If this is an emergency, hang up and dial 911…

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Currently, in American healthcare, experts are wringing their hands in confusion.  I mean, people have insurance, right?  And yet, healthcare is still expensive and dang it, people just keep going to the ER.  Visits are climbing everywhere and I can speak from personal experience when I say that we’re tasked with more and more complex and multi-varied duties in the emergency departments of the 21st century.

I’m not a medical economist.  I do have some thoughts on the well-intentioned but deeply flawed Affordable Care Act. However, I won’t go there right now.  What I do want to address is the ‘go directly to the ER’ mentality of modern American medicine.

Call your physician.  If it’s after hours, the recording for any physician or practice of any sort in America will have a message:  ‘If this is an emergency, hang up and dial 911.’  It’s a nice idea.  But of course, it presumes that everyone really understands the idea of emergency.  In fact, they don’t.  We understand that, or we try to, but we see lots of things that come in ambulances, or just come to the ER, that really aren’t.

‘I feel fine, but my blood pressure is up.’

‘I was bitten by a spider and I watch nature shows and I know how dangerous they are.’

‘I have a bad cold and I have taken two rounds of antibiotics.  I have an appointment with my doctor tomorrow but I thought I’d just come on in to get checked out.’

The list goes on.  In part, it’s because we do a poor job of educating people about their bodies and their illnesses.  Online searches usually result in someone self-diagnosing Ebola or cancer, so that doesn’t help much.

But in part, it’s because the ER, the ED, has become the default.  Surgical patients are told to have wound rechecks in the emergency department.  Kids with fevers are directed there by pediatricians or family doctors or secretaries.  People who need to be admitted are sent in ‘just to get checked before they go upstairs.’  Or sometimes, so the physician on duty can do the negotiation with the hospitalist, rather than having the primary care physician do so.

Why is the ED the default? In 1986 Reagan championed and Congress passed EMTALA, the Emergency Medical Treatment and Active Labor Act, which says you can’t turn anyone away for reasons of non-payment.  Another well intentioned bit of government meddling, it never provided any funds for it’s expansive act of compassion so many emergency departments and trauma centers simply shut their doors.  You can’t see patients for free all day and still meet your budget.  I think something needed to be done, but it probably went too far.

Fast forward.  Insurance is expensive even when the government mandates it. Whether for fear of litigation or due to over-booked schedules everyone else can always send patients to the ED day or night for any reason.  We still function under EMTALA and that will never, ever change.  Patients have little to no expectation of payment when covered by Medicaid and know it (and thus use the ED for everything, and I mean everything.  We are seeing expanding life-spans for the elderly, but with more complex illnesses being treated and ‘survived.’   We have fewer and fewer primary care providers.

Who actually thought emergency department visits would decrease, and why?  Did they ask anyone who saw patients on a daily basis? Or only lobbyists, administrators and progressive academics with starry-eyed fantasies?

I want to take care of everyone. But the Titanic that is emergency medicine in America is sinking.  We really, honestly can’t bear the burden for all of the chaos of our national healthcare.  And don’t tell me that if we have a single payer system it will change everything, because it won’t.  EMTALA will go on and doctors paid by the feds will not be more productive than they are now, so everything will still flow to the emergency departments and trauma centers of the land.

This isn’t about rejecting the poor, or even criticizing Obamacare.  It isn’t about single payer or Medicare for all. It’s about entrenched behaviors and facing the reality of the system we’ve created which allows one part of the system to attempt to carry the limitations of the rest.

Herb Stein, father of Ben Stein, famously said:  ‘If a thing can’t go on forever, it won’t go on forever.’

And if its’ true anywhere, it’s true in the emergency departments of this great land of ours.

Where the answer to every crisis is: ‘hang up and dial 911.’

The doctor will show compassion after he’s finished charting

I was working in a hospital recently and saw a note from a CEO on the computer. Notes and memos are ubiquitous these days. Bathroom walls, break-rooms, computer screens. Everywhere there is another reminder to check this, do that, mark those, record metrics, hurry up, don’t make mistakes, sign orders, complete charts, be nice and all the rest.

