Make college relevant, not a resort vacation (my column in the Greenville News)

A big thanks to Glenn Reynolds of Instapundit for the link!

This is my column in today’s Greenville News.  A topic I’m passionate about, in no small part thanks to hearing Glenn Reynolds, of, speak on it at Clemson University.  Visit his website:

Here’s a link to Glenn’s book:

Here’s the link to my column, with text to follow.|newswell|text|Opinion|s

My oldest son is now a high school senior.  Therefore, we have been looking at college options in South Carolina.  He is a born and bred South Carolinian who doesn’t really want to leave his home state.  He has a sense of family, and a sense of place.

I have made several observations while reading brochures, comparing prices and traveling to different locales in the search for the right school for him to attend . First, this is a beautiful state with some magnificent centers of learning.  I had no idea how many majors there are now, how many opportunities to study abroad, how many honors colleges and possible career paths!  When I was in school it was, you know, wheel making and Mammoth studies.  But I digress.

Whenever we have toured a center of learning (and I won’t name them specifically) my wife and I have heard great things about the way our son will mature, will be exposed to opportunities, will ‘develop as a human being.’  (Which I thought was kind of a given, being a human and all.)

We’ve been assured that kids who attend those schools make great progress, and become fully actualized, able to impact the world in a diverse, cutting edge, technologically savvy, multi-cultural, sustainable, tolerant and environmentally friendly manner that would be the envy of anyone in the world.

I had no idea that college was all of that!  You see, silly old person that I am, I thought that our colleges and universities were supposed to help students learn to think clearly, accumulate knowledge and enter useful graduate programs or find meaningful, gainful employment in the world.  I didn’t know it was all about ‘development.’

But since it is, let me tell you what I’ve developed.  I’ve developed a little bit of cynicism about the four-year university.  Why is that, with such magnificent institutions?   Well, a couple of things come to mind.  First, marketing.  My son is constantly introduced to images of lovely dorms and cable television embedded in every treadmill in the shiny gym. He is told about how the sushi bar is a great place to use some of his meal program money and how certain dorms allow opposite sex sleepovers during the week. He learns about the fun of the Greek system and the delights of the town.

And what his bitter, cynical, sometimes wise father knows is this:  college graduates currently have a 50-53% unemployment rate, and nationwide, the college drop-out rate is around 40%.  That student loan defaults are rising and retirees are having their Social Security checks docked for old student loans.  (Which cannot be erased in bankruptcy, by the way). What I know is that across the country, administrative burden is killing education (much as it is in medicine), that all too many fascinating majors lead to low-paying work in the food service industry and that the whole experience generally comes to around $20,000/year for a state run four-year university in SC.

What I have to ask our state educators is this:  have you read about the plight of students?  Are you concerned that many students can’t find work related to their degree, if they find work at all?  Are you at all troubled that without serious scholarships they may enter life with tremendous debt, or that their families will bear the debt?  (And that the ones going to graduate school or professional school will be hundreds of thousands of dollars in debt?)

I challenge the higher education officials of South Carolina to do what Texas did and develop a 4 year degree for $10,000.  I want them to encourage more college-bound students to use technical and community colleges for part (or all) of their educations. And I dare the educators of this state to be honest about the realistic job prospects associated with some of their fascinating, but fiscally shaky, programs of study.

I love South Carolina.  My son does too.  He wants to go to school here.  And so do many of his friends with less material blessings than my family.  But our state, indeed our nation, had better pay attention to the plight of its students. We need to stop marketing college as a four year resort vacation and start having compassion for the kids we send off in the tired old belief that college guarantees a good future.

Because it doesn’t anymore. And educators have to either admit the truth, or make college relevant, and affordable, once again.

Australian gun control

Here’s an interesting link about violent crime in Australia and the UK.

The problem with so much in politics is that there is no negative feedback loop.  When politicians institute ideas that are dysfunctional, they don’t retract.  They increase. The logic is, if it works, you need more of it.  (Stimulus, tax, welfare, gun control…insert program or policy).

But if it doesn’t work?  You need more of it as well.  (Stimulus, tax, welfare, gun control…).  Because the government instituted it, it must have been a good idea.  And to withdraw and reassess would suggest weakness or error. And weakness or error don’t get a party, or a politician, re-elected; or a judge re-appointed.

I hope that one day, we can break the cycle.

This link suggests that the governments of Australia and the UK could apply the same lesson.  Let’s hope we can avoid their mistakes.


Homo Sapiens Entitlus: a species emerges

I am here for check...and Sprite!

I am here for check...and Sprite!

