How Tech Can Turn Doctors Into Clerical Workers - The New York Times

Tom Benzoni benzonit at GMAIL.COM
Sat May 19 02:37:34 UTC 2018

I will submit that this starts, as with all that we do, with a proper, old
fashioned, internal medicine history and physical.
Any H&P has to contain a risk factor profile.
What are factors that needed to be known?
If a physician has been reduced to being a cog in the wheel (demonstrable
by the 4K clicks/d) then, if they burn out, replace them with a new cog.
I admit this is dystopian, but I think we'd better recognize that rose
colored glasses won't help.
You will find support for this concept in the adoption of a manufacturing
model for health care.
To the extent that we adopt these measures, to that extent so we agree that
Physicians are replaceable cogs.


On Fri, May 18, 2018, 16:45 David L Meyers <dm0015 at> wrote:

> If you’re not worried, you’re not paying attention!
> David
> David L Meyers, MD FACEP
> Listserv Moderator/Board member
> Society to Improve Diagnosis in Medicine
> |
> Save the Date: Diagnostic Error in Medicine, November 4-6, 2018; New
> Orleans, LA
> How Tech Can Turn Doctors Into Clerical Workers
> MAY 16, 2018
> There are times when the diagnosis announces itself as the patient walks
> in, because the body is, among other things, a text. I’m thinking of the
> icy hand, coarse dry skin, hoarse voice, puffy face, sluggish demeanor and
> hourglass swelling in the neck — signs of a thyroid that’s running out of
> gas. This afternoon the person before me in my office isn’t a patient but a
> young physician; still, the clinical gaze doesn’t turn off, and I diagnose
> existential despair.
> Let’s not call this intuition — an unfashionable term in our algorithmic
> world, although there is more to intuition than you think (or less than you
> think), because it is a subconscious application of a heuristic that can be
> surprisingly accurate. This physician, whose gender I withhold in the
> interest of anonymity and because the disease is gender-neutral, is burned
> out in what should be the honeymoon of a career. Over the years, I have
> come to recognize discrete passages in a medical life, not unlike in
> Shakespeare’s “Seven Ages of Man” — we have our med-school equivalent of
> “the whining schoolboy with his satchel and shining morning face” and the
> associate professor “jealous in honor, sudden and quick in quarrel.” But
> what I see in my colleague is disillusionment, and it has come too early,
> and I am seeing too much of it.
> Does this physician recall sitting before me as an idealistic first-year
> medical student, keen to take the world in for repairs? It was during those
> preclinical years that the class learned to use the stethoscope, the
> ophthalmoscope and the tendon hammer, to percuss the body, sounding out its
> hollows, the territorial boundaries of lung and liver. After the
> preclinical come the two clinical years, though I think of those phases
> these days as precynical and cynical. When students arrive on the wards
> full time, white coats packed with the aforementioned instruments,
> measuring tape, tuning fork, flashlight and Snellen eye chart, they are
> shocked to find that the focus on the ward doesn’t revolve around the
> patients but around the computers lining the bunkers where students,
> residents and attending physicians spend the majority of their time, backs
> to one another. All dialogue among them and other hospital staff members —
> every order, every lab request and result — must pass through this
> electronic portal, even if the person whose inbox you are about to overload
> is seated next to you.
> In America today, the patient in the hospital bed is just the icon, a
> place holder for the real patient who is not in the bed but in the
> computer. That virtual entity gets all our attention. Old-fashioned
> “bedside” rounds conducted by the attending physician too often take place
> nowhere near the bed but have become “card flip” rounds (a holdover from
> the days when we jotted down patient details on an index card) conducted in
> the bunker, seated, discussing the patient’s fever, the low sodium, the
> abnormal liver-function tests, the low ejection fraction, the one of three
> blood cultures with coagulase negative staph that is most likely a
> contaminant, the CT scan reporting an adrenal “incidentaloma” that now
> begets an endocrinology consult and measurements of serum cortisol.
