Sunday, October 21, 2012

Clinical Creativity In The Era of Evidence Based Medicine

One of the most interesting features of the i-Tunes store, is the effortlessness with which you may accumulate a listing of 'covers' to various songs. For example, I have play lists consisting of many, many versions of 'All Along The Watchtower', 'Boots of Spanish Leather', 'Moondance', and "Buffalo Skinners'. These songs fascinate me with respect to their lyrical value in my eyes and from my perspective.

I find it a fascinating and enlightening exercise to listen to familiar 'tunes' done by both the original artist in different venues as well as 'covered' by other artists. This activity emphasizes to me the centrality of individual creativity and stylistic differences; while the true essence of the music and lyrics are expressed and preserved at the same time you are compelled to undergo an expansion of your appreciation of the piece. Contrast this to an imaginary concert in which 30 'different' and 'individual' Elvis Impersonators all performed renditions of 'Blue Suede Shoes.' I hardly believe my appreciation of the song or the process of performing the song are deepened or enlightened by a mechanical attempt to reproduce the original effects of the 'king' during his performance of the piece.   

The question hidden within the above hypothetical 'mind' concert is what is the true relationship between the Evidence Based Medicine movement and the practice of medicine?  Should it be analogous to my playlist of versions of 'All Along The Watchtower' or rather a concert of 'Elvis' Impersonators? 

Tuesday, October 16, 2012

The Ghost In The Shell Vs The Ghost in The Machine .....

When trying to consider the full impacts of medical IT on the practice of medicine, it is difficult to not become cynical, discouraged, and frustrated.

As I have argued in previous posts to this blog, 'good medicine' is less mechanistic than is generally acknowledged. Furthermore, what my years of practice have taught me is that narrative medicine is the superior approach to obtaining the clinical history ( 

What I consider the narrative medicine based history is really encapsulated by the fervent and passionate belief that  'medicine is a dance, in which the patient leads.' Furthermore, allowing the patient the time and space to  present their problems in their own language, in their own way, and according to their own priorities is a highly efficient form of practice. When I was engaged in the teaching of house-staff in Internal Medicine, my trainee's were impressed with the speed and effortlessness at which my clinical interviews with their patient's would end at the right clinical conclusion. Why? Because at the core of the clinical encounter is the patient's true interest in having their issues acknowledged, dealt with, and hopefully solved. Only the rare patient, the explicit malinger or the Munchausen's patient has the desire to frustrate the search for clinical truth.  

All wise clinicians appreciate that at the core of even the most modern 21st century patient is a primitive sub-personality in perpetual fear of the extinguishing of the flame of mortality ever threatening at the perimeter of their personal event horizons.  Therefore, the true healer, wishes to be more than a highly compensated healthcare technocrat, the true and wise physician wishes to wield the power of the Shaman as well as the Scientist. 

Furthermore, all patient's long for a therapeutic relationship with their physicians... they wish to be healed and cured, not simply to be treated and processed. The more serious and grave the illness, the more the patient's vital needs and interests attempt to compel us to wield this ancient power  forgotten or ignored by physicians in our headlong rush towards automation and professional anonymity and a 'balanced' and manageable lifestyle.
When you embrace the practice of narrative medicine as well as understand the patient's quintessential longing for healing, as well as the healers existential need to heal; the use of current medical IT systems becomes to feel like a poisonous dart sunk deep, slowly leaking toxin into your living heart & soul, a evil and malign dart that simultaneously leaches your humanity, your compassion, and most importantly robs you of the time you need to effectively employ the hidden shamanistic dimension of medical practice.     

It is explicitly and manifestly true that 'Time Heals All Wounds'..... but time is ever vanishing for the medical practitioner. As Thoreau so presciently observed....But lo! Men have become the tools of their tools. (Walden, Economy, pg 64).  And the current state of these IT tools are sorry, sad, inept, and inadequate to the task. What takes time away from the consulting room, what stands between me and the careful, intelligent, and passionate interest in every patient's unique story of pain, suffering, and fear of illness and death acts to make me a more ineffective doctor. Medical IT tools need to optimize the capture of the patients narrative and story, while enhancing the healers ability to develop, deploy and employ therapeutic concern for the patient's welfare.     