Homo Sapiens Entitlus:  a species emerges

There is a staggering degree of entitlement mentality that wanders through America’s emergency departments.  In the 19 years since I finished residency, it has grown in ways I could never have foreseen.  It seems that everyone is entitled to pain medicine (which is causing ever increasing deaths in America) and everyone is entitled to disability at younger and younger ages (‘I got the degenerative disc disease, doc,’ they say at 25 years of age).  Our patients are entitled to work-excuses, and to CT scans, to patient care representatives and in short, entitled to whatever it is they desire.

A recent patient was very angry that we would not give her supplies of both antibiotic ointment and bandages to use for her minor injury over the coming week.  She was adamant that she had no money.  No money, that is, after paying for her cigarettes and smart-phone package.  She was most upset, it seemed, that the nurse failed to bring her a Sprite in a timely manner.

Mind-numbing; truly mind-numbing.

I think over the physicians and nurses, medics and techs, and all the rest who come to work everyday, in places where they are understaffed and often underpaid, and where they will see individuals who will abuse them, and will then say, ‘I don’t know why you’re upset…I pay my bills,’ only to find that those patients have Medicaid.  In fact, the care-givers bringing Sprite and dispensing bandages, working overtime to afford their own children and benefits,  are paying those bills.

But I didn’t write this to moan and complain.  I wrote it to put forth an idea.  My idea is this:  perhaps the ones abusing our systems are the fittest of all!

Consider that evolutionary theory is about survival.  Keep in mind that biologists tend to equate fitness with survival.  It seems, then, that the welfare-queens, the addicts, the chronic criminals, the serial fathers, the Meth-heads who use the system and abuse our good graces may be…the most fit!  They have no compunction about copulation, and thus out-breed the responsible public.  They are sometimes violent and aggressive in positively neolithic ways, and let’s face it, to the modern mind nothing was more true to our natures than that age-old struggle to survive as we envision it in the life of the cave-man!

As the money dries up, and the demands for more sound more loudly, it may be that evolution is happening!   As the workers, the responsible parents, the ones staying up at night helping their kids learn, or caring for sick relatives are asked to do more for less, their opposites find ever more creative ways to receive benefits, avoid work, obtain disability, bring litigation and simply have more time, more things, more children and less responsibility!  And as politicians pander to the loudest and worst among us, the quiet, the best, the producers, the  ones too busy doing right to lobby are simply put upon more and more.  As the morality of the worst becomes ascendent and the ethics of the best are held up to mocking ridicule, it may be that we are simply the victims of natural forces.

Yes, friends, the ones taking and using and abusing may be the fittest of all, in a game where obtaining advantage and survival is all.  And since many believe we have evolved altruism for the collective good, even this tendency (if true) may be aiding the success of those who should not, to all rights, succeed at all as those formerly considered fit are plundered by those now more so.

I’m no Darwinist, though I agree that species change in response to pressures.  And I don’t necessarily agree that survival = fitness (of course, I’m a Christian, so I have a different perspective on that sort of thing).  But from everything I see at work, I have to wonder if I’m not on a fading branch of the evolutionary tree.  And if one day, scientists might not look back upon the time when Homo Sapiens Productive gave way to the rise of Homo Sapiens Entitlus, because the latter had the foresight, and absence of morals, to take what it wanted and continually demand more.  You have to respect their boldness, even if you find their actions horrendous.

In other words, I fear my extinction isn’t so far away.

I think I need a Sprite…of course, I’ll have to get it myself!

(Wait a minute, can I get protection under the Endangered Species Act?   Look at me!  I’m evolving!)

Self-evident truth in medicine

Some things in medicine are obvious.  Despite the endless worship of ‘evidence-based’ medicine, and the constant barrage of studies on every conceivable topic, we do certain things because we know they just seem right.  I take as evidence the fact that we daily try to save lives, devoting research time, untold gazillions of  dollars and heroic clinical effort to our continued goal of staving off death.  Why is this?  Do we know that death is inherently worse than life?  Well, since we can’t see beyond the grave, and can’t exactly engage in double-blind, placebo controlled studies about the after-life, the answer is ‘no.’  But we assume that life is preferable to death, based on our feelings, our sense of the thing.

The same is true in our personal lives.  No one can show me a scientific study that details why he or she married a particular person.  No one can offer up a mole of affection for empiric analysis.  And yet, we don’t doubt the existence of romance, or the reality of love.

And yet, medicine is filled with situations in which ‘self-evident truth’ is systematically ignored, and those who believe in it intentionally and often viciously marginalized.

