn’t walk. She had a fever of 104.5F, was barely conscious, and recoiled when the doctor touched her abdomen. They removed a gangrenous appendix that night and put in drains to help with the infection. There were no antibiotics available at that time.
She remained semi-conscious for days. The surgeon would check on her, and occasionally put in a new drain, sometimes did a sort of lavage, and each day he described exactly how she was doing and what his plan was. I felt like I was making rounds with him in real-time, even though he’d probably been dead for 75 years.
He did a great job. She was in the hospital for over three weeks, nearly dying twice. But eventually, she started eating again, and eventually went home. She walked out of the hospital, after being carried in a few weeks earlier.
And due to the skill of the surgeon and the nurses, despite what now looks like primitive equipment and techniques, I was now seeing this patient 90 years later, after she had had a wonderful life with children, grandchildren, and so on. Her surgeon was dead and gone, but she was not. Outstanding work, sir.
What I remember most clearly, though, was the chart. The entire chart for her hospitalization of over three weeks was one sheet of paper. Filled on one side, and about halfway down on the backside.
And I knew exactly what had happened, every step of the way.
Our charts now are sort of the opposite of that.
They are enormous. I’ll have a patient spend one night in the hospital for a routine CHF exacerbation, I’ll request records, and I’ll get 75 pages of, um, just all kinds of stuff. It’s incredible, really, how much data they can collect on one patient in 24 hours. But here’s the problem.
When I look at those records, what I really want to know is, what did the hospital doctor think was wrong, what did she do to treat it, and how does she think this is likely to go? What might go wrong? What should I be watching for?
The chart I get will include, on page 56, the name of the nurse who changed the patient’s sheets that morning. But it will not include the two or three sentences that I’m looking for. What happened exactly?
It’s like asking for a glass of water and getting thrown into the pool.
Paperless chart systems are designed to generate as much paperwork as possible as quickly as possible. Because in modern medicine, we get paid to produce paperwork, not to take care of sick people. Now, when I make rounds in the hospital, there are nurses up and down the halls working on their mobile PC units. It’s unusual to find a nurse with an actual patient. Because the patients don’t matter. But the documentation does. Thank you, Medicare.
One of the entries from the surgeon in 1898 was something like, “I changed the drain to a new site yesterday. Pt much worse today. I fear that may have been a mistake. We’ll see.” Or something like that.
That is very helpful. He’s telling you what he’s observing, and what he’s thinking. Which is very important. In fact, it’s all that really matters.
In today’s legal environment, such thinking is prohibited. Or at least, you keep it to yourself. Which means that honest communication between doctors has been banned, for all intents and purposes. So if I want to know what happened, I have to talk to the doctor personally, off the record, and ask, “Hey, Sarah, you sent an unstable CHF patient home on freakin’ Spironolactone in 24 hours? What’s up?” And she’ll explain. And it will probably make sense. Off the record. Then, and only then, will I know what’s going on.
So it’s like going back to before we had charts. The only way to get any real information is word of mouth. Like in the days before Sanskrit.
So charts work for Medicare reimbursement. Sort of. I guess.
But they don’t work for doctors. Or patients. Or nurses. They have become useless. Worse than useless. They distract nurses and doctors from what used to be the most important part of all this: The patient.
It makes me sad.
That’s why I’m a bleeding-heart conservative. Leftism is heartless. Big government is heartless. Centralized control is heartless. It always is. There is no other way.
I’m not heartless. That’s why I went into medicine to begin with.
I don’t fit in this system.
The system doesn’t care about my concerns, of course. It’s heartless.
My patients do care. But they don’t matter any more than I do.
In a leftist system, all that matters is leftism.
And leftism is heartless.
Published in General
This is, obviously, a slightly different angle on a recent brilliant post by Dr. Craniotomy. Go back and read his post. It’s outstanding.
It also explains why no one seems to know what’s happening with the patient – who might have been in the facility for days – every single time a new professional walks in the room. It’s as if everything is completely new and unknown about the patient. There seems to be no knowledge transfer among working professionals. So – said professionals ought not to be surprised that family members do their own “research” on behalf of the patient and are determined to participate in their care and advocate for the patient. I think it will not get better any time soon.
Add to that the new Coronavirus reality that hospitals will not allow anyone to visit the patient. So the patient is compromised. Perhaps unconscious. And there is no one there to act on her behalf.
She’s screwed.
In my own humble opinion, the industry of medicine has become dependent on that advocate for the patient. And during the age of COVID, the advocate is no longer in the picture. And exposed a huge, gaping maw.
There really ought to be more structure to the records that are kept. Some way of reporting the information of interest and not including who changed bedsheets when. This shouldn’t be tough, but it doesn’t sound like there is any underlying method to it at all.
