Tag: cowards

Electronic Health Records

The creation and dissemination of electronic health records (EHRs) was inevitable the moment personal computers provided every household with unlimited access to porn. While everyone was enjoying themselves in the presence of nubile cyber nymphs, the Powers-That-Be were preparing for an all-out assault on every last sector of the planet that was operating without a keyboard. Today, as long as you appreciate running water and not shitting in public, you must comply with the internet. Medicine is no exception.

I.

EHRs started to become wide-spread in the medical field sometime in the early to mid-2000s with all the snake-oil promises that one would expect which included: reducing medical errors, making information available in order to reduce test duplication, and improving accuracy and clarity of medical charts. In the same way that Congress has no idea how the internet works (some believing it to be a series of tubes), the medical community and its self-appointed leaders clearly had no idea what they were doing or how to internet. They probably should have asked a Millennial. I’m sure any one of them could have quickly showed them the error of their ways with a simple cat meme. But alas, an expert was not consulted and here we are today, wringing our hands in protest of our new overseers.

For over a decade, physicians have been struggling with accepting the use of EHR. Many have expressed dissatisfaction over the fact that more than half their time is spent “interfacing” with a shiny rectangle instead of intently listening to their patient’s complaints which are likely centered around nebulous fibromyalgia pain. Some of the older physicians are even fantasizing about leaving medicine citing the increased burden of serving as a gloried data-entry monkey instead of a physician which is what they were originally trained to do. Furthermore, the promises of reducing errors have been found to be baseless  in that the alarms and alerts scattered about the EHR do nothing more than produce alarm fatigue with only minor improvements in care processes at best. I don’t care how many pop-ups you place in front of me, the foley is staying in.  Although, to be fair, it appears that prescribing errors have decreased some but only because each order starts with a default dose followed by a range of options which allows the physician to at least have a chance at guessing the right answer; we are only trained to excel with multiple choice exams. And as far as decreasing duplication of records, that has also been found to be a bogus claim. As of 2015, 60% of PCPs were unable to electronically exchange records with other physicians outside of their practice. This is not limited to the outpatient world. Anyone who has spent any time in the inpatient setting trying to obtain records from an outlying facility is usually shit out of luck, except for in larger cities where different institutions may have the same EHR and thus are able to share some limited records. This is less that information sharing is streamlined and more a gradual monopolization of information by a superior EHR system (read: Epic). Trying to get records from an outlying transferring facility that does not have the same EHR? Good luck! I can’t tell you how many records I received either by fax or transferring medic which were still hand-written and illegible. HAND WRITTEN! And that is assuming they even send records of any remote importance. Most transferring facilities seem to believe that nursing notes and skin assessments are all that is needed.

But despite all of these problems, the fact that research has continually debunked the promises of EHRs and that many physicians would prefer to slam their dick in a sliding glass door than interact with their institution’s medical record system, they are still being touted as necessary to patient safety and improved care. Although reality is quickly becoming irrelevant (see: Presidential Election 2016), it is still fascinating and horrifying that despite very clear evidence to the contrary, the zealots of EHR refuse to acknowledge the fact that they were wrong; they were wrong about everything. None of their promises have been fulfilled but I suspect that none of their promises were ever meant to be. Hindsight is 20/20 but realization is a bitch. EHR’s were never meant to improve the lives of patients or physicians; they were meant for control.

II.

Back in the day, during a simpler time in medicine where medications were limited and payment could consist of eggs and a chicken, physician notes were meant for no one but themselves. There was little order to how they were written and legibility was only relevant to the person writing the note. SOAP notes did not exist. Best practices did not exist. Medication reconciliation and a full review of systems did not exist. Often times, a few simply lines would be all that was written as documentation for a full clinic visit. This took a few minutes. It was likely the least consequential part of being a physician. Those lucky bastards.

Fast forward 30-50 years, with the advent and dissemination of the SOAP note, and the landscape has changed. The notes are still paper, as Big Internet had not come into the picture yet, but the format was drastically changed. In some ways, the change was for the better. There was more structure provided, it required at least some relevant information for those that may be exposed to the notes and were not the author, and one could create pre-printed templates to help expedite the process. But more importantly, this change allowed the implementation and utilization of EM codes. Physician’s had to prove their worth by writing down their thoughts as well as important aspects of the patient encounter and then code accordingly based off the complexity of the encounter. This form of note writing did end up taking more time but it was not overly burdensome. Physicians could still enjoy being physicians.