Tuesday, August 28, 2012

Physician Burnout News!! or New?

Consider this article from the Archives of Internal Medicine dated 17Jul2001

It considerabily predates the current Archives of Internal Medicine article of Shanafelt et al ( Physician burnout is therefore not new or news per sae to physicians. However, it is news apparently to the general reader.

Shanafelt's study employed a structured questionaire the Maslach Burnout Inventory (MBI) (, and canvased physicians via email. A major problem with the study was the dismal return rate for the questionaires. Specifically, 89,831 physicians were contacted by email but only 27,276 physicians actually opened the 1st email request to contribute to the study. Of the 27,276 physicians who actually recieved and acknowledged the email request to participate in the study, only a paltry 7,288 physicians actually replied and submitted a completed inventory response form. Thus the study conclusions are based on a 26.7% overall response rate, something that would have appaled my biostatistics mentor.

However, barring the extreme self selection implied by the overall response rate, the study is of value to highlight something that I believe most physicians recognize, that the professional rewards of medicine are plumetting in a sustained free fall.

The authors of the study make few (as is proper) speculations as to the cause of the high burnout rate seen in their study. However they do make an interesting point with respect to the comparison of physicians with other workers within the US. Specifically, "after adjusting for hours worked per week, higher levels of education and professional degrees seem to reduce the risk for burnout in fields outside of medicine, whereas a degree in medicine (MD or DO) increases the risk." This paradox, finding a protective factor for burnout in the general population (non-MD/DO) related to educational achievement and possessing a professional degree warants my emphasis.

Furthermore the authors comment that ' The fact that almost 1 in 2 US physicians has symptoms of burnout implies that the origins of this problem are rooted in the environment and care delivery system rather than in the personal characteristics of a few susceptible individuals...' again demands my re-emphasis.

What then may be the root causes of this phenomenal 'burn' rate? The usual suspects are the loss of professional autonomy, the proliferation of mindless corporate and governmental regulations/rules and policies, the increased demands of patient's for solutions to the non-medical or social problems that are tightly integrated into their health problems, the maddening 'accountability without authority' crush that has demoralized our educational colleagues, ever expanding demands for paperwork to jusify the care plan and to justify billing, ever expanding specialized paperwork needed to document 'pay for performance' measures, JACHO mandated best practices/core measures, justififcation of the meaningful use of your practices EMR's, the cumulative fatigue related to disrupted sleep with an accompanying limited opportunity to recoup and regroup that characterizes medical work, and the ever declining fraction of time available to spend with patient's are a partial list of contributing factors.

One of the most significant factors not generally acknowledged in the discussion of physician burnout are the consequences of the generally awful system and software design and  poor business process integration that characterizes most office and hospital EMR products and implementations. Quite frankly, I believe that a significant contributing factor to physician burnout is the forced and strained conversion or more aptly the disruption of the conventional physician directed medical processes of history and physical examination as related to its capture by the available information tools. 

As noted in this slide presentation from the slideshare website ( some CPOE (computerized provider order entry) implementations have initially decreased provider efficiciency by as much as 20-40% over baseline values. Such a decline in productivity is unheard of in any other industry with respect to their computerization efforts. And too date there is limited, non-existant, or conflicting data to demonstrate that ultimately there will be payback for the time investments made in electronic transformation of professional medical processes.

This then represents what I believe to be the hidden dimension to the current epidemic of physician burnout -- MD/user fatigue and frustration related to the use of poorly designed and implemented information tools and the inappropriate deployment of information technologies that are designed for the benefit of every player/stakeholder in the care environment except for the physician and his patient.

Sunday, August 26, 2012

"Do or Do Not".... Yoda's 1st Law Of Health Quality And Performance Improvement

"Pay For Performance" May Have No Impact On Patient Outcomes.
The National Journal (3/29, Fox, Subscription Publication) reports, "One of the planks of the 2010 health care law, paying hospitals to improve the quality of care, doesn't appear to help patients survive any better," according to a study published in the New England Journal of Medicine. Investigators "compared two hospital systems over six years – one that took part in the so-called pay for performance plan offered by the Centers for Medicare and Medicaid Services, and one that didn't." Altogether, "more than 6 million patients went through the 3,600 hospitals from 2003 to 2009."
        Modern Healthcare (3/29, McKinney, Subscription Publication) reports that the investigators "say they found no significant difference in overall mortality between hospitals that participate in the program and those that don't."
        HealthDay (3/29) reports, "The researchers also found no differences in results for conditions specifically targeted by the incentive program, such as heart attack and coronary bypass graft surgery."