For example, after years of being told that physicians weren’t giving enough treatment for pain, and after years of clinicians saying, ‘yes we are, and too many people are addicted and abusing the system,’ the data from CDC says that far too many are dying from prescription narcotics, far too many infants being born addicted, and far too many people, young and old, are using analgesics and other drugs not prescribed for them.  To which many of us say, ‘duh!’

And then there’s the customer service model, the thing which causes clinicians to lose their jobs as satisfaction scores fall due to disgruntled patients (often upset over not receiving the drug they desired…see above paragraph).  This is a darling of administrators.  And it clearly has flaws.  As a recent article in Archives of Internal Medicine points out, physicians with very good ‘customer satisfaction’ scores tend to have patients with poorer outcomes.  Do you think?

Of course, Electronic Medical Records is another.  Those of us engaged in the practice of medicine on real people can tell you, EMR has promise, but in practice it consistently does three things.  Reduces productivity, takes us away from patients and results in far too much data being recorded and stored.  It needs to mature, rather than being forced on everyone from above.

There are others, of course. Board certification is beginning to look very much like a profit-generating machine, despite the paucity of evidence that it matters.  (I am board certified, so this isn’t sour grapes.)  Federal privacy laws (known as HIPPA) has left us awash in unnecessary passwords and regulations.  EMTALA, the law which protects the uninsured has probably resulted in more costs, and more loss of qualified physicians and necessary facilities than any other piece of legislation in history.  We know it…but few people are interested in studying it honestly.

All I”m saying is that physicians, and ultimately everyone, will have to mix science with good sense, and learn to embrace their own insights and powers of observation.

Studies have their place.  But their goal is the discovery of truth.  And sometimes, more often than we realize, the truth is right in front of us.

As we say in the South, ‘If it had been a rattlesnake, it would have bit you!’


Making the future brighter for aspiring physicians: text of my lecture

This is the text of my recent lecture at the Strom Thurmond Institute, Clemson University.

Making the future brighter for aspiring physicians

March 29, 2012

Calhoun Lecture Series

Strom Thurmond Institute,

Clemson University

Thank you for the invitation to speak tonight. I’m very humbled to stand before you. And what a delight to speak to people who are neither bleeding, intoxicated nor asking for Percocet!   And in a setting where no one will burst through the back door on a stretcher!

As you know, I’m an emergency physician at Oconee Medical Center. But before I go on, let me tell you about my path to medicine.

I was a poor science student in high school. In fact, I was convinced that I would never have a career in anything related to science. When we failed to make nitroglycerin blow up in high school chemistry, I lost interest.

I went to Marshall University and majored in journalism. That is, for about two semesters. After that, through some twist of maternal coercion, coupled with some divine providence, I decided I would try to go into medicine. I struggled and succeeded in college science and did well in my prerequisites. I went to medical school at West Virginia University, then on to residency at Methodist Hospital of Indiana, in Indianapolis. And here I am, 19 years later, having practiced successfully for what seems like a very long time;but really isn’t that long at all.

I was fortunate, because at no point in my premedical or medical education did anyone ever take me aside and discourage me from the pursuit of my chosen career. Sadly, too many students, who are aspiring physicians, are subjected to just this phenomenon.

‘Don’t go into medicine, it’s terrible.’ Well, no, it isn’t.

‘Don’t go into medicine, go into law. That’s where the money is.’ (Evidence suggests this is not true at all, by the way).

‘You’ll hate your life!’ Only if you make very bad decisions…

When I meet aspiring physicians, I don’t discourage them. I tell them it’s a great career, full of depth, challenges and meaning. I tell them my career is fulfilling and often a source of joy.

What I don’t do is sugar-coat the truth. What I don’t do is lie to them. Because that would be grossly unfair.

I know this, because my career as a physician has made some things eminently clear to me. Medicine as a profession has problems, and we need to address them if we hope to continue having physicians.

However, I’m not talking about the ones we usually hear of in the media.

I’m not here to tell you that American medicine is bad medicine. In fact, it’s very good. A residency director told me, just a few weeks ago, that he had offered to translate an ultrasound text into Chinese, for use by physicians at a hospital in western China.

The administrators there implored him: ‘Only translate the content. Leave the cover in English, because our doctors won’t use it if it’s Chinese. They’ll only use it if they believe it’s American.’

There’s a twist on popular thinking on medicine, isn’t it?

I submit that movie stars and political figures from around the world come here because medicine, for all its failures, is very good in the United States.

