The Doctor Will See You Now

by Cory Franklin

  In addition the EMR was supposed to reduce paperwork, but when a paper copy of a chart is required for any reason today, it can result in thousands of pages of unreadable, superfluous information. Recently I saw a printout of a patient’s hospitalization that was over eight thousand pages, probably ten times as many pages as her entire paper medical record since birth.

  The most pernicious aspect of all this has been that in many cases, the EMR has become a wedge between patients and caregivers. I hear patients complain that their physician spends more time looking at the computer than looking at them. A recent study found doctors in training spend only 12 percent of their time in direct patient care compared with 40 percent of time spent in front of computers. At the same time, physicians complain more and more about the extra hours they spend in the hospital or clinic because documenting a patient encounter in the EMR takes more time than actually seeing the patient.

  Without question, the EMR has certain advantages. Some advocates counter the pessimism over EMRs with stories of how the systems facilitate retrieval of patient labs, X-rays, and medications; how poor penmanship is no longer a problem; and how easy it is to access the latest medical literature. Yet those things could have been accomplished for a fraction of the expense without undermining the system that existed, by implementing computerized retrieval of clinical information in a more limited fashion.

  And although no one would admit this, the primary value of the EMR currently resides not as an aid to patient care but in its reliability as an efficient record of things the hospital can charge for (charges that no one can explain anyway). Thus hospitals collecting medical payments have no incentive to change the system. Moreover, a whole generation of physicians, nurses, and health care personnel has grown up knowing nothing but the computer. (The other day on the hospital ward, I asked if anyone had a pencil and was met with strange looks all around.) It would seem hopelessly Luddite for a hospital or clinic to revert to the paper record, no matter its advantages.

  Some experts insist that EMRs are still in their infancy and that eventually a single, workable system will be developed. If anything the problem is far more intractable than it was three decades ago. Future improvements in the EMR are likely to occur only at the margins of the technology and will likely be of more benefit to hospital collection than to patients.

  There is little anyone can do about the state of affairs. One suggestion would be for patients to develop their own condensed personal medical record, especially for clinic visits. With help from their physicians, patients could carry a list of their conditions, medications, important lab tests, and a summary of their doctors’ findings, updated after every clinic visit. It won’t replace the EMR, but it might help caregivers who see patients.

  Sadly, patients and their caregivers are destined to remain captives of the dysfunctional EMR. It is here to stay and will change the practice of medicine irrevocably. There is no going back: as any experienced hiker can tell you, once you go deep enough in the forest, you can’t count on retracing your footsteps.

  26

  MEDICAL PROTOCOLS AND CHECKLIST MANIFESTOS

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  Our ideas must be as broad as Nature if they are to interpret Nature.

  —SIR ARTHUR CONAN DOYLE

  IN HIS INFLUENTIAL BOOK A Checklist Manifesto, Dr. Atul Gawande describes how simple checklists can revolutionize medicine. The use of hospital checklists has already produced significant benefits, including fewer surgical mishaps and lower infection and hospital complication rates. Most checklists are simple and easy to understand, so outside review organizations have embraced them in the practice of medicine.

  But improving medical care through checklists is not the sum and substance of practicing medicine, which requires accurate interpretation of patients’ signs and symptoms, awareness and ability to assess treatment risks, and very often a sixth sense of when to act. Guidelines and protocols only describe these intangibles incompletely. As such, they are the GPS of medicine—they can make the journey easier, but it’s best having a professional who knows the territory and terrain.

  A current case in point is the plight of obstetricians/gynecologists, specifically regarding cesarean section and the timing of delivery. The American C-section rate has risen from 5 percent in 1970 to 32 percent today, a trend common to other parts of the world, with similarly high rates (and little financial incentive to perform C-sections) including South America, China, and Europe. When deciding to perform C-sections, physicians are responsible for the well-being of mother and baby; this means accounting for many complex factors. In the United States, the reasons for the C-section increase are primarily medical—greater use of drugs to induce labor, older and heavier mothers, higher rates of diabetes and other maternal diseases. An important nonmedical reason is the litigious environment, obstetrics being a fertile area (no pun intended) of medical malpractice claims; many physicians believe C-section reduces the risk of being sued.

  Physicians also use fetal monitoring more often than in the past, which has created a concomitant trend toward delivery before the “ideal” delivery date of thirty-nine weeks. This is problematic because babies born before thirty-nine weeks have higher incidences of death and neurologic and pulmonary problems. Neonatal intensive care units nationwide are experiencing greater rates of admission, a tragic and extremely expensive problem. Understandably the government, the American College of Obstetricians and Gynecologists, and the Joint Commission on Accreditation of Hospitals (JCAH) have all put in motion efforts to decrease the rate of C-sections and eliminate nonmedically indicated deliveries before thirty-nine weeks. On its face this would seem to be a no-brainer. But it’s not that simple.