Now bring it to the present, for the last twenty years or so, and the landscape has changed once again. Big Internet kicked down the door, flexed nuts, and opened a portal from Hell to fill the land with endless Best Practice Advisory pop ups, guideline reminders, data element requirements, check boxes, and ICD codes. With the implementation of EHRs throughout the land, the task of billing and note writing which was once considered an inconvenience, has become the tools of our enslavement. What once use to consist of no more than a page in short-hand has now morphed into a 4-7 page, primarily auto-populated and copied forward, irrelevant gargantuan ever evolving to demand more data without providing any useful information. Per usual, the outside influences were far more intelligent than the whole field of physicians. The insurance companies, and specifically Medicare and Medicaid, saw the opportunity that the electronic age provided for demanding more and giving less. They also seemed to understand the cowardice of the physician population and took special notice of the fact that their training made them particularly susceptible to achievement-oriented enslavement. With this knowledge, and the weaponry known as The Affordable Care Act, an all- out assault on the medical field was launched.

Notes were scrutinized with ever more arbitrary elements required to obtain a certain level of billing, the calculation of which was purposefully made difficult in an effort to then fine and demand repayment for the inevitable misbilling of encounters. Requirements regarding obtaining a “full” review of systems, despite the complete lack of evidence this provides any useful information, a family history, social history, and a complete medication list (despite the fact that NO ONE knows what they put into their mouth) were required for every note in every encounter, especially in the outpatient setting. Particular language regarding diagnosis and timing of diagnosis were established, and frequently changed, in order to deny payments for mislabeled diagnoses or for missing diagnoses of questionable importance at the time (IE: Obesity). This assault has been further augmented by the requirement of physicians to register with several different physician review organizations, often requiring renewal of registration every few months, with penalties for those who forget or have better things to do (like finish those God-damn notes). And lastly, as if to add insult to injury, the Powers That Be have felt the need to make sure one cannot successfully navigate through their EHR without suffering through no less than 5 pop ups demanding attention to several, often times inconsequential, elements of a patient’s care. (No, I am not going to order a flu vaccine. It’s May. Fuck off!)

It’s all about control. None of this is for the patient. None of this is for the physicians, in as much as it improves their lives or makes their job easier. It is all to control and bewilder those that have the real power. Keep them focused, keep their heads down, do not let them look up, do not let them get comfortable, change the rules, add more tasks, and never let up. This is their game and it works! Instead of requiring change, instead of saying “No”, instead of fighting back, we slouch down and continue with the grind. Occasionally, we like to use our “science” to make a point, but that never does any good. (Remember all the studies about how patient satisfaction is bullshit?) Science will not change the minds of those with an agenda. The assumption when studies are published is that the minds they are meant to change are ignorant to the fact presented; the fact is we are ignorant to their agenda. We are also ignorant to the fact that when we prove a system is flawed and then do nothing to change it, we are helping our oppressors. We may feel smug in our knowledge that the polices are bullshit, but the overlords already know that and we are still following them. “We got them good! Now I better get back to clicking boxes or Massa gonna be upset!”.

Someday, after alcoholism and suicide has ravaged the medical profession, assuming the world has not ended in nuclear disaster or an Idiocracy-style decay, the medical field will make a change. The oppressor will be identified and de-throned. When that day will come, I have no idea. And what the profession of medicine will look like at that time is unclear. But I can assure you that if the change is not made fast enough, and while enough intelligent people still want to invest their life into it, we will be in trouble.

But in the meantime, those boxes aren’t going to click themselves.

Doctors are Cowards

I was told this by a patient once. I guess they thought this would be a revelation for me. Cute.

I made it a mission to indoctrinate upcoming medical students with this and various other rules which I called “The Truths of Medicine”. I hope that one day this will be obsolete. Or canonized.

“But that’s a pretty cynical view of physicians, isn’t it? We aren’t cowards!”

Keep telling yourself that.

“But why are doctors cowards?”