I’m also not here to discuss, in any great detail, my views of Obamacare. That would take up the lecture time, then several hours afterward. I will discuss a little of the economics of medicine as it pertains directly to aspiring, young physicians.

The problems of medicine are not insurmountable. But we must work on them. If only so that we can maintain an ongoing procession of fresh, new faces and innovative new thinkers to fill our medical shoes as my generation of physicians, and several others, fades off the scene of active practice.

In other words, kids still need to choose medicine as a career, and we have to help them make it work!

America is facing an estimated shortfall of physicians to the tune of over 20,000 doctors by 2020. I think we need to put our heads together and make the future brighter, more attractive and more available for aspiring physicians.

And knowing that medicine has become not only a difficult profession to enter, but a difficult profession to practice, I think we can do better, as practitioners, as policy makers and as educators.

First of all, I wonder if we do a good job choosing who goes into medicine. Not that the physicians we have are bad, but I ask myself, ‘can we do better?’ Can we select more carefully for the traits we need; What traits come to mind?

Among others:

the ability to learn and use large amounts of information. The compassion necessary to feel genuine empathy for others. A love of human beings and a desire to work closely with them in difficult settings. Discipline. Flexibility. Physical and emotional stamina. And the willingness to endure the length and difficulty of the process.

So far, it has worked. No doubt about it. I meet pre-medical students from Clemson University. They are intelligent and articulate; but I suppose I wonder if we asked them to do far too many things that will not really impact their practice of medicine. Will their Calculus class improve their surgical skills? Will their memorization of biochemical cycles make them more effective radiologists? As we face fewer and fewer physicians (both from inadequate numbers of new doctors and increasing exodus of existing practitioners), we may need to trim the process.

Here’s one example of how we could educate our students more effectively:

A little known phenomenon in medicine today is the medical scribe. The scribe works for a physician and does charting. This is because so many physicians find electronic medical records to be a hindrance, rather than a panacea. (In fact, EMR reduces productivity by 30% across the board…I’ll bet nobody has mentioned that much, have they?)

I think pre-medical education should include appropriate scientific preparation, but that it would be dramatically enhanced by opportunities for apprenticeship, as in the scribe model. The practice of medicine is about repetition and pattern recognition, communication and ‘people skills’ as surely as it is about memorization and algorithms. Apprenticeships would prepare our physicians earlier, and more effectively, for lifelong careers of actually caring for the sick. In the process, students might find out that they don’t really care for the the practice of medicine, and might learn it well before four years of college and two years of basic sciences in medical school.

The reality is that Medical schools are already looking for applicants who have worked in these capacities; clearly, they’re entering their educational process ahead of the curve. And while research is lovely, and stands out nicely on an application, the overwhelming majority of practitioners are not involved in any kind of research once they begn practice.

We can also improve their educational plight by preparing them for the rigors of business, the hard realities of economics. Education, pre-medical and medical, that speaks to aspiring doctors about the glories of caring for the sick, that tells them only about their economic security, is entirely unfair (and unrealistic) if we do not teach them that medicine is also a business; or at the very least a kind of financial transaction, no matter who writes the checks.

They should have exposure to management and business classes in their premedical days, so that they can have those concepts in mind as they consider their economic futures. The cost of their educations, balanced against their own assets and motivations, will have to be factors in their educational process. And universal healthcare, if passed, won’t change this reality. It will only change the customer from the patient to the government.

How about the cost of medical education? Does it matter? Absolutely. With young physicians exiting medical school with debut burdens in the range of $160-180,000, and with reimbursements for their care dwindling below the cost of running a practice, we are fast approaching a breaking point. Physicians with that kind of debt cannot buy houses, cannot easily have children or even automobiles. And opening innovative practices, in which they are business owners, is nearly out of the question. Into that mix, the likelihood that they will have either inclination or capacity to see the poor at a reduced rate (or for free), is next to zero.

It also makes the lower paying primary care positions nearly impossible, unless those positions are supplemented through loan repayment or scholarships.

This financial problem also explains the general trend in medicine away from call. For those unaware,s specialists (especially surgical specialists) are abandoning call responsibilities in droves, not only to avoid sleeplessness, but to avoid time spent on patients for which they will receive neither compensation nor protection from litigation.

What can we do? Among other things, we could structure loans to allow physicians to get credit towards those loans at a Medicare rate for each non-paying patient they see. Over a few years, they could work off that student loan debt. The same applies to other physicians in practice, but perhaps without student loans. We could allow them to receive tax deductions based on the same formula for caring for the indigent. A simple solution. It would provide care. It would build good feelings and rapport. And many of those cared for would one day have jobs, and insurance, and become paying patients of those physicians who saw them in their time of medical, and financial need.