But this note stood out. In it, the administrator was reminding the medical staff that their job was tolerance, compassion and understanding. I’m not surprised by this. I’m aware that some administrators make ’rounds’ in patient areas and assess how things are going. (Concerns about HIPAA seem irrelevant, as I mentioned in a recent post.)

It seems, in a kind of ironic inversion, that the business side of medicine has tasked itself with telling the medical side how to be nicer doctors, better doctors, caring doctors. I’m not surprised; but I suspect it isn’t due to any collective epiphany about medical professionalism. Ultimately it’s really less about patient satisfaction, that Golden Egg that drives almost everything in medicine now.

But the irony runs deeper. While the CEO can hold forth on lofty, but important themes like understanding and tolerance, while various administrators can stroll through the ICU or various units shaking hands and making nice, physicians are doing something else. Lots of something else.

In the emergency departments where I work, physicians scurry out to see patients then run back to chart. And chart. And chart. And in many instances to sift through the endless possibilities of ICD-10 codes (I recently saw ‘2nd degree burn due to water skis catching on fire.’). Sometimes we are expected to code in more detail. Discharging a patient is, itself, often a complex process filled with orders, searches, clicks, signatures and locating the right printer.

I recently worked at a site with a shiny new nationally known EMR. ‘Please call the hospitalist,’ says I to the secretary. ‘Alright. Will you enter the consult order in the computer so I can document it?’ I’ve been handed faxes to fill out myself and of course, nothing gets done until it’s ‘put in’ the computer. Another rant for another day, as I digress.

The physicians rarely look up from their keyboards to chat, except when running off to see the patients who inconveniently stand between them and their real job of data entry, billing and coding. All done real time. If you don’t do it, by the way, you’ll get e-mails or texts the next day about your unsigned orders. ‘The coding department needs these right away.’

There was a time of collegiality. There was a time when we discussed cases and our feelings and our sorrow and our passion. That was when medicine was about people. Remember them? The upright primates on whom we practice medicine? Now? Now it’s about numbers and billing, metrics and tracking, satisfaction scores and rewards…and punishment.

Little wonder the CEO can round, or hold forth on the intangibles that lured many of us to love medicine in the first place. Physicians aren’t physicians anymore, not since we handed the reigns over to administrators so that we could ‘focus on the practice of medicine.’ And not since billing became so complex in order to justify every pen stroke, every bandaid, every pillow fluff. And not since the growth of administration, which has itself dramatically increased costs just as it has in universities across the country.

I want us to be tolerant and caring, compassionate and kind. But it’s hard to do when your entire job is less about humans and more about business. It’s hard to do when the volume of patients explodes thanks to unforeseen consequences of the ACA, the endless beatdown of EMTALA and the unending medicalization of everyday life. It’s nearly impossible when you’re tracked like a Caribou for every action and every key-stroke. It’s hard to do when there are no rests, no pauses, no coda in the great dance of emergency, or any other, type of care.

I often work in small, slower places. I do it in part because I can sit and talk. I can breath. I can think. Heck, I do it because I can act like a CEO.

Medicine is great. I love my work. But that’s the thing. I love my work. My real work. Meeting the sick and injured, figuring out what’s wrong, sifting through truths and untruths, danger and anxiety, solving problems.

I don’t love the slavery of modern medicine, which will be the same whether it is run by corporations or government. (So don’t kid yourself that nationalized care will solve this problem.) Governments and corporations are virtually interchangeable anyway.

Perhaps worst of all, I don’t like seeing my colleagues, young or old, as the joy escapes from them shift by shift, only to be replaced with exhaustion and bitterness. Or fear of some unknown repercussion from some faceless manager who leaves takes an hour lunch every day and leaves at five.

Maybe CEOs need to be lectured on how to have compassion and understanding towards their physicians and nurses. I think I’ll start rounding in their offices.

And writing my own memos…

HIPAA for thee but not for me…

Time for a rant!  I’ve written a lot lately about caring for our patients, and about caring for our spouses and those things make me very happy. But now and then, things rub me the wrong way.

I was recently working at TMH, or Tiny Memorial Hospital…my vague name for small facilities since I work at several and wish to preserve their anonymity.  While there a patient checked into the ED for a fairly unremarkable complaint, for which she was evaluated and treated in a reasonable time.

