On Doctors And Data Entry

Managers are typically keen to know how hard the bees are working in the beehive.

When the bee is, say, a factory worker it's fairly easy to measure work output and quality: count the number of glass objects placed on a conveyor belt in an eight hour period and note the amount of breakage, if any.  Workers can be easily compared using this metric.

When the bee is a family practice physician or internist measuring work output and quality of work becomes problematic because the work elements that count defy straightforward analysis.

Undaunted by the complexity of this task managers sometimes plow ahead with a simple measurement, believing, it seems, that if something can be measured, it should be measured, regardless of how limited the return.

For example, I recently learned about a very good clinic that came up with the very bad idea of reviewing physician performance based on their skill and versatility at data entry.  

In this case, a computer review of physician records evaluated how often doctors documented that they, among other things, recommended colonoscopies and mammograms to their patients.  The information had to be entered in a specific place in the electronic record or it was assumed that the doctor did not make the recommendation, even if the information was entered elsewhere.

Getting to the designated documentation spot involved navigating the electronic record with a variable number of clicks depending on where the doctor was in the patient record.   The time necessary to click and enter the information likely ranged from a few to thirty seconds.

When the study period was over the computer analyzed all the data and the physicians were assigned grades (a report card).  Those who scored low were encouraged to shape up.

Using the computer, with its pixilated wisdom, to answer the above questions is actually a good idea.  The documentation of screening tests is important.  And placing the information in a standard place makes lots of sense.

But considering that the average fifteen minute appointment is chock a block with patient concerns, doctors have precious little time for data entry.

It's of great interest that two of the very best clinicians in this study got the lowest grades.

Why?

It appears that given the choice of talking with their patients or entering data, they chose the former. What really counts - empathy, availability, ethics, intelligence, thoughtfulness - cannot be measured in the usual sense and certainly not by a doctor's talent for data entry.

In the end, the measure of a doctor is not subject to formulas but by reputation, the child of character.

The Annual Exam

Patients often emerge from an annual exam wishing that they had stayed home, especially after the doctor freights them with enough new findings and diagnoses to shatter the most bullet proof sense of good health.

A typical list of problems and recommendations might look something like this:

You have freckles galore, almost always innocent, but you never know, so on to the dermatologist you go.

You mentioned heart burn, probably due to simple esophageal reflux, but you never know, so off you go to the cardiologist, it could be angina. 

You have a deviated nasal septum. 

You have bilateral heel spurs.

You have a creaking of the neck (arthritis?).

No wonder many fear the annual exam more than root canal. 

Still, the idea of finding problems before they hatch, seems both important and logical.  If this were indeed true, then  maintaining good health would doubtless trump the negatives of going through the exam.

However, the Cochrane Group, the epicenter of evidence based medicine, has studied the annual exam issue extensively and concluded, in an October 2012 study, that large groups who have them regularly fare no better than those who do not.

There have of course been individuals who have benefited greatly from a screening exam.  Finding a melanoma on the back in its earliest stages or unequivocal elevation of blood pressure in an asymptomatic individual come to mind.   

It's just that if you compare large groups of individuals who take annual exams with those who do not, their health outcomes are very much the same. This applies also to illness related to cancer and cardiovascular disease, leading causes of morbidity and mortality. 

But if some people benefit from the screening exam, then, why not have one?

Traditionally, lots of information is collected during the exam (do you have gas, do you have trouble swallowing?) that takes up lots of time to gather with surprisingly little benefit. 

Since most of these patients will do no better than the unexamined, it is likely that many of the diagnoses made will actually be a form of over-diagnosis.

Over-diagnosis oftentimes leads to unnecessary tests and, even worse, unnecessary treatments.  Side effects in this scenario are especially intolerable as we ask the patient to buy risk with little prospect of benefit.

Finally, there is the matter of squandering health care dollars at a time when savings are badly needed.

So what can physicians implement to replace the current annual exam?

Let's replace the annual exam, with its painting by the numbers motif, by one that allows the patient to engage the doctor, in an unhurried way, about their concerns (it is common that the concerns of doctor and patient differ widely during exams).

So while the physician is hell bent on asking questions about every organ and body system (rarely decisive or illuminating), the patient is keen on discussing their longstanding backache or worries about memory loss.  Perhaps our exams could begin like this: "Hi Joe, what would you like to discuss today?"

In whatever form this new style exam takes it is necessary that there be ample time to discuss prevention strategies and immunizations.  

Given the research of the Cochrane group fewer people will get routine screening exams. When, how often and if to take these exams will be guided by further research on health outcomes.  For now decisions should be made on an individual basis.

What appears clear, however, is that we are putting too many patients through routine exams with little to show for it.  This is counterintuitive but supported by good research.

Whether one gets routine exams or not the following are major factors in achieving and sustaining good health:

Always notify a doctor when experiencing new signs or symptoms.  It's especially necessary when the changes are outside ones experience or when they represent an acceleration of a known problem.