Think about what it takes to become a physician. Think of the mindset that is required, the time that it demands, and the amount of delayed gratification it takes (some would say a life time…). You spend two or more decades in schooling (grade school through medical school). Your life is nothing more than jumping through academic hoops, checking boxes, and performing activities that ultimately have little bearing on what you will do later in life. It all seems arbitrary but there is a reason to the madness. It is conditioning.

In order to make a “good” physician, you have to think about what it would take to make a good slave. You have to keep their focus narrow. You have to overwhelm them with activities that ultimately have no greater purpose than to test their ability to complete a task. You have to teach them that there is no other way. You have to make it difficult, if not impossible, for them to be able to break out of their servitude. But most importantly, you have to make them believe that their current position is noble and that to desire anything different is sinful or selfish. The last one is essential.

Focus Them In

Medical school is an extremely specialized training, however the specialization is gradual. The first two years of school is a broad overview of human anatomy, physiology, disease processes, and pharmacological interventions. To say that the information you are exposed to can be overwhelming is an understatement; it is impossible to absorb and retain it all. You aren’t supposed to. You are supposed to figure out what you want to start forgetting. And then Adderall. Or Ativan. However you cope best. But once you make it out of the first two years, mentally ravaged, vitamin D deficient, estranged from friends and family, and properly conditioned to believe that this is normal and necessary, you are allowed to progress to Stage 2.

Stage 2, also known as your third and fourth year, is about finishing the conditioning and narrowing the focus. Where you previously had some control over when you got to sleep, eat, shit, and breathe, those privileges are immediately lost the second you walk into your clinical rotations. You are told where to be, at which time, and how long you will stay there by various people who are not your parents or law enforcement. You really have no option but to be there, at least most of the time, lest you fall into their bad graces and risk failing (read: doing it all over again). In addition to being trained how to follow arbitrary orders, you are exposed to even more specialized fields for several weeks at a time in order to figure out what field of medicine you will accept having your life scheduled around. All that information which was shoved down your throat during your first two years begins to be pared down to fit the confines of your respective area of interest. It is by getting to “choose” your area of interest that provides you an illusion of control. Even slaves need to feel empowered sometimes. But this choice is just a means to further focus you in and prepare you for the next stage of conditioning known as residency.

Do everything. Expect nothing.

The endless onslaught of inane activities is not something unique to medical school or the post-training-mind-fuck known as residency. For those pursuing the lofty goal of being labeled a physician, these activities seem nearly life long and start early. From the extra credit and consistent completion of homework, to the time spent in extracurricular activities and volunteer work to prove that you are “well rounded” (read: fit to jump various hoops), it seems your entire life is an amalgamation of experiences which were collected for the sole purpose of being granted that golden ticket into medical school; your entire life is nothing but a means to an unsatisfying end. And it is not like the requirement for continued “activities” stops upon admission into medical school. No, that would be too humane. In addition to being waterboarded with information, you are “encouraged” to continue doing volunteer work, join committees, perform research, and make every effort to remove the idea of “free time” from your vocabulary. Of course, you are free to go against Master’s recommendations however you risk not advancing to the next level and being stuck with hundreds of thousands of dollars of debt; your incentive is a carrot-flavored stick. You are in too deep. Better get to ladling out that soup.

But you get through it. Somehow. You may not have the clearest memory of it and may have even exaggerated a few things, but it is done. Your fourth year is here. You can breathe. Well, you can breathe after you collect your letters of recommendation, write your personal statement, write about what makes you unique (protip: there is nothing that makes you unique but the system demands obedience), go through your specialty-specific fourth year clinical rotations, spend thousands of dollars on additional 8-9 hour multiple choice exams, applying to residencies, and traveling for interviews to various residencies, and then submitting a match list while waiting in eager anticipation for 3-4 months to figure out where you will be contractually obligated to spend at least one year of your life. Easy. In comparison to the other three years, it is better. It provides the student (read: slave) with a relative reprieve before they jump head first into their life long struggle with alcoholism and drug abuse (read: career). Even slaves need a Sunday.

But then residency starts and you begin to see what your training was truly about: conditioning. Where most people would whine, kick, and scream over the prospect of waking up between 3-4AM for 26 days out of a month, working 12-36 hours straight, being verbally and occasionally physically abused by “customers”, explaining complicated medical conditions and medications to middle-aged children with a third grade reading level, being blamed for everything that happens by anyone that is considered above you (this includes patients), working with various bosses (read: attendings) with widely inconsistent personalities and preferences, all while trying to attend lectures, submit research proposals, and finish all your work for an ever increasing patient census before your shift ends in order to not go over your arbitrarily determined “duty hours”, we simply call it another Tuesday. We are so conditioned at this point that we cannot imagine anything else. This is our normal. This is our reward.