As many know, Bill Clinton's heart surgeon, Dr. Craig R Smith has some of the 'worst' statistics for heart surgery of any surgeon in the country. Why? because he is such a talented surgeon that he is willing to take patient's considered too high risk by less able physicians. Additionally, as the head of an internationally respected department of surgery committed to meaningful experimental surgical research, both he and his department have mortality statistics that reflect the sometime experimental nature of their work.

What this is all meant to emphasize is that all datum are not created equal. Unfortunately, simple measures of quality are simply that, simple. I would characterize anyone who tries to understand a complex system using simple measurements of that system and who expects profound insights on the system, or enhanced decision making from those measurements to be niave or disingenous.

Again, while I understand the drive to measure and the belief that the process of measurement will make things better, the ability to game the numbers and game the system, especially when such games result in superior renumeration makes the goals of the 'health quality' movement practically unrealizable.  

Monday, March 5, 2012

It Bears Repeating... In Fact It Thrives in Repeating----The Prayer of Maimondes

Almighty God, Thou has created the human body with infinite wisdom. Ten thousand times ten thousand organs has Thou combined in it that act unceasingly and harmoniously to preserve the whole in all its beauty - the body which is thee envelope of the immortal soul. They are ever acting in perfect order, agreement and accord. Yet when the frailty of matter or the unbridling of passion deranges this order or interrupts this accord, then the forces clash and the body crumbles into the primal dust from which it came. Thou sendest to man diseases as beneficent messengers to foretell approaching danger and to urge him to avert it. Thou has blest Thine earth, Thy rivers and Thy mountains with healing substances; they enable Thy creatures to alleviate their sufferings and heal their illnesses. Thou hast endowed man with the wisdom to relieve the suffering of his brother, to recognize his disorders, to extract the healing substances, to discover their powers and to prepare and to apply them to suit every ill. In Thy Eternal Providence Thou has chosen me to watch over the health and the life of Thy creatures. I am now about to apply myself to the duties of my profession. Support me, Almighty God, in these great labors that they may benefit mankind, for without Thy help not even the least thing will succeed. Inspire me with love for my art and for Thy creatures. Do not allow thirst for profit, ambition for renown and admiration, to interfere with my profession, for these are the enemies of truth and of love for mankind and they can lead astray in the great task of attending to the welfare of Thy creatures. Preserve the strength of my body and of my soul that they ever be ready to cheerfully help and support rich and poor, good and bad, enemy as well as friend. In the sufferer let me see only the human being. Illumine my mind that it recognize what presents itself and that it may comprehend what is visible, but do not permit it to arrogate to itself the power to see what can not be seen, for delicate and indefinite are the bounds of the great art of caring for the lives and health of Thy creatures. Let me never be absentminded. May no strange thoughts divert my attention at the bedside of the sick, or disturb my mind in its silent labors, for great and sacred are the thoughtful deliverations required to preserve the lives and health of Thy creatures. Grant that my patients have confidence in me and my art and follow my direction and my counsel. Remove from their midst all the charlatans and the whole host of officious relatives and know-all nurses, cruel people who arrogantly frustrate the wisest purposes of our art and often lead Thy creatures to their death. Should those who are wiser than I wish to improve and instruct me, let my soul gratefully follow their guidance; for vast is the extent of the art. Should conceited fools, however, censure me, then let love for my profession steel me against them, so that I remain steadfast without regard to age, for reputation, or for honor, because surrender would bring to Thy creatures sickness and death. Imbue my soul with gentleness and calmness when older colleagues, proud of their age, wish to displace me or to scorn me disdainfully to teach me. May even this be of advantage to me, for they known many things of which I am ignorant, but let not their arrogance give me pain. For they are old, and old age is not the master of the passions. I also hope to attain old age upon this earth, before Thee, Almighty God! Let me be contented in everything except the great science of my profession. Never allow the thought to arise in me that I have attained to sufficient knowledge, but vouchsafe to me the strength, the leisure and the ambition ever to extend my knowledge. For art is great, but the mind of man is ever expanding. Almighty God! Thou has chosen me in Thy mercy to watch over the life and death of Thy creatures. I now apply myself to that profession. Support me in this great task so that it may benefit mankind, for without Thy help not even the least thing will succeed. re is an ancient physicians oath which articulates the physicians deeply felt obligation to heal the sick. Maimondes, as a devoted physician and guide for the perplexed, composed an oath for all physicians, Jews and gentiles1, which expresses the profound obligation of the physician to heal with devotion and humility, and a prayer for God's assistance and intervention. r