But before she left, we received a phone call from ‘the Mother Ship.’  TMH is part of a large system of hospitals.  The phone call was from the ‘foundation.’  Turns out our patient was a donor well known to said foundation.

Mind you, we never called them, texted them, e-mailed or faxed them. No consultants were contacted, no transfers arranged.  We were just doing our simple doctor and nurse thing.  But the Mother Ship was inquiring how she was.  Which means that someone was notified about her visit to the ED.

Now mind you, it may be that she agreed to this in the process of supporting the institution.  Maybe it was a perk.  I didn’t ask.

But what bothers me is that if any one of the nurses on staff had so much as looked up their own lab-work, they would have been terminated for a violation of HIPAA, the privacy statute.

http://www.hhs.gov/hipaa/for-professionals/privacy/

This is a common policy, but let me repeat it.  According to most hospitals’ interpretation of federal privacy statutes, looking up one’s own results on the hospital computer is a firing offense.  Not only so, but spyware is installed so that the staff’s home addresses are cross-linked to those of their neighbors just in case they look up someone else’s information…a friend who asks for information, for instance.

Furthermore, I cannot even hand a patient his or her lab-work to take to his or her physician the next day. Why?  It’s a violation of privacy.  I don’t understand, but I doubt if I’m supposed to understand.  (Almost all things federal dwell in a kind of fog impenetrable by logic and reason.)

But donate enough and someone will know when and where you went to the ER.   And that’s just good customer service, right?  Right.

Privacy, HIPAA, is for little people.

And yet: Quis custodiet ipsos custodes?

‘Who will guard the guards themselves,’ or as it is commonly rendered, ‘who watches the watchers?’

I don’t know, but I guess we all need to watch ourselves lest we end up fired.

The only other alternative, it seems, is to donate a lot of money.

The Leap Physician Satisfaction System

This is my column from the November issue of Emergency Medicine News.  Observations on keeping physicians professionally satisfied, healthy and happy.

http://journals.lww.com/em-news/Fulltext/2015/11000/Life_in_Emergistan__The_Leap_Physician.7.aspx

The Leap Physician Satisfaction System

I have never been the director of any professional group. I have, however, been directed. As such, I have a few tips for those who are directors and administrators. I give you my ‘physician satisfaction system.’ It is arranged in no particular order.

In every physician break-room or lounge, there should be a wall for photos of girlfriends, boyfriends, children, spouses, parents, dogs, cats, horses, boats, new shotguns or whatever makes those doctors happy. Emphasis on children and spouses, boyfriends and girlfriends, moms and dads. See below.

Post this where physicians work. ‘If you have a husband or wife, please avoid having a girlfriend or boyfriend. It is unfair to your spouse and children. And it is very, very expensive, as hobbies go. You’re better off with a boat.’

In every physician break room there should be: 1) a recliner 2) a refrigerator with snacks and drinks 3) a television with cable 4) a computer with Internet and without the silly hospital fire-wall. Pay for it yourself if you must.

Know your doctors. The best way to do this is to talk to them. It’s tough to really talk on a shift. The best way to do this is away from work. A quarterly group dinner is a nice touch. Or simply, ‘hey, let’s go to lunch one day and catch up.’ You have to mean it though.

Remember that a married doctor is a unit. When there are important decisions to be made (into which you and your partners are allowed input) invite your doctors’ husbands and wives to give their opinions. You’ll be grateful for the wisdom a loving spouse brings to the table. And remember, nobody is more motivated to make the group money than a spouse with a mortgage to pay and babies to raise.

If you really want to score points, send a card or note to the group spouses now and then. Thank them for their service, their encouragement, their patience. Ask them how their family is doing. Remember that being married to a physician ain’t exactly a pony ride. Everybody needs a kind word.

Attend weddings, celebrate births, have anniversary parties. Visit the sick in your group. Send condolences. Mourn at funerals. Laugh and cry. If you take the time to know them, it won’t be hard. They’ll be family.

Lead…from…the…front. If your docs tell you nights are really hard, work a string of nights. If they tell you that someone on staff is really hard to consult, talk to that person yourself a few times. (Tell those difficult doctors to back off and play nice.) If everyone hates the EMR, do everything you can to make it work for them. Never ask your ‘troops’ to do something you won’t. Never, ever.

