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.