Thursday, February 23, 2012

A Brave New World?

This image taken from the marvelous silent film sci-fi masterpiece "Metropolis" exactly captures the work ambience of the ED's I am currently working in. I know that it has become fashionable to declare the transformation of medical work into a brave new world of streamlined and efficient medical processes and 'have a nice day' plastic practitioners who make the patient, read that, the medical consumer happy with their encounter but I find these initiatives if not downright revolting at a minimum disingenuous and misguided.

When I was actively training house staff, one of my favorite sage things to say was; that the clinical encounter was a dance, in which the patient always leads. This idealistic epigram was meant to offset the usual house-officer obsession with his or her pain, weariness, depressions and to focus once again on the Maimonidean perspective that in the 'sufferer let me see only the human being.' However, I find now that because of the horrific demands of payors and employers that the needs of the many are being sacrificed for the profits of the few... a common enough theme (can you whistle Dixie?) in the CSA (Corporate States of America). The ED's in which I labor now, remind me of this poor wretch pictured above, struggling to keep up with the demands of a demonic clock, which ticks, ticks, ticks relentless but heartless and my task to no longer care for patient's but rather to document care processes which justify payment of cash for services rendered. The tick/tick/tick at times feels like the drop/drop/drop of my own blood being spilt on the ground in front of my eyes. As I have noted before in this blog, the most disheartening thing about the information revolution in healthcare has been the relegation of the physician into the role of data entry technician. I was discussing the situation with my colleague earlier today as we were passing each other at the end of his shift and the beginning of my own shift in the ED. He cited for me a statistic in that based on outside observers noting the work flow of the Emergency Medicine practitioner, that in a busy ED, the physician is interrupted on average every 90 seconds. The consequences of this ADHD work style is hard to imagine for someone not used to this type of workflow. It makes it doubly frustrating in such a dynamic work environment to find an information tool that makes you a slave to its screen dynamics and performance. In any case, I know of few instances were workers productivity is so drastically reduced and performance so drastically decayed as those of medical professionals using poorly designed information tools. What makes the medical domain so hard, is that at the level of the physician, we are reluctant, in fact are imperiled by taking for granted the information gathered by those others on the health care team. As a concrete example, the information system I now use has a series of tailored data entry screens based on the chief complaint of the patient. The trouble begins at the entry of the patient into the system by the triage nurse as a conservative 40% of the time the triage nurses triaged 'chief complaint' bears no clear cut resemblance to the true reason the patient is actually in the ED. Since the first law of problem solving is make sure you understand the problem, the consequences of such a miscarriage of logic or such a misunderstanding of the patient's true complaints at best wastes time and in the setting where the chief complaint drives a 'work up' resources. In fact, while the chief complaint is the most fundamental component of the clinical encounter, it is surprising how often even the patient is confused about his/her problem. As any good lawyer can relate from his or her own professional experiences, the client often times is completely confused on the nature and need for professional services and consultation. This situation is also often operative in the medical domain. At a profound level of analysis it might also be axiomatic that in a professional encounter, in contradistinction to a commercial interaction, it is NOT true that the customer is always right, in fact, most of the time they are totally wrong, otherwise they would not need professional services. The Pres Ganey model of 'patient satisfaction' scoring, etc would hardly be embraced by my legal colleagues now or in the foreseeable future. Based on my own limited by expensive foray's into the legal world, my lawyer in his role as professional counsel told me several upsetting and not customer happy revelations over possible outcomes in a suit I was personally involved in between myself and an unethical hospital. As unhappy and unwelcome was his advice, I would have been an idiot to have fired him and find someone who told me what I wished to hear. This is the reality of professional practice.