Be fiercely partisan towards your guys and gals.

Help your doctors develop long-term plans, including an exit strategy. Don’t talk about it, do it. We can’t all go into urgent care or academics, but we can plan for a slow, steady withdrawal as the years go by. Encourage wise decision making, especially in the young Jedi.

Develop a sabbatical. Encourage your doctors on sabbatical to travel, take a class, enjoy sleeping in their own beds. It may be the longest time they’ve slept all night with their husbands or wives consistently in years. It may be the first full reset of their circadian rhythm since medical school.

Watch your doctors closely. It’s easy to become overwhelmed, depressed, anxious. Help them through mistakes. Let them decompress. Let them be sad. Don’t chastise, teach. Find a local counselor in case they need to talk about that death, that tragedy, their personal demons. Doctors kill themselves sometimes. Try to keep it from happening.

Identify the strengths in your doctors. Some are born leaders; let them move in that direction. Some are brilliant clinicians, use that. Some are great with people. Let them mentor. Some have hobbies or interests that make them better physicians. Celebrate the unique individual gifts that every partner brings to the table. Now and then, use these to remind the hospital what a unique and valuable team you have.

Take pride in your group. A logo and t-shirt would be a nice point of pride. Brag about your doctors. Tell the local newspaper about them. Help them be invested in the community, treasured by the community.

Praise your partners, both to their faces and to others. Write down the good things they do for future letters of reference.

Give your team permission. Permission to succeed, permission to fail. Permission to try new things and sometimes, permission to leave it all behind.

On really busy nights, call in pizza from home. On terrible nights, come in and use your authority to make things happen more smoothly.

There are a lot of schedules, in a lot of ED’s, with holes in the schedule. If you don’t want your entire group to realize this, and leave, and then come back making more as locums than they did before, then be their advocate.

We have a hard job. But with the right leader, it can be wonderful even when it is hard. It’s up to you, directors, to set the tone. Good luck and Godspeed.

Tell me about your little hospital!

I’m putting together a project on small hospitals.  While I’m particularly interested in critical access facilities in rural areas, other small facilities (urban and rural) are welcome.  I’ve always contended that big teaching centers get all the ‘love.’ There are television shows and books and movies about the enormous referral hospitals in big cities.  But not so much about the little hospital at the end of the road on the mountaintop, or on the windswept coast or in the desert Southwest.

And yet those places have dedicated staff who do great things, save lives, comfort the sick and do most of it on a pretty limited budget and in all kinds of weather.

So if you are interested in being part of this project (I’ll reveal more in time), tell me about your hospital.  Where it is, why it matters, its great successes and struggles.  If you have anyone I can contact there, please let me know that as well.

I want to hear your stories!

You can respond here or e-mail me at edwinleap@gmail.com.

Sincerely,

Edwin Leap, MD

 

 

 

Summer Wants You Dead! My column in today’s Greenville News.

http://www.greenvilleonline.com/story/opinion/contributors/2015/08/08/ed-leap-careful-summer-wants-dead/31298333/

Enough of the tedium of politics and culture! Let’s focus on the real enemy. Which in the South is clearly Summer. I was working in a Southern ER recently, in a location which is beautiful, full of Northerners, and which shall remain unnamed. We’ll call it ‘Vacation Memorial Hospital.’ Lying before me was a charming lady of some 80 years, who had fainted.

‘What happened?’ I asked.

‘Well, my husband and I decided to ride bikes to lunch. It’s such a pretty day and all. And after about three miles I just felt funny and when I sat on a bench I passed out.’

(Relevant fact for the reader: The heat index was 115 that day.)

‘Oh my! It’s very hot outside. Where are you from?’

‘We’re here from Chicago.’

‘Do you ride bikes at home?’

Laughing, says ‘Oh no, only when we’re here!’

So, living in a city which feels nearly Arctic most of the year, my patient comes to South Town and rides a bike three miles in heat that makes the hardiest Southerner cling to the AC unit with something akin to worship. But this was certainly not the only misguided person I saw who did something similar. There were variations of course: ‘I drank a 12 pack and went to the beach for a few hours.’ Or, ‘I paddle-boarded for 8 hours against the tide, starting at noon.’ You get the picture.