> The living, breathing source of the data and images we juggle, meanwhile,
> is in the bed and left wondering: Where is everyone? What are they doing?
> Hello! It’s my body, you know!
> Advances in Pattern recognition applied to X-rays and CT scans and retinal
> scans will be very helpful, but as with any lab test, what A.I. will
> provide is at best a recommendation.
> My young colleague slumping in the chair in my office survived the student
> years, then three years of internship and residency and is now a full-time
> practitioner and teacher. The despair I hear comes from being the
> highest-paid clerical worker in the hospital: For every one hour we spend
> cumulatively with patients, studies have shown, we spend nearly two hours
> on our primitive Electronic Health Records, or “E.H.R.s,” and another hour
> or two during sacred personal time. But we are to blame. We let this happen
> to our trainees, to ourselves.
> How we salivated at the idea of searchable records, of being able to graph
> fever trends, or white blood counts, or share records at a keystroke with
> another institution — “interoperability”! — and trash the fax machine. If
> every hospital were connected, we would have a monster database, Big Data
> that’s truly big and that would allow us to spot trends in disease so much
> earlier and determine best practice and predict complications. But we
> didn’t quite get that when, as part of the American Recovery and
> Reinvestment Act of 2009, $35 billion was eventually steered toward making
> medicine paperless.
> My A.T.M. card is amazing: I can get cash and account details all over
> America and beyond. Yet I can’t reliably get a patient record from across
> town, let alone from a hospital in the same state, even if both places use
> the same brand of E.H.R., for reasons that are only partly explained by
> software that has been customized for each site. This is not like sending
> around a standard Word file. And so, too often the record comes by fax.
> What the E.H.R. has done is help reduce medication errors; it is a
> wonderful gathering place for laboratory and imaging information; the notes
> are always legible. But the leading E.H.R.s were never built with any
> understanding of the rituals of care or the user experience of physicians
> or nurses. A clinician will make roughly 4,000 keyboard clicks during a
> busy 10-hour emergency-room shift. In the process, our daily progress notes
> have become bloated cut-and-paste monsters that are inaccurate and hard to
> wade through. A half-page, handwritten progress note of the paper era might
> in a few lines tell you what a physician really thought. (A neurosurgeon I
> once worked with in Tennessee would fill half the page with the words
> “DOING WELL” in turquoise ink, followed by his signature. If he deviated
> from that, I knew he was very worried and knew to call him.) But now, with
> a few keystrokes, you can populate your note with all the listed diagnoses,
> all the medications, all the labs, all the radiology reports, pages and
> pages of these, as well as enough “smart phrases” — “.EXT2” might spit out
> “Extremities-2+ pedal edema, normal pulses” — to allow you to swear you
> personally examined the patient from head to foot and personally took all
> the elements of the history, personally did a physical exam separate from
> the admitting physician that would put Sir William Osler to shame, all of
> which make it possible to bill at the highest level for that encounter
> (“upcoding”).
> As a result, so much of the E.H.R., but particularly the physical exam it
> encodes, is a marvel of fiction, because we humans don’t want to leave a
> check box empty or leave gaps in a template. Over the years, I have met
> one-legged patients with “pulses intact in both feet” and others with
> “heart sounds normal, no murmur or gallop” whose mechanical heart valve’s
> clicks and murmurs are so loud that the patient in the next bed demands
> earplugs. For a study, my colleagues and I at Stanford solicited anecdotes
> from physicians nationwide about patients for whom an oversight in the exam
> (a “miss”) had resulted in real consequences, like diagnostic delay,
> radiation exposure, therapeutic or surgical misadventure, even death. They
> were the sorts of things that would leave no trace in the E.H.R. because
> the recorded exam always seems complete — and yet the omission would be
> glaring and memorable to other physicians involved in the subsequent care.
