Thursday, December 13, 2007

EHRs --- The AMC Pacers of the Computing World

Although I am a surgeon, I have enjoyed using computers since I was a teenager. My father worked with computers for IBM, and was so excited to one day open a box and set up a Radio Shack TRS-80 computer on the kitchen table. The "Trash-80" was no favorite of my mother, but despite her desperate attempts, it lived in the kitchen -- on a TV tray -- for quite a while. It was cool -- with a 4 MHz processor and 4K of RAM; today, that kind of blazing speed will maybe be enough to run an old sprinkler system.

Soon thereafter, I took my first computer course as a freshman in high school. As I recall, there was a Univac machine the size of a DeSoto in a corner room of my high school, and we would type up simple programs on keypunch cards to get it to calculate the square root of 42 or other such nonsense --- we were "programmers" in the sense that a guy changing his oil is a mechanic. But, it was fun, and kept me interested in the potential of computers.

Fast forward a few years to 1984, when I was about to enter the best medical school in the country. IBM had introduced the PC, and I just had the overwhelming urge to plunk down a good 5 grand of hard earned money to buy me one -- with two floppy drives, an AST expansion board (fully loaded down with a screaming 384K of RAM), and a color monitor, no less. Smokin'!!

What would that baby do? Well, after booting it up, I could use the good old WordPerfect word process software I had purchased to, well, word process. And word process I did, to the tune of $30 per medical school lecture to help pay for the darn computer (and buy beer) ---- because we had a lecture note taking service, and some folks just really didn't like to type up a lecture for distribution. Not only did I make a few bucks, but I learned the material a bit better by listening and taking notes, and then typing them up while listening to the lecture tape all over again. And, in the process, I learned quite a bit more about computers, with an awareness of how they could become much more functional in medical care in the future. Then came residency. Zoom -- the computer world completely passed me by, as I had no time to take care of bodily functions on a regular basis, much less screw around with bits and bytes.

Why do I write this? To tell you, and remind myself, that I am no technophobe. I bristle when I read in blogs and newspapers that physicians simply are too technophobic to "accept" electronic medical records. I love the functionality of computers, the simplicity of e-mail programs, the elegance of my Microsoft Excel spreadsheets, and yes the word processing prowess of Microsoft Word. I can use HTML --- OK, I'm a real novice --- on this blog and two websites that I have had to maintain. I can navigate my way around most programs and within a few minutes figure them out so that I can be functional.

I'm not a computer dumbass, dammit!

Except, of course, in the narrow minded world of the electronic medical record programmer. The systems that I have seen are so non-intuitive, so counter-productive, and so blinking difficult to navigate that they make other business world programs seem so advanced that they were given to us by time travelers who had spent time with Captain Kirk. Some of them have the feel of a potpourri programs forced to work together but which were written in different programming languages in different decades, and they look as elegant as the interior of an AMC Pacer (why do I know what that looks like? Don't ask, and please don't ask my wife).

Doesn't this thing have drop down menus? Well, yes, but only on certain screens, which you must access by retyping your password, but this time with "caps lock" on (don't forget to turn off "caps lock," though, because otherwise you sometimes get frozen out of the system). Can I just click here to get to the next piece of information? Er, no. Hit F12. F12?? What program for average people still uses the function keys??? Quicken? Nah, didn't think so.

How about this. I need to look at all of my patients' vital signs and ins & outs for the past 24 hours, can I do that? No, because the system hasn't been programmed to recognize anything other than a midnight-to-midnight time frame. We hope that will be patched in the next version --- which might be upgraded to include Pong if we're lucky!!!

How about my 128 character sign-on password that must include capitals, small letters, at least a dozen numbers and the symbol for that guy who used to be called Prince --- do I really need to change it on alternating Tuesdays and every new moon? Oh, yes. And don't forget -- if you leave the computer for 3.7 nanoseconds without any activity, it will shut you out and you need to sign back on. After, of course, you have called the help(less) desk and waited on hold for approximately the length of time Mars has been in phase with Jupiter for the past decade and begged forgiveness.