Please excuse my bluntness and paranoia, but the fact that non-Southerns don’t realize about our summers is this: nature wants to kill you. Heat and humidity are its favorite weapons, and dehydration and heat stroke it’s favored techniques. (It’s the opposite of life in the far North, where nature wants to terminate you by turning you into a solid block of ice.)

However, as I realized long ago, it’s more than the heat. Summer in the South has many weapons at its disposal. For instance, it has water. More specifically, water and alcohol, the combination of which makes a fine cocktail but a very poor form of recreation. Summer doesn’t mind drowning the unwary.

Summer also employs creatures. I spend a large part of my summer finding, and destroying, the dozens of wasp nests that inhabit our property in the summer, and which make every expedition outside an exercise in looking for ‘booby traps.’ (I’m not vindictive; one of my sons is dangerously allergic.) There’s a nest on every door frame, in every shed, in the ground over which we mow, under the diving board, in the old can in the woods. Ditto for spider webs; a giant black widow was living happily under my wife’s lawn chair last week.

And I’d be remiss if I didn’t mention venomous snakes. Copperheads have been particularly busy over the last couple of summers, causing painful bites and no doubt receiving financial kickbacks from the makers of $2000 per vial antivenin. Apparently, they have also been communicating with the shark population on the Carolina coast to start some form of horrible insurrection worthy of a B movie.

However, perhaps the most insidious technique of summer is the use of the lawn. The lawn compels us to expose ourselves to the intense sun, to stinging insects and to power equipment. Now, I’m pretty careful about blades turned by engines. But if I ever have a heart attack, odds are it will happen while I’m trying to start the 2-cycle engine of a weed-eater, already partly destroyed by ethanol-containing gasoline. Furthermore, it’s not only a danger to my earthly body. The anger and profanity that boil up while working with the weed-eater, or reprobate mower, are surely enough to make a Baptist into a backslider.

I know, this sounds crazy, but I’m ready for Autumn. And especially for that first freeze when stinging and biting things take a break, when the lawn grows more slowly and when a bike ride needn’t be accompanied by a 9-11 call.

I have a theory about why Southerners make up such a large proportion of our Armed Forces. It’s because of summer. As Southern children we learn that nature, for all it’s wonders, has it in for us. And we spend our time fighting and enduring temperatures, creatures, Kudzu, Poison Ivy and every other nefarious thing thrown our way. We learn caution, appropriate distrust and how to fight dirty. These are lessons that our visitors would do well to understand. Because like it or not, Summer wants you dead.

Now go and enjoy your bike ride!

 

Sinners’ stories leave the deepest impressions. (And we’re all sinners, by the way.)

My column in Sunday’s Greenville News.

http://www.greenvilleonline.com/story/opinion/contributors/2015/03/27/ed-leap-sinners-stories-leave-deepest-impressions/70569286/

I have met some characters in my career, and their stories are forever archived in the library of my mind. Some of them were physicians, of course. I recall one who, when paged, always called back collect. I could only laugh and shake my head. There was another who made me so angry that if dueling had still been an option, I might have asked, ‘sabers or pistols, sir?’

I recall one of my residents in medical school who disappeared on call nights and in ‘morning report’ (the daily debrief of the night’s joys and terrors) explained how shocked he was that his pager just hadn’t worked all night! Not a good way to earn the love of your co-workers.

Crazy doctor stories are always fun, but in the end they pale in comparison to the stories we hear from our patients. Privacy laws being what they are, I am constrained. Nevertheless, I recall crime confessions made while a knife protruded from one patient’s back. (The prospect of one’s possibly having a luncheon meeting with the Almighty apparently provides a certain moral clarity.) I remember the addict who had perfect, flawless hair and told me the same story, like a church liturgy, every single time I saw him. In short, someone always stole his pain pills.

I’ll never forget the alcoholic (a previously convicted violent criminal), who in his antiquity threatened to kill us every few ER visits. And then, in the harsh, bright, relative sobriety of morning would laugh and shake hands, and amble his way out the door to go home and begin the cycle all over again. My heart breaks at the thought of the young man with mental illness whom we legally couldn’t hold, but whose mother wanted to admit for his own good. I hope she saw him again after he sat down in the taxi, stone-faced, and drove away into the night as she cried.