Make and keep friends.

Search for intimacy.

Choose your parents and blood line wisely.

And most importantly, do all things in moderation.

OK most things.

Doctors and Guns

When I saw patients for routine exams, I would ask them, among other prevention issues, if they wore seat belts, had functioning smoke alarms  and whether or not they owned firearms.

The great majority wore seat belts and seemed to accept research showing a marked reduction in injuries and fatalities in those who buckled up.  When it became illegal to not wear them, most of the remaining stragglers appeared to sign on.

Patients were oftentimes puzzled at why I asked about smoke alarms.  They caught on when I suggested that it would be a shame to have corralled  their cholesterol and blood pressure with diet, medicines and exercise, only to go up in flames.  On returning one year later, many informed me, with great gusto, that they had installed fire alarms and regularly checked the batteries.

Asking about guns was another matter.  Most patients openly wondered at what gun ownership had to do with medicine.  While not comprehending the reason for the question, most listened politely to my concerns.  At least two individuals, however, became quite hostile about being asked  and told me it was none of my business.  I wondered if they possibly thought me an undercover agent for the Alcohol, Tobacco and Firearms Bureau (ATF).

With as much diplomacy as I could muster, I explained to all my patients that my concern was not over whether they owned guns but whether or not they were safely maintained.

That meant that the guns should be locked up so that children and intruders would not have access to them.  The ammunition should be stored separately from the guns and also locked up.

Why?  It is not unusual to read of children who kill themselves or their friends when playing with loaded guns which they have come across in explorations around their homes.  It's thought that about 2,800 children and teenagers die a year from gun related deaths.  This includes an appalling number of teen suicides.  Moreover, it is very common for intruders to disarm gun users and then turn the weapons against the owners.

Additionally, I recommended that those who kept guns loaded by the bedside (not at all unusual among patients living in high crime areas)  separate the gun from the ammunition, explaining that loaded weapons in the home resulted in more deaths of family members than criminal intruders (read: husband's night flight is cancelled and he comes home, unannounced at 1:00 AM, to a hail of bullets, set off by a terrified wife.) 

Over the years, it seemed that at least half of my patients had firearms, mostly rifles.  It was not at all unusual for a patient to say he had a rifle but hadn't seen it for twenty years and couldn't say exactly where it is.  This is where the kids and bad guys come in.  They have a nose for missing weapons.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     Finally,  if I thought a patient suicidal, and learned that they owned a gun, I did what I could to get them and/or their families to disarm the individual.  This was especially urgent as guns are both a gateway and final destination for the majority of people determined to kill themselves.  

My efforts were not in vain as many patients would tell me they had locked up their guns and kept them unloaded as a result of our discussions.  

While I sometimes felt like  the nanny (nag?)-in-chief, I firmly believe that a discussion of gun safety issues belongs in the routine medical exam. Management of violence and mayhem is unarguably a health issue.

Guns And Can Openers

The events in Newtown have many of us thinking about the horrors of gun violence.

That’s when the NRA springs into action, trotting out its ballistic mantra, one of the most egregious dodges of our time: it’s not guns that kill people, it’s people who kill people.  

Hmm.  So it must be equally true that it’s not can openers that open cans, it’s people who open cans.

Go try opening a can without a can opener.

And go try killing someone without  a gun, the weapon of choice for murderers, who like to keep their hands clean and value the savage efficiency of rapid fire guns and exploding bullets. 

Indeed, guns are, at the very least, guilty by association.  If we do not contain them, it will not be going over the budgetary cliff that will ruin us so much as a firearms induced state of poisonous incivilty.

Let’s talk to each other and our political representatives as much as possible about new gun laws, including reliable background checks, a ban on assault rifles and large bullet clips as well as more attention and resources for mental health issues.

If not now, then when?

Holding On

Leaves finally give way to gravity, painting the ground with a riot of color, dancing all the way to their deaths.

Still a few stalwarts, going dry, pale and cracked, refuse to let go, suggesting that we just might be able to hold on too till the next wave of leaves, popping out audaciously, full of themselves, ride in on the next season and its green destiny.

Word Pouncing

We pounce on words and somehow red turns blue

We pounce on words and they pile up into books, literature, not literature, mortgages, advertisements, curfews, claims of love, claims of hate, report cards, the price of bananas, instructions for an electric toothbrush, speed limits, a history of Atwater Beach

Which of these words deserves coronation and which the guillotine?

Words, rolling around in the stream of understandings and mis-understandings, which they forge, makes it hard to know 

But isn’t that the game?

Survivors

We are holocaust  survivors

The sun lays a late afternoon table of luminous shapes

Our children read the script and always graduated with honors

Desultory  and panicked walks in the forest became the stuff of legend

School children push and shove to breathe in the ether of bravery which perfumes us  

And yet we are still holocaust survivors, nothing more or less, leaving us in mourning, wondering who we are, and who we might  have been, hoping to find at least a trace of our remains.