Why have we gotten here? Why do we have elegant, well-written programs to allow us to do everything from blog to run the books at major corporations, but the medical system has programs that might have been adequate in the 70s? I think there are a few reasons, and since nobody else will listen to me, I feel justified in inflicting my opinion on those 2 people who have gotten this far:
  1. All hospital computer systems were originally written for one purpose -- billing. As a result, the folks that have been the most heavily involved in getting us new programs start with the premise that billing is the most important function of the code that is to be written.
  2. Money, part one --- hospitals decided they needed to act just like other businesses, and adopted one of the corporate world's worst attributes, the constant worrying about this quarter's projected budget and last quarter's revenues against the projection. Not net loss or gain, mind you, but imaginary numbers that must be met, or heads will roll. How are you supposed to outlay a lot of cash for a new computer system if you are worried about this quarter's budget?
  3. Money, part two --- hospitals, and doctors, rightly see that their income is going down, so unless a new computer system can pay for itself over the long haul, why bother? And if CMS says you have to have one, spend the least money for it.
  4. Janet Reno and Bill Clinton --- my pet theory is that Bill Gates and that giant group of smart people in Washington could write a great program that would work for every hospital in the land, make it easy to use, and make it affordable. And they'd make a ton of money doing it. But, of course, the Clinton Justice Department jumped all over them a few years back for creating a "monopoly," which obviously never existed, so why would they bother with creating a potentially real one? So, Mr. Gates took his money overseas to help folks with malaria.
  5. Last, but not least, there are not a whole lot of physicians who write code in their spare time, so getting a program that fits the needs of docs, hospitals, nurses, et al is a tall proposition.

So, what to do? Most nights, I dream of short circuiting the hospital's computers so we can have nurses go back to actually taking care of patients instead of poking on keyboards. Most mornings, I have to restrain myself from hurling hot coffee at the computer screen. And most evenings, I leave the hospital resigned to the fact that there is nothing that I can do, and that really ticks me off. So, again, what to do? I guess have a martini and forget about it.

Thursday, December 06, 2007

St. Looney Tunes Hospital

Ah, youth. It never surprises me how certain people and situations bring long-hidden memories instantly to mind. Unfortunately, in the hospital I am frequently reminded of childhood cartoons, rather than the inspiring novels I read in my teens and twenties. Just for an introduction, let me familiarize you with the cast of characters that inhabit my --- and every other --- hospital:

Foghorn Leghorn --- This is the older surgeon, used to getting his way, who treats any surgeon younger than he as an underling, ready and willing to do his bidding at any time of the day or night. "Boy! I say, boy!" is his constant refrain, as in "Boy, take this call night for me," or "Boy, I need you to see my patients this weekend (even though we don't share call)." Likes to hear the sound of his own voice -- as in "That's a joke... I say, that's a joke, son". Means well, but one can get very tired of him very quickly.

Chickenhawk --- The other end of the spectrum from Foghorn Leghorn. The young surgeon, fresh out of training, for whom the term "dogmatic" was invented. Never backs down from a challenging case --- an admirable quality at times --- but sometimes needs an older, wiser physician to hold him back a bit.

Daffy Duck --- To paraphrase the Looney Tunes official description, this is the middle-aged doc who has become so frustrated at the idiocies he experiences every day that he as become "more self-analytical, competitive, peevish, paranoid, and neurotic. Eventually, (the doc finds) himself more and more at the mercy of a (hospital) that seemed to favor everyone but him. So why do (patients) love him? Despite his failures, Daffy, like the Greek hero Sisyphus, is a victim of injustice who continuously protests. And it's his refusal to surrender his will to the whims of the conspiring universe that makes him heroic." This is the doc who blows his top occasionally, but only when some stupid hospital policy has the potential to cause harm to his or her patient. Irascible, but lovable.

Bugs Bunny --- everybody loves Dr. Bugs Bunny. Funny, able to pull the wool over the administration's eyes, and in the end smells like a rose. Never -- I mean never -- can there be a Bugs Bunny surgeon. Such flippancy is erased the first time a surgical complication occurs. No, Dr. Bugs Bunny is usually an infectious disease doctor, or an anesthesiologist. Loads of fun to talk to.

Tweety Bird -- pardon the sexism, but Dr. Tweety Bird is a female physician. This is the type of lady doctor who is always unflappable, never sweats under pressure, and always looks cute and put together (even in the middle of the night). A delight for older male patients.

Marvin the Martian --- the hospital CFO. Nice, eager, and totally clueless about how we take care of patients in the hospital. Eager to submit the whole place to his will of cost cutting, but unable to achieve that goal because of the wildly bizarre personalities that make up a hospital.

Taz --- the hospital attorney. 'Nuff said.

Yosemite Sam --- the staff blowhard. A physician of any specialty who views the administration offices as his personal spot to blow off steam. Bad food? Go yell at administration. OR not running on time? Ditto. Like Sam's guns, he's frequently on the mark, but his misses are so wild that no one pays him any real attention.

Elmer Fudd --- this is a surgical blog, right? That means I can make fun of internists! Elmer Fudd is the caricature of the physician who is more interested in chasing zebras when he hears hoofbeats than in rounding up the horses around him. Serves as the butt of many jokes from surgeons, intensivists, gastroenterologists......but, does catch the silly wabbit on occasion!

Porky Pig --- the hospital CEO. Calm, but somehow that calmness seems to come at the expense of any realization of what exactly is going on elsewhere in the building. And just when you need him to do something important, it's "that's all folks," and he's off to be a CEO at another, larger institution.