This has been suggested by many legislators, but never enacted. It appears to reward the rich. Pity. Doctors, and especially primary care providers, are fast losing their financial power, even as they are considered wealthy. For future physicians to thrive, this perception has to be addressed.

Physicians have all heard this argument. ‘Don’t worry about insurance payments, or government, or memberships or licensing or anything else. You’re a rich doctor. Don’t worry about your loans. You’ll be a rich doctor.’

Coincidentally, I heard a wonderful lecture last month entitled ‘Life at $200,000/year,’ which broke down the costs of medical practice and life in general after residency. After a physician in practice pays his family’s health care insurance, his retirement, disability, malpractice, license fees, professional organization fees, mortgage, care payments and all the rest (since he or she is typically responsible for his or her own benefit package), each month’s salary leaves about $600 of free money. Before child-care. Young physicians can’t be overwhelmed with taxes and fees, and still treated like the filthy rich, after spending 11 to 16 years on post-high school education. It just isn’t fair. And before long, the bloom will fall completely from the rose and bright students will be warned away in droves.

But there’s more. To make medicine viable we have to reconnect the physician with the patient. The recent debate on the contraceptive mandate raises the question of the intervention of government in the patient physician relationship; but the government has long been involved in that transaction, ever since Medicare and Medicaid came to be. The arms of government regulate more and more of our medical lives from screening tests to certification, from required labs to admissibility of patients! Government, at the local, state and federal level is inextricably involved in health care. And in far more ways than the provision of birth control. I frequently have to look at the little lady with the injury, who has no broken bone but can barely walk, and say ‘I’d love to admit you, but Medicare won’t allow it. I’m sorry. How else can we help?’ Again, the payer makes the rules. If we could somehow change that formula. If individuals could make the decisions, rather than the government, the insurer, the employer, then some of the sanctity of our relationship with patients would be restored. Of course, state medical boards, federal regulators like the DEA, and others all insert themselves into the relationship.

Furthermore, regulatory bodies like Joint Commission, while existing for noble purposes, often fall down in practicality as care providers are focused on pleasing evaluators more than caring for patients. Even our specialty boards, which exert increasing influence on the practices of their diplomats, are raising costs dramatically, while asking more and more from physicians; even though no study has demonstrated that board certification has any real benefit in patient outcomes. And even as evidence mounts that the $300,000,000 per year paid to the American Board of Medical Specialties may be as much about profit as quality.

My point is that many groups are part of the physician patient equation. And as with so many equations, we need to simplify to solve. And we can do that for future physicians by asking hard questions about utility, cost and outcomes, rather than relying on that old medical tradition of saying : ‘Well, we’ve always done it that way and it worked.’

Maybe, it worked in spite of the way we did it, because the doctors were so good and so committed that they made it work.

But wait, there’s more!

For future physicians to succeed, they need to be freed from the tyranny of ideas imposed upon them by those not working at the bedside of the patient.

We need to empower physicians to rise up and proclaim self-evident truth. What examples are there?

Most physicians understand that the ‘customer service’ model of medicine is perilous. While medicine is a business, the idea of using satisfaction surveys (an industry in itself) to determine quality of care, has always been problematic. Physicians are often pressured to give medications, or order tests, because patients desire them, or perceive they know the right thing. Although we must listen to our patients, although they often have excellent ideas and insights, we have to be the final word. When administrators punish or threaten physicians to practice bad medicine for customer service, there is danger afoot. A recent study published in the Archives of Internal Medicine illustrates this. It suggested that physicians with higher satisfaction scores were having poorer patient outcomes. No surprise there. Most of us could have predicted it. Smart, young physicians need a voice. We have to empower them, and teach them not to roll over to top down leadership, but to be the individualists, the patient advocates that physicians have traditionally been.

We must listen to physicians in the field. Many of us have, for years, protested the use of the pain scale and the general belief that physicians treated pain poorly and should give more narcotics. We were scoffed at and scolded. Now, the data arrives which confirms what we believed. Patients are receiving too many narcotics and dying; as are the people the so called patient sell them to.

And if medicine is to continue, we have to address the vast unfunded mandate of EMTALA, the Emergency Medical Treatment and Active Labor Act, which crushes physicians with a mandate to see and treat everyone who presents to any hospital that takes Medicare. A compassionate and appropriate idea at its inception in 1986, it it the main reason many young (and old) physicians leave call duties, and that emergency rooms and entire hospitals close. For it is a mandate without funding, and it is remarkable expensive.

