Graduating from medical school in 1978, I started my hellish internship while reading Samuel Shem’s classic, “The House of G-d,” a scathing indictment of medical education and the mercenary incentives in patient care. I found it shocking, crude at times and disillusioning—but at its core, absolutely correct about what was happening in medicine that was so wrong.
Thus it seems fitting that I received a review copy of Shem’s new book, “Man’s 4th Best Hospital,” as my medical career is coming to a close. Once again, Shem nails where medical care has lost its way. Physician “burnout” and dissatisfaction are increasing in step with patients’ unhappiness.
Much of the blame can be attributed to two things—corporate greed and electronic medical records, which are like conjoined twins. There’s no small irony that this is what is forcing many experienced physicians, like myself, out of practice prematurely, contributing to a waste of both talent and experience that is needless and costly.
Electronic Medical Records (EMRs)
Come with me as I describe some of the changes in my own career that are reflected in Shem’s writing.
In the olden days, for example, I used to graph out when each antibiotic was started and stopped on the “TPR sheet”—the hand written graph the nurses charted the patient’s “vital signs” on with temperature, pulse and respiratory rate. Sometimes I noted a new medicine or a positive blood culture. This visual display of quantitative information was invaluable to me in following the course of my patients’ illnesses and puzzling things out when they didn’t respond as expected to therapy. For example, you could regularly see that a new fever corresponded to the addition of a particular new medicine, rather than infection.
No more. Even the early EMRs eliminated such graphics, replacing them with rows of data. While some have a generic graphical display option, among the half dozen EMRs I’ve had personal experience with, none could be annotated with what I need, as I did by hand.
That was decades ago. Back then, the lab would call doctors with critically abnormal labs. For me, the emphasis was on abnormal blood and spinal fluid cultures. EMRs are not without any redeeming qualities. Meditech, my first hospital’s system, had one valuable module. I could readily see my patients’ positive cultures including those from previous admissions. They were flagged and easily visible. None of the other half dozen systems I’ve used in the past decade has had that capability.
In mid-career, I conducted many clinical trials for pharmaceutical companies, working (primarily) to develop new antibiotics and other treatments for life-threatening sepsis. Electronic gadgets replaced people who actually measured a temperature, felt a patient’s pulse, or counted the respiratory rate. These mechanically generated results were often wildly inaccurate, but were recorded automatically and could not be readily edited. This made identifying patients for trials, or following their course accurately on the trial, nearly impossible. Shem had number of Laws of the House of G-d. The applicable one here was #10 “If you don’t take a temperature, you can’t find a fever.”
Those EMRs were problematic, but nothing like the new generation.
Epic and newer EMRs
EMRs have lost their way, along with the rest of medicine. The initial idea dating back to ~2008 was to have interoperability and to gather data, which could be used to improve care. What has happened to that more idealistic goal?
(Note, I will refer to Epic, since I have the most recent experience with it and it is named “Best in Klas,” but my current criticisms could be leveled against most, if not all, EMR systems).
EMRs no longer seem to even pretend to be about patient care. The goal is to optimize billing through upcoding. You do that, in part, by “documenting” more, through check boxes and screens that you can’t skip. The more you upcode and the more quickly you get patients discharged, the more profits go to the corporate overlords.
Physicians now spend two hours on the computer documentation for every hour with the patient on site. Many have 2-3 more hours “pajama time” EMR work at home. Notes used to be concise and problem lists useful. Now there is needless bloat.
The EMR in fictionalized “Man’s 4th Best Hospital” is “HEAL,” described by its President Krashinsky, “For billing…we monetize.” As protagonists Dr. Roy Basch and Berry reminisce,
“The choice in medicine back then? The Fat Man’s Dream or the Money. The money won. The money wins. Not just in medicine, in pretty much everything American now, and worldwide…”
UPMC case study
Shortly after UPMC bought Lancaster Regional Medical Center (LRMC), where I had been working, EPIC training began in late 2017. This was an extraordinarily time-consuming and expensive process. One physician told me the conversion cost $ 20 million; I am awaiting confirmation from the hospitals. Six months after the launch, Epic was upgraded, requiring additional training.
UPMC announced closure of LRMC in Dec 2018. More than 500 employees were affected, though it’s unclear how many lost their jobs. It’s also unclear how Lancaster General, the other hospital in town, can absorb the additional patients as well as how patients, particularly those who are poor, will manage to reach care in a different part of the city.
Most of the staff I worked with disliked Epic and felt it hurt patient care. I saw some instances where its rigidity hurt patients. Some physicians said they were retiring rather than learn such a complicated and time-consuming system. (For a bonus, humorous thread on Epic, see “Eye Contact is Evil” and EPICParodyEMR on Twitter.)
EMRs and physician burnout
This complaint, that EMRs are a huge time sink was not limited to Epic. At Susquehanna, some physicians complained that their EMR system, NextGen, lowered their “productivity” by a third. Since their pay was tied to performance, they were not happy about either pay cuts or angry administrators. By far the worst system I had to learn was the Army’s AHLTA; I hear pretty good things about the VA’s EMR.
A study from the Mayo Clinic found that over 50% of physicians experienced at least one symptom of burnout and that the frequency has been increasing.
As Dr. Atul Gawande stressed in “Why Doctors Hate their Computers,” Mayo found that one of the strongest predictors of burnout was how much time an individual spent tied up doing computer documentation.
Gawande observes, “I began to see the insidious ways that the software changed how people work together. They’d become more disconnected; less likely to see and help one another, and often less able to.”
Shem nails these problems with EMRs and money-driven medical care in spades, and more graphically than all the medical journal articles. He explained to me,
“It’s not burnout. It’s placing doctors in a moral bind. It’s like being in a war you don’t believe in. That kind of thing…It’s abuse of doctors, simply put. Because we can’t practice the way we want to. We’re hirelings.”
He stressed that electronic records are “probably a pretty good thing.” It is the way they are linked to money that is the problem.
Many physicians miss caring for patients. We are now regarded by many large health systems as interchangeable widgets and shift workers. EMRs have destroyed our relationship with patients, as we are forced to interact with the computer screen rather than our patient.
In this sequel, Shem emphasizes the danger of isolation from patients and coworkers and the healing power of good connections. He waxes more philosophical and Buddhist threads run through the narrative. Basch muses,
“it’s our job, being with patients at the crucial times in their lives, yes, illness, old age, and death—we’ll suffer less, spread less suffering around and…heal.” “Heal both ways. Us and them.”
The Laws of the House of G-d were funny, cynical with apt insider jokes about medical training, like Law VIII. “They can always hurt you more” and XIII “The delivery of good medical care is to do as much nothing as possible.” EMRs, practice guidelines and fear of liability pushes towards doing more. We would be better if we remembered the Fat Man’s mantra, that sometimes “Less is more.”
The Laws of Man’s 4th aren’t as catchy, but reflect a wise maturity in how we should respond to the crisis in health care. II. “Isolation is deadly; connection heals.” VIII “Squeeze the money out of the machines. IX. “Put the human back in medicine.”