Thinking over these tales of woe, I realized how few of the things I remember best were good news, or easy situations, or ‘nice’ people (in the traditional sense). I don’t have a great list of happy stories told by polite, productive citizens who were injured while feeding orphans. I remember the difficult ones. I remember the problem children, as it were.

I’m sure any competent evolutionary biologist can devise a reasonable explanation for this. For example, perhaps they were all object lessons. I remember them so that I won’t repeat their mistakes. I once saw a shirt that said, ‘it may be that the entire purpose for your life is merely to serve as a warning to others.’

On the other hand, I remember them in part for the same reason that I read the names in old, overgrown graveyards; so they’ll not be forgotten. Not yet. The same reason I read names on monuments, or the dedications in books. As homage.

But on a different level, I think I remember them because it’s the difficult people, the hard people, the wounded and sad people who need our attention the most. They are the lost children. They the squeaky wheels. Maybe I remember them so that I will know who to look for in the future, and be attentive to their special needs, their deeper wounds, shattered dreams and aching hearts. So I’ll know to look beyond intoxication and anger to the slightly smudged and tarnished image of God before me.

They help me, you know. Here in the Bible belt, it’s always a dangerous temptation to associate worth with being clean and proper and good. One only needs to go back to the scriptures to see that for the lie it is. Some of the best of the cast of Biblical characters were, in some very real ways, some of the worst.

This Palm Sunday we remember Jesus, himself a lover and teller of stories, a man ever drawn to the lives and stories of the broken and suffering, riding into Jerusalem near the end of his time on earth. He was ready to complete his mission to ‘seek and to save that which is lost.’ One of the many accusations against him was that he was a ‘friend of sinners.’ A sinner myself, I’m happy to hear it.

But honestly, it’s no wonder! They recognize their deep need. And they almost always have better stories than ‘nice’ people.

 

Enough sarcasm! Healthy kids need more than vaccines.

Thanks to the current Measles outbreak, the news is full of stories on vaccines and anti-vaxxers. The ‘blogosphere’ and ‘Twitterverse’ and all the other social media dimensions are buzzing with invective against ignorant unvaccinated savages and their backward science denial. For the record, I’m a pro-vaccine physician. My children have been and are vaccinated, despite being unsocialized homeschoolers.

I’ve had my own share of needles; physicians are mandated to have Hepatits B, Influenza and all the other standards. As a former Air Force Officer, I also enjoyed the singular delights of Typhoid and Yellow Fever immunization (although I managed to miss out on Smallpox).

Granted, I have been unimpressed by this year’s Influenza vaccine. Science and scientists are imperfect; sometimes vaccines are as well. If you don’t believe this, chat with someone who was paralyzed by Guillain-Barre’ syndrome after a vaccination.

While watching the many recent news stories and Internet posts on vaccines, the thing that has most intrigued me is the sense of superiority by those who are pro-vaccine. It’s the old ‘anything for the children argument,’ coupled with ‘everyone who disagrees with me is a knuckle dragging idiot.’ I think it merits discussion because there are quite a number of things that are good for children, but which are not so generally accepted by modern Americans.

For instance, it’s well known that modern kids don’t exercise enough. We are growing generations of overweight children because they simply don’t go out and play. Despite our knowledge of this, their parents lavish them with televisions, video games, tablets and smart phones and plant them squarely in front of convenient electronic nannies at the earliest possible convenience. From what I’ve seen in some of my pediatric patients, it’s much easier for mom or dad to text their friends or play poker if the toddler is busily watching Frozen on the i-Pad. What could go wrong?

Next, how about antibiotics? By which I mean this: well educated, pro-vaccine parents still go to the pediatrician expecting (and too often receiving) antibiotics for the viral head-colds their kids are spewing. ‘Whenever he gets this, his doctor gives him some Amoxicillin and he gets better every time, so I’d really like a prescription.’

Of course, he was going to get better anyway. What are they, anti-science? It’s well known that antibiotics are overused, for everything from head colds to cough, ear infections to sore throats. Sadly, my colleagues often cave to the pressure and steadily, more strains of bacteria are resistant to the drugs we count on to kill them.