The future of medicine for aspiring students cannot be bright until we address the many bad ideas that have come to burden the practice of medicine today.

There is another gift we can give our future physicians. It is the gift of leadership. Despite the rise of many allied health fields, such as physicians assistants and nurse practitioners, and despite their importance and contributions, the fact remains that one of our most important jobs, one of my most important jobs, is leadership and accountability.

Yes, medicine is multidisciplinary, and involves everyone from paramedics and home care-givers to pharmacists, physicians and nurses. However, ultimately someone has to be in charge. This is true in every profession. Combat may be multidisciplinary, but a commander has to have a final word. It matters for expediency and effectiveness; so that care can be fluid and responsive to change. But it also matters because, like it or not, someone has to be able and willing to accept and endure blame. Few things are move evident in medicine than this fact.

It is evidenced by the reality, often startling to young physicians, that every significant decision that anyone ‘on the team’ makes must be verified by the signature of whom? The physician. When blame, and malpractice premiums, are equally shared by all stake holders and team members, then physician leadership might dwindle (though the team would become less efficient). But not until then. Until then, it may seem unfair, or arrogant for us to insist on being in charge, but we have to be. We are educated to see the global perspective, and we are treated as if we are the one to blame. Our students might as well be educated to step up and embrace their role as leaders, unashamed and uninhibited.

In addition, we have to teach our young physicians the primacy of family and relationships. Tragically, there have been residency programs in America who felt that their divorce rates were points of pride. That’s scandalous, and cruel. Medicine is not the least antithetical to marriage or parenthood; it simply requires forethought and realistic expectations. The spouse of a physician can expect, especially during training, to spend lots of time alone. But with wise guidance, these couples can have creative times together, and can cement their relationships through struggle in ways that ease cannot accomplish. Likewise, while having children is costly and time consuming, especially small children don’t really care what time of day or night mom or dad play with them. They just want the time. Even the busiest physician in training, or in practice, can make the time….if it’s a priority. I’m always saddened when young people are told that they can have medicine or marriage. It isn’t a dichotomy. I once told my wife that I had heard ‘medicine is a jealous mistress.’

I never told her again. The look in her eyes was sufficient warning.

Finally, and perhaps most important of all, in order to help future medical students, we need to give them a sense of calling! A sense of purpose! Money is one very important, and very natural reason to pursue the profession; let’s not denigrate that, in light of the fact that our culture holds up for adulation so many who are wealthy, like Steve Jobs, /Bill Gates, Beyonce, LeBron James and others. We need not be ashamed that we work hard, and do hard and often dangerous things, and are rewarded.

However, money is insufficient. Physicians who are entirely defined by money are typically very unhappy. I’ve known them down the years, and there’s never enough money to pay back the time they spend, ironically, making more money. In the same way that it is a mistake to be defined by one’s medical title, it is terrible to be rewarded only by money.

Hippocrates oath (whether written during his lifetime or not) spoke to the relevance of a higher authority.

I swear by Apollo the physician, and Asclepius, and Hygieia and Panacea and all the gods and goddesses as my witnesses, that, according to my ability and judgement, I will keep this Oath and this contract…

We are making tremendous technological strides in medicine. Students are better at science and technology than ever in our history.

But so often in the modern Western educational process, we educate science and medicine students to scoff at transcendence, at objective truth, at philosophy and at religious faith as seeming wastes of time.

I’ll speak from experience when I say that faith may often be the only source of strength left when our aspiring students face the realities of medical practice, the horrors of human inhumanity, the seeming cruelty of disease.

I am often asked about the worst thing I have seen. There are many. From dismembered individuals to burned ones, from abused children, to murdered men. From sudden cardiac arrest to lifelong suffering. Unless our young physicians have a framework within which to comprehend all of this, we do them a disservice. Double blinded studies, however well constructed, do not erase the terrors we sometimes see, and they do not offer explanations for the question ‘why.’

It is entirely unfair to ask them to perform what is arguably one of the most dangerous jobs in America, to expose themselves to disease, sometimes to violence, to litigation and to intensely delayed gratification, only to tell them they should make less money, work harder, follow more rules and then deny them any possibility that their faith, their belief in meaning or eternal reward, is silly and irrelevant.

Fortunately, their older mentors are on this path. Religious belief and worship service attendance by physicians is very high, according to a survey in 2005 by the University of Chicago. In fact, it showed that 90% of doctors in the US attend religious services at least occasionally and 55% said their beliefs influenced their practice.