  Some ob-gyns worry that the drive to manage how and when delivery should occur could become a heavy-handed mandate tying doctors’ hands. This concern deserves a hearing for several reasons. First, while earlier delivery and C-section result in greater neonatal morbidity and mortality only after the baby has been delivered, some literature suggests there are babies who would otherwise die in the womb but can be saved by delivery at thirty-seven or thirty-eight weeks. Hence the decision when to deliver becomes a delicate balance. Second, “nonmedical” indications can be vague; some diseases of mother and fetus are subtle. To diagnose correctly and intervene requires knowledge and judgment. Finally, doctors in the trenches are understandably reluctant to be judged harshly by hospital quality-indicator committees or the JCAH. Lawsuit or not, the physician attempting to do the right thing for the patient may find him- or herself abandoned if a delivery goes wrong.

  The drive by outside organizations to improve obstetric and other medical care is commendable. But some doctors’ fears of procrustean rules preventing them from practicing in the right manner are also real. No organization currently mandates a specific C-section rate or time for delivery, but it is not hard to see how “one size fits all” recommendations might eventually become a standard of care. Doctors deal with the uniqueness of each case, honing their ability and skill to recognize inevitable outliers. They don’t want to see that ability hampered by a spate of rules and regulations.

  In 1847 the man who ultimately became history’s most famous obstetrician noticed that pregnant women in Vienna were six times more likely to die if delivered by physicians than if delivered by midwives. Decades before the cause of infections was known, Ignaz Semmelweis realized the deaths were due to “putrid material”—that is, bacteria doctors unknowingly transmitted to women. He believed the doctors, who did not wear gloves and worked in the autopsy lab before going to the delivery area, picked up this material in the lab. He felt strongly that virtually all the deaths could be prevented if the doctors simply washed their hands with household bleach before attending the women (presaging Gawande’s checklists).

  Influential idea, but stubborn European obstetricians refused to wash their hands, reviled Semmelweis, and tragically destroyed his medical career. Eventually his controversial recommendation was v
indicated, saving countless women. Today, reputation restored, he is recognized as the pioneer of hand-washing and antisepsis, a medical giant with clinics and a university named for him.

  Critics point to the story of Semmelweis and his detractors as proof of the medical establishment’s long-standing arrogance and dogmatism. The indictment has some merit, but those who do point to this miss something else in the story—the hero who revolutionized medicine was not some bureaucratic organization but a brilliant, iconoclastic physician. In the new organizational world where shadow practitioners may dictate medical rules though protocols, might the next Semmelweis go forever undiscovered?

  27

  AN AMERICAN DISGRACE

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  Caring for veterans shouldn’t be a partisan issue.

  It should be an American one.

  —GOVERNOR JENNIFER GRANHOLM

  SURELY WE OWE OUR VETERANS better than the enduring travesty of what is happening at our veterans’ hospitals. As part of the ongoing national scandal, the Department of Veterans Affairs’ Office of Inspector General revealed that in 2014 and 2015 staff at Houston-area Veterans Affairs (VA) facilities improperly manipulated over two hundred wait times for Texas veterans looking to schedule medical appointments at VA clinics. By shifting the blame for cancellations from the staff to patients, VA employees made it appear waiting times for clinic visits were shorter than they really were. Veterans often waited an average of nearly three months for rescheduled appointments.

  Even worse, this nationwide embarrassment is a recurring problem. In 2014 VA employees in Phoenix, Arizona, entered false dates into the appointment system, so veterans waited far longer than the recorded waiting times—with some patients dying as a result. That scandal cost then VA secretary Eric Shinseki his position and prompted a massive reform effort, which obviously didn’t make its way to Houston anytime soon. The federal report states, “These issues have continued despite the Veterans Health Administration having identified similar issues during a May and June 2014 system-wide review of access. . . . These conditions persisted because of a lack of effective training and oversight. . . . Wait times did not reflect the actual wait experienced by the veterans and the wait time remained unreliable and understated.”

  And waiting times are only one problem among many. The appalling rates of severe post-traumatic stress disorder and suicide among veterans remain unacceptably high. Besides that, in the decade after 9/11, the Department of Veterans Affairs paid out $200 million to nearly one thousand families in wrongful death cases.

  The experience of former marine and Massachusetts representative Seth Moulton (D) tells much about the system. It took Representative Moulton, a veteran of four tours in Iraq, over a half hour at a Washington, DC, VA hospital just to prove he was a veteran. When he sought care, he did not have his VA card. Opting not to identify himself as a congressman but simply as a veteran, he provided what should have been sufficient identification while observing other veterans who had been sitting in the waiting room for hours.

  He described to NPR what happened: “I checked in at the front desk, and about 30 minutes later, they told me that they had no record of me. They couldn’t prove that I was a veteran. But they would consider taking me as a humanitarian case. . . . [They had] more than enough things to put into their computer system, supposedly the world-renowned VA computerized medical records system. . . . If that’s the care they’re giving to a United States congressman, you can imagine what the average veteran is getting at many of the VA facilities across the country.” (The VA has since adopted a new computer system.)