Guess what else research tells us? Hold on, because this is going to be difficult. Kids are more upwardly mobile when they live with a married mom and dad. And even poor kids (in single parent homes) do better when they live in neighborhoods where there are lots of stable two parent families. I mean, you can deny it, but you know, science. Not only so, when dads are at home (you know dads, those old, out-of-date accoutrements from ages past), the kids are less likely to get into trouble with the law, with drugs or with promiscuous behavior; a few among a host of positive side-effects caused by involved, physically present fathers.

And of course, there’s the fact that promiscuity and depression in teens may be related. (Whether causally or not is debatable, but there is an association.) In addition, according to HHS, ‘four in 10 teen sexually active girls have had an STD which can cause fertility or even death.’ http://www.hhs.gov/ash/oah/adolescent-health-topics/reproductive-health/stds.html That is to say, our Hollywood inspired, cool parent take on teen sexuality, ‘everyone is doing it and that’s OK’ may be a little, well, unhealthy. Sorry, it’s science.

Finally, the cost of college is soaring and increasing numbers of kids are unable to pay back student loans. This is largely because, despite their amazing, expensive degrees in sociology, gender studies, multicultural studies, film and assorted other less than marketable fields, they simply can’t find good jobs. If we love our kids, and those kids aren’t on their way to really good, lucrative degrees, we should nudge them towards the trades that allowed their ancestors to prosper. In the current economy, they’d be better off as carpenters, builders, plumbers, welders, mechanics and all the rest. Think of those programs as ‘economic vaccinations’ in an era of epidemic financial struggle.

Look, vaccinate away. I’m for it. But if we really care that much about the kids, there are a lot of things we can and should do to secure their long-lasting health and prosperity.

Let’s have a lot more dialog and a lot less superiority in these discussions. And let’s remember that vaccinations are only part of a bigger picture that includes physical health, education, economics and the very fabric of our family structures.

Hospitals should pay for charting time

Pay clinicians for their EMR time!

nurses-charting

 

I have a unique perspective as a physician.  Having traveled to many hospitals in the past two years, working as a locums emergency physician, I can comment on a variety of issues with a reasonable amount of experience.  One of those issues is EMR, or Electronic Medical Records.  I have spent plenty of time writing about this in the past, and I will continue to do so.  Because all across the country the same problems, the same frustrations are evident.  And the institutional lack of concern is well-entrenched and well understood by everyone affected.

Whether working in an academic teaching/trauma center or a small community department, one theme emerges.  EMR is so inefficient, and patient volumes and acuity so high, that charting isn’t done real-time.  Unless it is accomplished with scribes, or by dictation, doctors stay after their shifts, or chart from home, or come in on their days off in order to complete their documentation.  Needless to say, this is unlikely to create the best possible chart. Not only is this true, I have watched as nurses sat for one to two hours after their busy ED shifts, catching up on the ever increasing documentation requirements in their EMR systems.

Weary from a long day or long night, they sift through notes and charts, orders and code-blue records, trying to reassemble some vague estimation of what happened in the chaos of their 8 or 12 hours on shift, when they were expected to function simultaneously as life-savers and data-entry clerks.  Further, the nurses are frequently tasked with entering specific charges for billing as well.  It all constitutes an unholy combination for any clinician.

Dear friends, colleagues, Romans, countrymen; dear politicians and administrators, programmers and thought leaders, this is unacceptable. Entirely unacceptable. If the charting system is so poorly designed, and so counter-intuitive to the work we do that it can’t be used real-time, then it should be replaced with something far better.  And if it isn’t replaced, then everyone needs a scribe to chart for him or her, or we should allow dictation all around.  And if none of that is acceptable, if even those reasonable options are rejected, then every nurse and every physician who stays after shift should be paid their regular hourly rate for time spent charting. The thing is, these systems are generally not the idea of the clinicians who are saddled with them.  They are imposed by corporations and administrators who believe the salesmen and hope to capture more billing and data. They are imposed by the ‘Meaningful Use’ regulations of the Federal Government.  But as a rule, when we clinicians say a system is bad, or won’t work for us, we are patted on the head and dismissed.  ‘It’s fine, it’s an industry standard.  You can learn to use it.  You don’t want to be a problem doctor do you?’