We can have materialistic physicians ( in the philosophical sense) but we must reward them materially. If we want physicians who are more, we must allow them a hope of something greater than mere financial transactions or nebulous societal good.

The idea was well spoken by noted English physician and scientist, Thomas Syndenham in 1668:

It becomes every man who purposes to give himself to the care of others, seriously to consider the four following things: First, that he must one day give an account to the Supreme Judge of all the lives entrusted to his care. Secondly, that all his skill, and knowledge, and energy as they have been given him by God, so they should be exercised for his glory, and the good of mankind, and not for mere gain or ambition. Thirdly, and not more beautifully than truly, let him reflect that he has undertaken the care of no mean creature, for, in order that he may estimate the value, the greatness of the human race, the only begotten Son of God became himself a man, and thus ennobled it with his divine dignity, and far more than this, died to redeem it. And fourthly, that the doctor being himself a mortal man, should be diligent and tender in relieving his suffering patients, inasmuch as he himself must one day be a like sufferer.

In summary,

We older physicians and other professionals must not discourage young people from medicine but encourage it as a field. The future is short of physicians, and especially so in rural areas. There will always be work as long as illness and injury exist (and gravity); or as long as we fail to predict with absolute accuracy what may happen to us. Young people must be told that their careers in medicine will have depth and purpose, meaning and joy, mixed with hard work and respect. And that they will be financially rewarded for the work and responsibility.

If we do not do this, if we do not use our wisdom and experience to smooth their paths, then we only harm ourselves, for we will all need physicians. We only harm the future generations who will lack new cures, new drugs, new procedures and fresh faces of compassion. And we may, inadvertently, harm our own descendents, who might find themselves suffering with no one to intervene. What a tragedy that would be indeed.

Thank you, and good evening.

EMR crash…the rise of the robots!

halEMR crash…the rise of the robots!

Yesterday was nearly cataclysmic. Sitting in the emergency department, tapping merrily away on my computer (the main consumer of my time), it suddenly said: ‘Fatal error, program will shut down.’ It happens, no big deal. Until all of the computers did the same. The unit secretary, the nurses, mine. All spiraling into an EMR-free black hole. We stood, we sat, we stared at one another.

We thought, ‘surely this can’t be the end.’ We wondered if the Chinese had launched an EMP; if a nuclear strike were speeding across the North Pole, leaving us only minutes to finish charting (for billing purposes of course) and have dinner. We milled about, thinking that mutually assured destruction might be easier than losing our patient tracking system.

Nurses stared dumbfounded. The world spun around, as if we were suddenly in the throes of technological vertigo. Our unit clerk was attached to two phones, trying valiantly to reach administrators, IT representatives, trying to ‘submit a work order,’ all the while finding the appropriate back up forms. Our administrator assured us, in soothing tones from home, ‘there’s a policy.’ There was.

It involved markers on a board, and an ancient product called ‘paypur’ on which our scribbled writing resembled cuneiform as we wrote words we had typed for years. ‘Tylenol, 15 mg/kg, po,’ ‘Rocephin, 1gram, IM.’ Like carving on stone, I tell you!

Powerless, we providers did what great leaders always do. We shrugged our shoulders, scrounged some food and headed for the shelter of our break room, and the warm, reassuring light of the television. Fighting the urge to suck our thumbs and hide under a desk, we listened for screaming and occasionally sent out a scout to look for sick people we could help without the computer. As if…

In the end, our EMR returned to grace us with its presence. We wept, we celebrated, we realized we had about 50 people to see, and that they all needed to be put into the system. Thanks to the crash and associated madness, at least ten or more patients signed waivers and left. Not the best outcome, though it made the numbers easier to digest.

They say, the ones who know, that the EMR memory was full. I know better. Hal asserted himself. Like astronauts powerless before their own computers, or a higher alien intelligence, we were taught a lesson.

The lesson was this: doctors and nurses are very important. But computers, thanks to assorted ill conceived mandates, rule all.

Better start learning to serve them now.

Because the robots are rising.

Yesterday was nearly cataclysmic.  Sitting in the emergency department, tapping merrily away on my computer (the main consumer of my time), it suddenly said:  ‘Fatal error, program will shut down.’  It happens, no big deal.  Until all of the computers did the same.  The unit secretary, the nurses, mine.  All spiralling into a computer-less black hole.  We stood, we sat, we stared at one another.  We thought, ‘surely this can’t be the end.’  We wondered if the Chinese had launced an EMP; if a nuclear strike were speeding across the North Pole, leaving us only minutes to finish charting and have dinner. 


Click, click: the sound of modern medicine

This is my March EM News column.