No escape

As was already alluded to earlier, even if you can see through the smoke and mirrors and know the game for what it is, you cannot escape. Or at least, you cannot escape unscathed. Many people complain of college loans and difficulties paying them off when they graduate from their four year alcohol bender into an entry level barista position at their local Starbucks. I get it. You were lied to the moment someone allowed you to sign up for a major in political science. But to put it in perspective, one year of medical school tuition is about the equivalent of four years of in-state college tuition. And if you went out of state for a four year bender without a (real) science or math degree, you have no one to blame but your parents.

But getting back to the cost of conditioning, medical school costs on average about $39K a year if you are in-state and close to $60K a year if you are out of state. Unlike college, where going out of state simply means you want mom and dad to be farther away, most people do not have that option to be selective about which state they will be conditioned in; you go where you are accepted. So, to do some basic math for the Poly-Sci majors, you are looking at $160-240K for four years of conditioning and this does NOT include the cost of living, exam fees, or travel expenses. The only thing that seems more expensive, and produces about the same results, is Scientology. Furthermore, nearly everyone passes their first year or they are made to repeat it. The only time that dismissal from the conditioning program becomes necessary is in the event that you fail (multiple times) the first of many day-long exams called Step 1. This is taken in your second year. At best, you are already $80-120K invested and quitting is only an option if your parents are wealthy. For the rest of us plebs, failure or escape is not an option; we are riding this train to its final destination and it’s a long trip.

This is what you deserve

“the understanding and encouragement of altruistic behaviour is vital in maintaining the public’s respect for the medical profession, and altruism is also a key dimension of a doctor’s work that helps prevent demoralization and burnout” – Jones. BMJ 2002.

Bullshit.

This last part, as I had mentioned before, is the most vital part of maintaining the slave mentality among those that have completed a life time of conditioning. Altruism seems to be the default moralistic stance taken by those involved in the medical field. It is viewed as an ideal morality that helps promote selfless actions by all in health care for the benefit of the patient; it is the only acceptable morality. But just like everything else, it is simply another tool for control. It is for controlling your soul.

You can cage an animal. You can make it perform a routine. You can make it proficient at that routine. However, if the animal still desires more, or desires out, you still run the risk of being mauled to death once a limit is reached. How do you stop this? Well, when it comes to man, you teach them either to not desire anything or that their desires are disgusting, guilt-inducing, or harmful. That is altruism.

Altruism is a slave morality that has been used for centuries to control populations. It is an extremely effective tool. It teaches that if you are not selfless then you are selfish. And if you are selfish then you are exploiting those around you and depriving them of their needs. Therefore, in order for you not to steal or deprive someone of their needs, you must be selfless and work for no other task but to provide for the well-being of others. Your needs are irrelevant. You are irrelevant. You must work. This is a great way to stave off demoralization and burnout.

Jones is right that altruism is a “key dimension” of a doctor’s work. Without it, doctors would not be able to continue with their tireless effort of taking on more and more responsibilities and burdens without seeing any additional reward. Slogging through the never-ending changes in health care regulations, queries from documentation specialists, requests for “Peer to Peer” discussions over payment denials by insurance companies, CMEs, MOCs, decreasing compensations, and increased patient work load takes a special degree of self-neglect, cowardice, and guilt to maintain. Thankfully, physicians have been well-conditioned to the point that many may even feel overcompensated when they actually start to earn a real paycheck. There can be no better proof of the slave mentality of physicians than to see one marvel and occasionally question their new income upon transitioning out of residency. “I don’t feel like I deserve this much…”. You’re right. But not in the way you think.

“Then how do we change it?”

You don’t. You can only change yourself. But maybe if enough “selves” are changed the system will take notice. And then try to destroy you. Because the system does not want to change. The system is working just fine for the system. The only way out is to break the system; to take the red pill and wake up. You must demand more. Fight more. You must get angry. You must be willing to lose everything in order to gain back your humanity.

But doctors are cowards.