Friday, July 31, 2009

ὕβρις

Buffoonery is generally easy to spot -- it's just that when it is the "emperor" making an ass of himself, few will call attention to the fact that he has no "clothes," or more specifically, no clue. I view buffoonery as a form of hubris (ὕβρις) begging for ridicule. From one of my favorite movies:

Emperor Joseph II: Your work is ingenious. It's quality work. And there are simply too many notes, that's all. Just cut a few and it will be perfect.

Mozart: Which few did you have in mind, Majesty?

Without a doubt, that is my favorite line of an outstanding film, and it makes me giggle even now. Present day buffoonery, however, gives me heartburn --- though "Gates-gate" has gotten more press attention, the following is no less egregious:
"Right now, doctors a lot of times are forced to make decisions based on the fee payment schedule that's out there. ... The doctor may look at the reimbursement system and say to himself, 'You know what? I make a lot more money if I take this kid's tonsils out.'"
Like I said, buffoonery. Which few tonsils did you have in mind for us to leave in, Majesty Mr. Obama?

Because there is always a deep well from which to draw upon in le cinema,

"Fat, drunk and stupid is no way to go through life, son."



Perhaps it is time for the people of this country to borrow a line from Dean Wormer to say the "emperor has no clothes:"
Arrogant, ill-informed, and condescending is no way to lead the country, sir.

Wednesday, July 22, 2009

Rosetta Stone, Medical Edition


It's summertime, summertime Sum-sum-summertime Summertime, summertime Sum-sum-summertime Summertime, summertime Sum-sum-summertime Summertime, summertime Sum-sum-summertime Summerti-i-me ......

(Feller and Jameson, The Jamies 1958)

Yeah. Summertime. I love it here in the Rockies. Unfortunately, so do a whole lotta folks who take summertime activities in directions God never intended. Which means sum-sum-summertime is a busy one for those of us who treat trauma victims --- motorcyclists riding without helmets, mountain bikers going "endo," and toxic mixtures of ethanol, testosterone, and high-horsepower vehicles keep us hopping. Our group has lost two members this year, meaning that this summer is busier than most for me. Which means, in the end, no sum-sum-summertime blogging lately.

Time to make amends. Let's chat a bit about electronic medical records. Really! It will be fun! Exciting! A real waste of your next 4 minutes!

A wide policy net was cast in January by the federal government regarding the potential for physicians and to get some of the "stimulus" money as (partial) reimbursement for purchasing EHR systems. The kicker came with the phrase "meaningful use" --- in other words, physicians would have to demonstrate that they were using their EHR to a meaningful extent in order to be eligible to receive funds. What, exactly, does "meaningful use" mean?

Some framework was put into place in mid-June when the meaningful use workgroup of the HIT Policy Committee released its initial recommendations for a definition of "meaningful use" of electronic health records. 22 specific objectives for EHRs to be qualified by 2011, including:

  • Allow patients to access clinical information;
  • Comply with state and federal privacy, security and data sharing regulations;
  • Document patient progress and provide clinical summaries;
  • Exchange critical information with other care providers;
  • Implement drug interaction safeguards;
  • Send patient reminders about follow-up and preventive care;
  • Submit immunization and laboratory data to relevant public health registries; and
  • Use computerized physician order entry systems to transmit prescriptions.
What is not included is the implicit understanding that all clinical information will eventually be part of a government database, as part of the Take Over The Universe Healthcare Act of 2009, but that's a discussion for another day. But I was drawn to the first item on this list:
Allow patients to access clinical information
On the face of it, this is a reasonable proposal. Patients should have access to their medical records. But how many of them will be able to interpret those records?

I'll give an example; this is not a real patient, but is similar to many folks that I see.
  • 59 year old lady
  • History of stage I left breast cancer, treated with breast conservation therapy
  • HTN, on Altace
  • Mild glucose intolerance
  • Family history of breast cancer, hypertension, diabetes and diabetes-related renal failure
  • Status post cholecystectomy, TAH/BSO, and appendectomy
  • Normal screening colonoscopy 18 months ago
  • Referred to surgeon by nurse practitioner in gynecologist's office for evaluation of an abnormal mammogram. The mammogram reads "indeterminate cluster of microcalcifications in the 5 to 6 o'clock position of the left breast, seen only in MLO view; recommend 6 month interval diagnostic mammograms and ultrasound."
OK. Let's hand the patient this problem list, so that she is fully aware of what her current clinical information is. By the time she gets to the surgeon's office, there is a pretty good chance that she will be far more confused than informed, and there is an excellent chance that having this information ---- without the ability to review it with a physician at the same time ---- will generate several phone calls. I have seen this happen on numerous occasions, especially since the government mandated that all patients receive a letter regarding their mammogram results. Add to that the note that will be generated by the surgical consultation, and we could end up with one very confused patient.

My little brother got an electrical engineering degree and mechanical engineering degree in college. Smart as a whip, even if he is a bit of a doofus. And even though he works in software now, I suspect he could make his way around an electrical wiring diagram in his sleep. But does he know what "indeterminate cluster of microcalcifications in the 5 to 6 o'clock position of the left breast, seen only in MLO view" means? Just as I can't make heads or tails of a microchip diagram, I wouldn't expect him to understand what a mammogram result means. It's in a different language, for all intents and purposes. And I wouldn't expect that he would understand that an abnormal mammographic finding in a breast that has been treated with breast conservation therapy for carcinoma is something that probably deserves a little more investigation than awaiting a 6 month follow-up study.

So, I have decided to drop this whole surgery gig and open up a new business venture. I'm going to publish a series of helpful little books designed to let patients navigate arcane medical jargon.
  • Surgical Diagnoses and Treatments For Dummies
  • Cardiology For Dummies
  • Pediatric Terminology For Dummies
Maybe the folks at Rosetta Stone will let me in on some of their action, too. I wouldn't mind hawking "Rosetta Stone -- Medical" at airports around the country!