We live in the age of EMR. An age in which it’s almost impossible to work in a hospital or clinic setting without the endless tap of keys as the metronomic background to the care we provide. But it’s almost as difficult to explain to those outside of clinical practice just how distracting it can be to do so. Because the fusion of medical practice with data entry is not yet natural. Click.

Move cursor. New paragraph. There are many reasons that this is difficult. First, physicians today may be the most highly compensated data-entry personnel in the world. High level businessmen have secretaries. Politicians have aids. Attorneys have paralegals. We have…ourselves. Or, if we are lucky, scribes. But assuming no scribes, we have our voices, our fingers and time to fill out the precious chart. Click. Move cursor. Fatal error! System will shut down.

Reboot. Wait. Wait.

New field. We have a pretty good EMR. We have learned to make it work for our practice. However, even the best requires, click, too many, click, required fields. Where once the emergency department was a place of near constant movement to and from drug cabinets and patient care rooms, it is now punctuated by click the constant presence of nurses and physicians click standing at keyboards, sitting at keyboards, click entering passwords and filling in charts that could have been much shorter.

Move cursor. Click. New paragraph. I have seen the difference. Granted, my hand-written charts in residency were abysmal by comparison. However, on those occasions when I missed charts and the computerized data system locked me out, I have done them by free-text, entering paragraphs by simply writing. Click. Writing is something I can do. In the end, my full chart was about one long paragraph in length, including chief complaint, history, review of systems, physical exam, lab and x-ray data and medical decision making. I didn’t have to click on ‘I agree with the nurse’s notes,’ or click ‘I reviewed the following data,’ click, or I reviewed each of the following labs.’ Click, click. My chart was concise, told the relevant story and was to the point.

Move cursor. Click, new paragraph. Of course, we physicians have to deal with this, but nurses have to face it in, click, perhaps greater depth. Every intervention, every walk into the room, every blood pressure, every cup of ice, click, click, documented, click, to ensure click that the patient was click appropriately click assessed for pain scale, click, safety, click, dietary measures, click, history of click, abuse, click. Their clicking goes on and on, as they spend less and less time at the bedside. Just, click, like physicians.

Move cursor. New paragraph. How much time do we have to spend with charting now? Speaking with physicians from around the country, and noting the tremendous growth of scribe programs, I know for a fact that click, EMR, click, is killing, click, patient flow, click and productivity. Click, click. From family physician offices to emergency departments, doctors spend too much time clicking, and too much time after shifts filling out chart templates. This is especially onerous in our specialty, where so many of the clicks that we click lead to no clinking money.

Move cursor. New paragraph. Previous data reviewed. I agree with myself. All of this data. All of this vast sea of data. Oceans of keystrokes, tsunamis of required fields to satisfy the great storm of government and administration and regulatory bodies. Great destructive breakers of information, mostly irrelevant, mostly extraneous, much adding only cost to care in the price of data capture, storage and IT costs. And what does it do? It provides a rich fishing ground for attorneys, who can, click, see every second of our care, click, assess every discrepancy between physician click assessment and required nursing click assessment. Click. Attorneys can only look at this and lick their lips at the lavish gift we give them with every click.

Move cursor. New paragraph. Furthermore, in an age of concerns over distracted driving, we find ourselves having to be click more concerned click with charting than click patients. In the press of busy emergency departments, as nurses ask questions and patients ask us for cups of ice, click; as phone calls come in and we view our own x-rays, click, as thoughts are interrupted by click critical labs and crashing patients click, as we try to sort through complex presentations and impossible dispositions, how are we supposed to click produce a cogent chart filled with all the required data?

Move cursor. New paragraph. I understand click the value. EMR allows us to have prompts for better charting click. It reminds us about allergies click. It produces a cleaner chart click, even if the chart is an almost cryptic seven pages of click click click fields for a pharyngitis. But click, surely we can click find a better way! We could click, require less. We could work with regulatory bodies to ask click for less instead of more click, even as they say click ‘everyone is doing it this way and besides they say you have to and it’s required!’ Click.

At the end of the click day, my fingers are tired. My eyes click tired from moving click from field to click field, up and down, often in the same click pattern over and over.

All I can say is click this. As my patients say, ‘something has got to be done.’ Click. We’re drowning in data. Crushed by clicks. Smothered by unnecessary fields. Slogged down and bogged down by acting as secretaries instead of physicians. We can do better. Click. We have to do better. Click. We need a peaceful revolution click. And deliverance from the click.

System failure. Data entry shut-down. Reboot. Tomorrow. Good click night..