When I was an intern long ago, I admitted a patient who was jaundiced. He was known to liver clinic as an alcoholic. In taking his history, he mentioned that he had had surgery as a baby. I called the hospital where he was born in Massachusetts and they had the records indicating that he had been born with biliary atresia in 1932. He was transferred to Boston Childrens’ where William Ladd performed the second repair of biliary atresia ever done. We later operated on him and tried to correct multiple strictures in his common bile duct, possibly related to the 1932 surgery. I had the x-rays and a liver biopsy to write up the case for years.
Until I finally quit two years ago, I was examining military recruits two or three days a week in LA for five years, then Phoenix. The law is that medical records must be kept until the patient is age 18. Almost no hospitals I called did so. Electronic medical records mean all that is needed is a button push.
Old quote: “Nobody understands the law but the lawyers, and they don’t know right from wrong.”
Now, now, now.
Do you not realize the endless billable hours created for financial and systems consultants to pursue the holy grail of electronic patient records? First, spend billions of dollars for years and years creating endless reams of contextless gunk. Next, spend billions of dollars for years and years creating endless reams of “context” and “focus grouped metrics” and KPI’s.
Its like we have a group of people who really don’t want to fix a problem but get paid to endlessly invent new ways to make it more difficult to fix the problem.
But, enough about COVID.
This reads like Post Of The Week to me, @jameslileks
It’s the way of the world, not just the medical world.
Remember your school years? I do. In my high school there was a principal, an assistant principal and a secretary. There were three counselors, tops, for a class of 700+.
Now when I go to my youngest’s there’s a principal for each grade. They all have their own secretaries. There are people there who do nothing but fill out paperwork for the state. And last time I checked there were 18 counselors. (My daughter’s elementary school has counselors for kindergarteners.)
We’ve done so much to complicate our lives in a quest supposedly for more transparency. We got our first mortgage in 1979 from a local bank. The full disclosure was on one page and it was easy for us to find what we wanted – amount of the loan and term, monthly payment, interest rate, and taxes to be paid monthly, so we knew what our total monthly payment was, and whether or not there was a pre-payment penalty.
Now thanks to several pieces of federal and state legislation designed by “experts” you have to search through 100 pages of repetitive boilerplate in order to find the same information we found so easily in 1979.
On the plus side, the private note on the balance of my new(er) place is about a page and a half. Including signatures and notarizings.
Similar story– Fifty years ago, my high school of about 800 had a principal, an assistant principal (who was also a classroom teacher), a guidance counselor, and a secretary.
I forwarded this OP to my MD brother and other friends and relatives. At least half of whom deserve a hard anti-leftism smack upside the head with what we used to call a clue-by-four.
A.I.
The high school I went to had about 600 in each level (soph, jr, sr.) so total about 1800. Maybe 2 counselors, I think. But my favorite thing to say about it was there was ONE computer in the whole school. And it was NOT in the office! In the office they used typewriters.
Reminds me that the last time I refinanced at lower rate before the 2008 recession, my bank told me over the phone, “yeah, sure, we’ll send someone over with the papers to sign”. There were about 100 pages of documents and a lot to sign but it was fast, within two weeks. Refinanced after Dodd-Frank passed and it took 4 months. And the mortgage was being refinanced with the same bank, which also held our bank accounts, we were paying off part of the mortgage so were borrowing less than the current outstanding balance, and had a spotless payment record over a decade. Unbelievable paperwork, including have to explain in writing credit card purchases. On the bright side, I guess the legislation named after the Senator from Countrywide Financial and the Congressman from Fannie Mae prevented me from defrauding someone.
I have an enlarged right kidney. I’m not in any pain, but it is upsetting everybody. :-) Finally, at my husband’s and kids’ insistence, after getting conflicting opinions on what I should or should not do, I made the long trip from Cape Cod to the Lahey Clinic in the Boston area to see a specialist.
Until this moment, I had seen only physicians’ assistants. So it was nice to talk to an actual doctor and go over the myriad tests I’ve had. He spent about a half hour with me–a luxury in today’s medical world. At the end, I asked the only question I had, which was, “I am a gardener, so I’m outside working all the time all spring and summer and early fall. Lugging mulch and soil around, not to mention small bushes, I end up drinking somewhere between three and four quarts of weak iced tea that I make myself every day. It’s practically water. Should I be drinking less now if you and everyone else are concerned about the right kidney getting ‘backed up’?”
I will never forget the look he gave me. He smiled. “That is the most important information you could have given me.” He laughed. “Do not stop. That is fantastic. It explains everything.” (My left kidney looks great. I think that’s what he meant.)
My point is, that wouldn’t have shown up in any other way except in a conversation between us. And he’ll never have to spend that time with me again. He knows his patient.
When I think of the hours I’ve spent in tests and with physicians’ assistants, I have to laugh.
Our doctors are the heart and soul of medicine. I read a great book years ago that delivers that message on every page. Regina Herzlinger is one of my top two favorite authors of books I’ve ever read.