Pepe lePew --- the nearly-retired doc who is in love with himself. This poor guy remains stuck in the world of 1972, when he was top dog at some now-shuttered academic institution, and has not read a journal article since the Ford administration. Tolerated, not well liked, and avoided in the doctor's dining room.

Hippety Hopper --- the quietest, smartest doc in the hospital. Most often a pathologist. Says almost nothing, but like the baby kangaroo, never ceases to kick those around him in the head when coming up with the right diagnosis.

Gossamer (AKA Rudolf) --- the staff pushover. Looks fierce, but in the cartoons let Bugs Bunny run roughshod over him, making him look like an idiot. In the hospital, he never says no, even when other docs or the hospital are dumping on him.

Rhode Island Red --- Foghorn Leghorn's rival in the cartoons, also his rival in the hospital. Mr. Smooth, the surgeon who seems to handle every untoward occurrence with grace and elan, whose patients love him, and whose complications always seem to turn out just right. Lasts about 3 years at every hospital he's worked in, because by then his schtick has worn thin, and bigger problems with his patient care start to surface.

Sylvester -- me. Sloppy in appearance, dogged in pursuit of an ever elusive goal -- which, in the cartoon, was Tweety, but in my case, some sign that the hospital administration "gets it" in regards to physician relations.

That's just an intro. We'd need to expand our list of cartoon characters to include the cranky ED doctor, the exasperated chief medical officer, or the heard-but-never-seen radiologist, to name a few. Just remember, though, that if you ever find yourself caught in the hospital, that everybody that works there has at least a little Bugs Bunny inside him or herself. Laughter, after all, really is the best medicine.


Counterintuitive: coun·ter·in·tu·i·tive (koun'tər-ĭn-tōō'ĭ-tĭv, -tyōō'-) adj. Contrary to what intuition or common sense would indicate

For some time now, the Powers That Be® have been stating that in the brave new world of the 80-hour residency work week we would have better rested, more motivated residents willing to tackle the challenges of training with vigor, good humor, and as much or more dedication as their predecessors. And for just as long, curmudgeonly surgeons such as myself have called BS on that idea, feeling that it takes a whole lot more than counting hours in training to make a complete surgeon -- or physician of any stripe -- concerned that the residency training system would eventually turn out fewer numbers of adequately trained surgeons. However, the Powers That Be® have more clout than simple surgeons such as myself, and have made persuasive arguments that the 80-hour work week would increase the number of students willing to go into general surgery in particular.

Do they have any data to back that up? Well, not quite. And, just because I like to throw cold water on social engineering masquerading as good medical policy, I'd like to share a little data with you that might come as a surprise.

In this month's American Journal of Surgery there is an interesting article entitled General surgery resident attrition and the 80-hour workweek. The authors sent a simple, seven question survey to all 252 ACGME accredited general surgery training program directors, and received responses from 124. Basically, the survey asked about attrition rates for categorical general surgery residents (those who entered the training program intent upon completing a 5-6 year course of training in general surgery) over a 4 year period starting just prior to the 2003 institution of the 80-hour rule. Now, it would seem intuitive to expect that attrition rates would go down, or at a minimum stay stable, following the implementation of the 80 hour rule. Of course, theories based upon intuition need to be tested and validated --- what was found was the opposite (from the abstract):
One hundred twenty-four of 252 programs (49%) responded, reporting a loss of 338 categorical residents. The total attrition rate increased from .6 residents lost/program/y to .8 residents/program/y (P = .0013). Lifestyle concerns were the most commonly reported reason for residents leaving during surgical training. The majority (56%) of those who left surgery entered other fields of medicine (ie, Anesthesia and Family Medicine most commonly).
Makes you go "Hmmm," doesn't it? Training programs, and their governing bodies, have gone out of their way to make general surgery training "easier," less time-consuming, and supposedly more attractive as a result, and what happens? Fewer residents complete surgical training!

This study begs the question "why?" Fear not -- as unusual as it is for me to offer an opinion, let me make a few observations. First of all, making an educational experience less rigorous does not necessarily make it more attractive. I subscribe to the idea that things worth having are worth working hard to get --- like SWIMBO, for example. Secondly, when surgery residency is advertised as "fun, and now easier!" it does not necessarily attract the type of applicant willing to put in the hard work it takes to end up as a practicing surgeon. After all, if "anyone can do it" is a good way to advertise for applicants, why isn't that posted on a sign at the base of Mt. Everest?

Last of all, we should all recognize that this happens because of the Law of Unintended Consequences --- whenever we make policy decisions with a social engineering intent, rather than based upon rational thinking, what we end up with rarely resembles a desired outcome.
And, since we all know there is no going back, the best we can hope for is a little more rational thinking in the next few years to ensure that good surgical resident training is preserved as much as possible.