> We got more than 200 such anecdotes. The reason for these errors? Most of
> them resulted from exams that simply weren’t done as claimed. “Food
> poisoning” was diagnosed because the strangulated hernia in the groin was
> overlooked, or patients were sent to the catheterization lab for chest pain
> because no one saw the shingles rash on the left chest.
> I worry that such mistakes come because we’ve gotten trapped in the bunker
> of machine medicine. It is a preventable kind of failure. Our $3.4 trillion
> health care system is responsible for more than a quarter of a million
> deaths per year because of medical error, the rough equivalent of, say, a
> jumbo jet’s crashing every day. Much of that is a result of poorly
> coordinated care, poor communication, patients falling through the cracks,
> knowledge not being transferred and so on, but some part of it is surely
> from failing to listen to the story and diminishing skill in reading the
> body as a text.
> Five years ago, I experienced a sudden asthma attack while visiting
> another city. The E.R. physician was efficient, the exam adequate. The
> nurse came in regularly, but not to visit me so much as the screen against
> the wall. Her back was to me as she asked, “On a scale of 1 to 10, with 10
> being great difficulty breathing ...?” I saw her back three more times
> before I left. My visit recorded in the E.H.R. would have exceeded all the
> “Quality Indicators,” measures that affect reimbursement and hospital
> ratings. As for my experience, it was O.K., not great. I received care but
> did not feel cared for.
> A senior colleague who was hospitalized for a longer spell, a person whose
> scientific and technological discoveries have helped transform care in
> virtually every hospital, told me with some chagrin that during his stay,
> the only people who got to know him as an individual human being were the
> nursing assistant and the housekeeper. The nurses, through no fault of
> theirs, were tethered to the COWs — Computers on Wheels — into which they
> entered data about him. But what, he asked, if it had been the other way
> around? What if the computer gave the nurse the big picture of who he was
> both medically and as a person? What if it reminded the nurse, because it
> was post-op Day 6 and his white count was rising, to check the surgical
> wound and the puncture sites where intravenous fluid was administered? What
> if the top screen reminded the nurse about his family members, his life
> outside this room and his unique concerns? What if it gave the nurse
> specific insights on how he was handling his suffering and suggested a
> strategy to support him?
> For all the effort that goes into data gathering and entering, too often
> the data is ignored. One of my brothers, a professor at M.I.T. whose
> current interest in biomedical engineering is “bedside informatics,”
> marvels at the fact that in an I.C.U., a blizzard of monitors from
> disparate manufacturers display EKG, heart rate, respiratory rate, oxygen
> saturation, blood pressure, temperature and more, and yet none of this is
> pulled together, summarized and synthesized anywhere for the clinical staff
> to use. The physician or the nurse walks in and looks at 10s of seconds of
> information, a snapshot at that moment. What these monitors do exceedingly
> well is sound alarms, an average of one alarm every eight minutes, or more
> than 180 per patient per day. What is our most common response to an alarm?
> We look for the button to silence the nuisance because, unlike those in a
> Boeing cockpit, say, our alarms are rarely diagnosing genuine danger.
> The biggest price for “digital medicine” is being paid by physicians like
> the sad case seated before me, who is already considering jumping to
> venture capital or a start-up, not because that is where the heart is but
> because it’s a place to bail out to. By some estimates, more than 50
> percent of physicians in the United States have at least one symptom of
> burnout, defined as a syndrome of emotional exhaustion, cynicism and
> decreased efficacy at work. It is on the increase, up by 9 percent from
> 2011 to 2014 in one national study. This is clearly not an individual
> problem but a systemic one, a 4,000-key-clicks-a-day problem. The E.H.R. is
> only part of the issue: Other factors include rapid patient turnover,
> decreased autonomy, merging hospital systems, an aging population, the
> increasing medical complexity of patients. Even if the E.H.R. is not the
> sole cause of what ails us, believe me, it has become the symbol of burnout.