One of my friends is in a group shopping for new systems.  When his partner asked to take the potential EMR for a ‘test drive,’ the salesman said, ‘sure, as soon as you sign the contract.’  Pathetic. I call on everyone involved in implementation of EMR to find the simplest, most physician and nurse friendly systems possible.  And to do it by asking and involving the end user.  By which I mean those who provide patient care, not those who cull through it for billing and documentation. Some people chart more slowly than others.  That can be an individual issue. But when a system consistently causes good, efficient doctors, nurses, NP’s and PA’s to stay long past their shifts, or come in on days off, or chart from their homes (which should be places of recuperation and rest), then we need to give them something back.   Equally toxic, some physicians and nurses can only get out in time by charting in a manner that results in a pages long list of check-boxes, rather than a descriptive, informative story.

America’s emergency departments are overwhelmed with passwords, required fields, clicks and key strokes, at the same time as they are overwhelmed with the sick and dying. They are the last safety net for the uninsured and underinsured. They are the point of rescue for the poor, the brutalized, the traumatized, the addicted, the psychotic.  Day in and day out, nurses and physicians in emergency departments, indeed all over the modern hospital, do their best against sometimes overwhelming odds.  In the midst of this, poor charting systems constitute a crushing blow.

Pay the staff for their time spent charting, or fix the systems.  Or both. But something has to give.

Edwin

 

Rape exams, drug screens and alcohol levels

When I was in residency, sexual assault exams were part of our training.  We spent a lot of time learning how to ask the right questions, how to be gentle and empathetic, how to gather evidence appropriately and thoroughly.

While many hospitals now have SANE programs (Sexual Assault Nurse Examiner), I have never enjoyed the privilege of working with one of them.  I have, for two decades, performed sexual assault exams on my own.

In 21 years of practice, I have been in court (as far as I can recall) no more than three times to testify in a sexual assault case.  That suggests to me that one of two things may have happened in the cases which involved me.  First, the case was never prosecuted for any number of reasons (the alleged victim recanted, law enforcement felt the case was too weak, the story was good but the evidence was inadequate, procedural problems, etc.).  Second, the case was prosecuted and the evidence was so damning that my testimony (separate from the evidence gathered) was irrelevant.  Third, the case indeed went to court but the story and evidence were so poor that no prosecution resulted and it was deemed unnecessary to involve me.  I am not of a particularly legal mind, so excuse me if I have missed other reasons.

I was recently thinking back to a patient I saw some years ago, who alleged that she had been sexually assaulted.  And then I thought back to residency.  And I remembered something that always troubled me.  In residency, I recall being told not to comment, in my chart, on whether or not the alleged victim had been using alcohol or drugs.  I seem to recall (and I may be wrong on this point) being discouraged from obtaining blood alcohol levels or urine drug screens.  (In like manner I was told to note in the chart whether I saw live sperm in samples, but not to remark on their absence.)

Back to the case at hand:  the patient I saw had been drinking copious amounts of alcohol and was clearly very intoxicated.  While I saw her, and law enforcement officers spoke to her, her story changed wildly from assault by multiple men to assault by no men.

Now, I ask you wide and gentle reader, was her alcohol use relevant to the situation?  When asked ‘who assaulted you and describe what happened’ would her recollections be trustworthy?  Would they be sufficiently lucid to possibly put a man, or several men, or a woman for that matter, in prison for years for what could have been consensual sex? And before you accuse me of sexism, remember that in an era of equality, both men and women are capable of sexual adventure as well as being capable of deceit and vindictiveness.

I believe that an alcohol level and drug screen was relevant.  Not in order to punish someone for substance use, not to ‘slut shame,’ but because like sexual assault, arrest and prison are serious, life altering things.  And because one’s ability to recollect what happens clearly can be influenced by drugs.

If I were intoxicated and said that I had seen young man commit a crime, and if my story varied wildly with each telling, it would be evident to all that my impairment was an issue in terms of the validity of my testimony.  I don’t see how it can be any less in sexual assault.

Sexual assault is a problem.  False accusations of sexual assault are also a very real problem. But covering up reality to attain a particular end, however gilded our intentions, is never the right thing to do.