Sunday, January 15, 2012

What appears to be axiomatic, may not be as obvious as it seems.

1 Jan 2010, Medicare cut cardiology reimbursements by an average of 40%. Most disheartening in this action was the support of as many as 20 medical sub speciality groups who felt that cardiology was being over compensated for its services.

I recall my own distress in the 1990's when it became fashionable to discuss the merits of medicine as a business instead of as a calling. I never favored this transformation then or now and consider this world view abhorrent and depraved. But for the sake of rhetorical argument, assume such a world view were valid, what legitimate business can withstand a 40% cash flow reduction occurring over the space of a month?

The net result of this pay reduction, a reduction particularly hard for cardiologists to absorb because a large proportion or rather the majority of cardiology patients are Medicare beneficiaries is that in the space of 6-9 months virtually every cardiologist in the city of San Antonio Texas became an employed physician.

What honest well run business has a profit margin of 40% and can withstand this magnitude of cuts? The answer is clear cut, no honest business can withstand this type of disruption. So it seems axiomatic to me, that the only independent survivors of such a draconian pay adjustment has to be those who systematically, efficiently, and cold bloodily cheat Medicare. What is the intention of health planners that they wish to benefit the cheaters while handing an unfair business advantagego the most egregious cheats of the health care system? To quote Christine Lavin 'What Was I Thinking,' (, or rather What Where They Thinking.

One of the causes of professional pride that I have had as a cardiologist, is watching the immense and unprecedented progress that my primary field of practice has wrought in the area of lives saved and function preserved. The relentless progress against the impact of the premature MI on the lives of Americans is a remarkable and singularly impressive accomplishment. In the era of the development of the 1st CCU's the 1960's the chances of death in the 1st month of an acute MI was about 30%. In the 2010 decade the 30 day mortality rate for AMI, all ages all comers is probably in most areas of the USA < 5-7%. I can't think of any other area in the field of medicine in which such impressive gains have been made with respect to mortality and morbidity outcomes.

In order to achieve these results many many physicians have had to labour day and night for decades to make the discoveries and implement the techniques required for these results to have become the norm rather than the exception.

As a physician who has dedicated most of my life to honing the skills that help me get these types of results for my patients, it took 4+4+3+4 years of academic and supervised practice experience prior to my independent practice of cardiology. Once this rigorous training is completed, the rewards for this investment, is a lifetime of what others may see as inconvience and sacrifice and possibly early death due to extreme job stress. The first law of cardiology, is that we all are only one heart beat from eternity. This realization and the fact that many of the patients that I have cared for over the years needed diagnosis and treatment delivered in the space of not hours but rather minutes and occasionally within seconds extracts a toil on the practitioner, unless of course you really are indifferent to the fate of those that fate and circumstance have placed in your path.

It is fashionable to decry the salaries of physicians in the context of making changes in American healthcare ( The comparisons of physician salaries seems to me pernicious in that while medical education is paid for in most advanced societies (England, Germany, Australia) and practice costs and practice burdens are shouldered by the government rather than the physician, but equally important the practice hours of these nations are capped at a reasonsable work week.

I know of no cardiologists (personally) who work less than 60 hours per week. In my own case when I left the US Military, I spent 8 years in solo practice as the only cardiologist and intensivist residing in a two county area of rural Texas with a service population of approximately 80000 patients. I had two weeks vaction every four years of those eight years and was on call 24/7 for that entire time frame working a minimum of 120 hours per week. I made about $400,000 per year in a good year, but these were the two poorest counties in the state and at least 1/3 of my provided services were never compensated for in any fashion.

Was I overpaid for my work? From my basised viewpoint I don't believe so, but I no longer do that job, I can't afford to do it, compensation for my services were cut without consideration for the needs of my communities.

The practice became a casuality of health care reform, something I passionately support, but which had unintended adverse consequences for those I used serve.