When I was a pediatrician before I was the last pediatrician allowed to become a radiologist, I was chief of the department of pediatrics in my hospital. The head of the nursing staff in the nursery informed all of my fellow pediatricians that the one piece of information that all of us relied on in evaluating the health status of the newborn babies we were charged with protecting was no longer going to be available because it was too primitive. What was it? It was a simple one page daily calendar where each nurse on every shift wrote down what each newborn baby did throughout the day in terms of eating and pooping.
That’s what babies do.
Try to find that in a medical record today.
Obviously, babies don’t eat and poop any more.
Which is much better for the environment.
Some of us do.
But I do recognize that my profession is the source of a significant part of this problem. I wish that I had a solution.
That’s really funny. That’s exactly what my pediatrician always told me about my three babies. :-)
“In my own humble opinion, the industry of medicine has become dependent on that advocate for the patient. And during the age of COVID, the advocate is no longer in the picture. And exposed a huge, gaping maw.”
Annefy, you inadvertently touched another sore nerve of mine when it comes to the industry of medicine. “Patient Advocate” is the oxymoronical appellation of the very limitedly trained social worker who is hired by the hospital to shift costly patients from the hospital into lower paying rehabilitation settings. There are no true patient advocates other than doctors and the patient’s families.
I only wish my post got the point across as eloquently as Dr. Bastiat did here.
For my own anecdote: we routinely accept neurosurgical trauma transfers at our hospital from outlying centers with no neurosurgical coverage. A patient will spend 15 minutes in an outside hospital ER, get stabilized, and then be shipped to us once it becomes clear that neurosurgical expertise is needed. The electronic chart will then be printed out and the radiographic images burned onto a CD. The chart that arrives with the patient will typically be over 50 pages long for a 15 minute ER visit. We have to also hunt down a computer that actually has a CD drive to review the images. To save time, when I consult with the transferring ER doc over the phone, I’ll ask for a video of the CT scan to be shot with the cell phone and texted to me (a video of someone scrolling through it to capture all the images, rather than a picture of one image). This is way more efficient than finding a computer to load some software which hasn’t been updated since the 1990’s and load images. I’ll often pawn off the chart to some poor medical student, instructing him to just find a few select laboratory values so we need not repeat them here. It’ll take some frantic shuffling through 50 pages of electronic consents, nursing documentation, auto-populated physician “notes” and other needless bureaucratic fluff before the frazzled student finds the valuable information. If I want to find out what really happened with the patient, I’ll call back the number that texted me the CT scan and just ask. Of course, all these steps are needless if the promise of electronic records were to be realized. It’s good technology which has been corrupted by leftism, as Dr. Bastiat shows here. Unfortunately a patient is often in extremis and every second counts. But who would care about efficiency when there is documentation to be done?
Just a thought: a usb external optical drive might be a good thing to have. It can connect to any computer with usb, which means all of them. (Might be good to get one that is also usb-POWERED, so that losing the “wall wart” is not an issue.)
One would think. Unfortunately there are a few problems. The patient chart isn’t one interchangeable save file which can just be downloaded from one EMR and uploaded into the next. That was never enforced with the EMR meaningful use guidelines. The radiology imaging is interchangeable, but often the files are big enough that hospitals won’t want to be giving out free high-capacity USB drives with patient transfers. They know they won’t get the drives back. Lastly, HIPAA means that any hospital which uploads patient data on to the drive is liable if that drive were to be lost, and liable in a way that isn’t covered by malpractice insurance. The headaches of dealing with HIPAA compliance after a device is lost simply aren’t worth it. For some reason, it’s less of a legal headache to risk losing a paper chart & CD drive. Don’t ask me why.
I meant an external/usb OPTICAL CD drive – not usb “flash drives” that might be lost with possibly-confidential data on them – to keep at the hospital to eliminate the need to “hunt down a computer with a CD drive.” Not something that goes from place to place. Apparently the places that send the patients to you, have no difficulty creating a CD. You just need to be sure you can read it promptly. And more and more, standard-issue computers including many used in doctor’s offices and exam rooms etc, have no internal optical drive.
Nothing in this “scheme” would be any more risky to confidentiality than the CDs already being created.
(P.S. Getting an external optical drive that is USB powered, not requiring a separate “wall wart” power supply that could be lost rendering the drive itself worthless, might mean you get one that ONLY READS, and is not cable of “burning” either a CD or DVD. So that’s something to look for in the specs. A combination cd/dvd-rom READER would be okay.)
Ah yes, sorry! Misinterpreted that. I did carry around an external CD drive during residency for this very purpose! Unfortunately, there was no safe place to store it, so it eventually found legs and wandered off.
As with many other tech things, these days the things are so inexpensive as to be practically disposable.
For example:
https://www.newegg.com/p/1B1-00CH-00002
That one is USB-powered, with an attached cord that can’t (at least in theory) be separated and lost, with plugs for both standard and Micro-USB, and with “internal cord storage.” Seems pretty ideal.
I wasn’t even aware that that was a thing. I was speaking specifically of myself when any of my children, my parents, or my husband were in the hospital.