  But the system apparently rewards failure; after officials covered up an outbreak of Legionnaires’ disease at a Pittsburgh VA that left at least sixteen veterans ill and six dead, the VA regional director, Michael Moreland, received a nearly $63,000 bonus. Amid all this, VA secretary Robert McDonald didn’t exactly inspire public confidence in 2016 when he compared VA care to a trip to Disneyland. He said of the long wait times that veterans must experience for clinic visits, “When you go to Disney, do they measure the number of hours you wait in line? Or what’s important? What’s important is, what’s your satisfaction with the experience?” (In fact Disney does indeed track how long visitors wait in line for attractions at its theme parks—but that’s beside the point.)

  When the agency tried to walk back McDonald’s obtuse remarks, it doubled down on the patient satisfaction meme: “We know that veterans are still waiting too long for care. In our effort to determine how we can better meet Veterans’ needs, knowing that their satisfaction is our most important measure, we have heard them tell us that wait times alone are not the only indication of their experience with the VA.”

  To be clear—in any hospital patient satisfaction is one, but only one, measure of care. The most important measures are how patients’ health and quality of life are being managed. Are acute diseases being diagnosed and treated correctly? Are chronic diseases being managed adequately? Is appropriate screening being performed? Is the quality of life being addressed in those with mental and physical disabilities? Those things should be the secretary’s primary concern, as well as the primary concern of the thousands of VA employees.

  Like Eric Shinseki, McDonald has since been replaced (which means the VA has had three directors in less than five years), and although McDonald’s remarks seem to have come out of Fantasyland, where a loop of “It’s a Small World” plays continuously, the VA health care system is not Disneyland. The comparison betrays disrespect for veterans and suggests it is unlikely the system will be corrected any time soon.

  When Shinseki was sacked after the Phoenix VA travesty, President Obama said, “We’re going to do right by our veterans across the board, as long as it takes. We’re not going to stop working to make sure that they get the care, the benefits and the opportunities that they’ve earned and they deserve. I said we wouldn’t tolerate misconduct, and we will not. I said that we have to do better, and we will.”

  But we haven’t. And the whole thing is an American disgrace.

  28

  THE FUTURE OF HEALTH CARE: MUCH LIKE THE PRESENT,

  ONLY LONGER

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  Life can only be understood backwards; but it must be lived forward.

  —SØREN KIERKEGAARD

  LIKE AN OLD CAR WITH TOO MANY MILES, American health care sputters along in a chronic state of disrepair. Although we pay more than $3 trillion annually, our health care system is broken, with no quick fix in sight. And in fact, it may be irreparably broken because each new solution instituted by payers and providers, whether effective or not, results in new, more insoluble problems.

  Consider an important example of an increasingly dysfunctional solution: the logic of insurance payment systems. In The Health Care Blog, radiologist Saurabh Jha explains how incomprehensible the system is. His experience with Medicare and private insurers is that they would refuse payment when he believed that a preauthorized test was wasteful or dangerous and he wanted to perform a simpler, safer test. Essentially, if he did less and billed for less than what the insurer agreed upon, they would not pay for anything, leaving the patient to pay the bill.

  Likewise, if he did more than what was preauthorized because he felt it was clinically indicated or might spare the patient future tests, the insurer, fearing fraud, would refuse all payment. In addition offering billable services to Medicare patients without billing Medicare, as an effort at charity care, put him at risk of the fraud laws—the government might actually consider charity care given to Medicare or Medicaid patients as fraud.

  Jha wrote,

  The reason insurers, and Medicare, would rather pay more, than less, for an exam, that is cut off their nose to spite their face, is that they don’t trust physicians. They don’t trust physicians because fifty years of health economics has yielded a spectacular insight—physicians, like crack dealers, are guilty of supplier-induced demand. This meme is now structurally embedded in payers. The inf
ormation to discern between physicians inducing their demand and physicians curbing their demand is too costly to obtain. So third party payers have a blanket rule—you can neither upgrade nor downgrade an imaging study, and if you do you’ll be paid nothing or will be done for fraud. . . . A costly game of chicken is being played between payers and providers. It’s a game of reverse chicken actually, where both sides avoid staring at each other, and adapt to each other’s pathologies.

  Welcome to what happens when insurers, government or private, manage care: waste, inefficiency, and aggravation. Our current bizarre system is the result of trying to correct the previous unworkable system, in which providers managed their own care and their income depended on provision of services. This resulted in too many tests and procedures. Again, no foreseeable solution, no matter what political party is in power.

  Is the answer a single-payer system to eliminate waste and inefficiency? That is a fool’s errand; one need only observe the egregious abuses in our veterans’ health care system.

  The basic problem is that health care has three aims: access for everyone, lower costs, and better quality. (Other industries have a similar triad: “faster, cheaper, better.”) Nowhere in the world has any system figured out how to provide all three. Moreover, when a system makes an effort to provide one, either or both of the other two may suffer.

  Western Europe prides itself on broad access for its citizens along with low costs, but in every Western European country, health care costs are outstripping the gross domestic product (and all this of course is financed by significant taxation). Like the United States, their systems are requiring ever-greater spending. Moreover, other countries with single-payer systems do not perform better. Our health care system is undeniably more wasteful but at the same time more technologically advanced and innovative than any in the world. America provides a medical tourism industry for the wealthy and powerful of other countries.