> Burnout is costly. My colleague at Stanford, Tait Shanafelt, a
> hematologist and oncologist who specializes in the well-being of
> physicians, is Stanford Medicine’s first chief wellness officer. His
> studies suggest that burnout is one of the largest predictors of physician
> attrition from the work force. The total cost of recruiting a physician can
> be nearly $90,000, but the lost revenue per physician who leaves is between
> $500,000 and $1 million, even more in high-paying specialties. Turnover
> begets more turnover because those left behind feel more stress. Physicians
> who are burned out make medical errors, and burnout can be infectious,
> spreading to other members of the team.
> I hold out hope that artificial intelligence and machine-learning
> algorithms will transform our experience, particularly if natural-language
> processing and video technology allow us to capture what is actually said
> and done in the exam room. The physician focuses on the patient and family,
> and if there is a screen in the room, it is to summarize or to share images
> with the patient; by the end of the visit, the progress notes and billing
> are done. But A.I. applications will help us only if we vet all of them for
> their unintended consequences. We need sufficient regulatory scrutiny so
> that we don’t have debacles like that of Theranos, a company that claimed
> it could perform comprehensive lab tests from just a few drops of blood.
> Technology that is not subject to such scrutiny doesn’t deserve our trust,
> nor should we ever allow it to be deeply integrated into our work.
> Starting with good data is critical for medical applications of A.I. and
> machine learning. The messy nature of medical data, of the E.H.R., makes
> the task difficult. Garbage in begets garbage out — sanitized, pretty,
> color-coded garbage, but garbage nonetheless. Advances in pattern
> recognition applied to X-rays and CT scans and retinal scans will be very
> helpful aids to the clinician. But as with any lab test, what A.I. will
> provide is at best a recommendation that a physician using clinical
> judgment must decide how to apply.
> I remind my young colleague that no one else can fulfill that final role:
> If data scientists complain about “messy data,” then there is nothing
> messier than an emergency meeting with a seriously ill patient when the
> information on what preceded this moment emerges in dribbles, and all the
> while we need to make a provisional diagnosis, start therapy, then make
> quick decisions as the disease evolves and recalibrate with more story from
> the patient, or from the firefighters who found the bottles of medication
> by the patient’s side, or from the friend or family member who suddenly
> shows up and mentions the sneezing parakeet, or from the lab numbers that
> come back. True clinical judgment is more than addressing the avalanche of
> blood work, imaging and lab tests; it is about using human skills to
> understand where the patient is in the trajectory of a life and the
> disease, what the nature of the patient’s family and social circumstances
> is and how much they want done.
> The seriously ill patient has entered another kingdom, an alternate
> universe, a place and a process that is frightening, infantilizing; that
> patient’s greatest need is both scientific state-of-the-art knowledge and
> genuine caring from another human being. Caring is expressed in listening,
> in the time-honored ritual of the skilled bedside exam — reading the body —
> in touching and looking at where it hurts and ultimately in localizing the
> disease for patients not on a screen, not on an image, not on a biopsy
> report, but on their bodies.
> I recall an occasion when we were on rounds seeing a patient, and suddenly
> a vile odor filled the air. Time stood still until an earthy and wonderful
> nurse said: “Do you all smell poop? Let’s fix that!” and stepped forward,
> and we did, too, rolled up sleeves and learned from a master, with minimal
> fuss and minimal embarrassment to the patient, how to take care of
> something that a keyboard won’t do for you, what no algorithm will
> sanitize. Medicine is messy and complicated, because humans are messy and
> complicated. That is why I love it. And what all of us in the trenches —
> housekeepers, nurses, nursing assistants, therapists, doctors — have in
> common is that humanity. We came to this for many reasons, but it sobers me
> how many people came because they had a sense of calling, because they
> genuinely care.
> So let’s not be shy about what we do and ought to do and must be allowed
> to do, about what our patients really need. As he was nearing death, Avedis
> Donabedian, a guru of health care metrics, was asked by an interviewer
> about the commercialization of health care. “The secret of quality,” he
> replied, “is love.”/•/
> ------------------------------
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> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine

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