• I don’t feel comfortable doing that.—I don’t know what you’re asking me to do (nurse to intern); I’m too lazy to do it (intern to resident); I think it’s a stupid idea and there’s no way you can make me do it (resident to attending); You’re not paying me enough to do this crap (attending to administration).
• It’s a light elective—You don’t need to show up.
• Needs to read more. (on a written evaluation)—I have no idea how much medicine this person knows. I barely know any myself.
• The family is reasonable.—Family members don’t ask too many questions and will agree with anything you say.
• The patient has xyz.—I’ve read in an old discharge summary that the patient has xyz, but have no idea how they established the diagnosis, what stage it is in, or what the hell xyz even is.
• The head is normocephalic, atraumatic. Pupils are equal, round and reactive to light and accommodation. Sclearae are nonicteric.—If I were to report the physical exam I actually did it would take five nanoseconds, so take these fillers to make it seem like I’ve put in some effort.
• Thank you for the thorough presentation.—Why did you waste my time with all that useless information?
• That’s an outpatient work-up.—Administration is already breathing down my neck because of this patient’s length of stay and you’re worried about a mild anemia and a positive hemoccult!?
• That’s her new baseline.—Her disease is worse and we don’t know why, so I guess she’s stuck with it.
• Please let me know if you have any more questions.—This is the end of our conversation, so please stop talking. I shall now leave.

…to me, this looks flaky. Yes, Scott Adams (of-Dilbert-fame) is right in saying your best bet for success in life is being pretty good in several skills rather than trying to be the best ever in only one. So, a plan like this:

1. Step one: become a decent entrepreneur
2. Step two: become a decent MD
3. Step three: ???
4. Step four: profit!

might indeed be a good idea. However:

• Medicine implies altruism. Entrepreneurship implies greed.
• Programs want their residents to be 100% dedicated to medicine in general and the program in particular. Can you do that with a small business on the side?
• Physicians in academia, i.e. those who conduct residency interviews, forgo 300k+ salaries so they could dedicate themselves to research and education. Are you sure telling them about your latest money-making scheme is a good idea?
• As a resident, do you look at each patient as an opportunity to help them and learn from them, or to figure out how to build a business around them?

Residency programs exist to train physicians, not CEOs. Residency slots are already in short supply. Would program directors give a position to someone who is more likely to end up not practicing medicine at all?

They let us peek into the sausage factory last week.

Nominally, the lecture was about RVUs Relative Value Units.. An accountant type in a pinstripe suit explained why the government came up with the concept and how more RVUs translate to mo' money for the hospital. Then he showed us a table. This is how much RVUs an average ophthalmologist makes in an hour. Here is an orthopedic surgeon. See here at the bottom? That’s an internist. This is how much you’re worth to us, scum. ⊕ Not his actual words. Actually, he sounded very apologetic when explaining it. Still stung though.

Then there was a chart. This is the last fiscal year. This solid line here are monthly RVUs for an average hospitalist. The dotted line is for a single physician in the practice. See how it’s always above the solid line? That’s good. We love that person.

We had medical students and interns just three months into training listen to this. It was blood-curdling.

Not because the hospital organized the lecture, mind you. It is a very good thing they did it, and it is good for doctors in training to realize as early as possible in what kind of a healtcare system they are expected to work. What is frightening is that there needs to be an entity, let’s call it administration, which views the hospital as a production plant and physicians as line workers who need to maximize outputs, optimize efficiencies and do other newspeak claptrap.

Administration usually lies—appropriately—on the ground floor, far removed from that other sausage factory of actual patient care. It looks at pie charts and histograms and RVU tables and keeps coming up with new and exciting ways to increase production while wondering why those bumbling doctors at the bottom of the list can’t do whatever the top performing docs are doing to keep the hospital in the black.

It’s modern medicine, it’s complex, it’s expensive, it requires that level of organization and detachment—you might be tempted to say. Yes, you could indeed say that, if not for the lonely example of every other country in the developed world which does it differently than the US.

But never mind that. With all the shenanigans the Congress has been up to this week, that end of the equation is unlikely to change. What administrators should do—and I understand the banality of the following advice—is see real physicians interacting with real patients for at least and hour each week. Interns being bombarded by page after page—from critical to comical—while trying to figure out a 15-minute window to eat, get coffee and use the restroom. ⊕ At the same time? — a thought will come to them, to be quickly dismissed. Residents finishing a 24+ hour ICU shift that started with three codes and ended with a difficult end-of-life care discussion, with central lines placements and intern supervision—but no sleep—sprinkled in between. Attendings getting yelled at while trying to explain to family members why they need to pay for the medications out of pocket or bring their own[^obs]. ⊕ Hello, observation status.

One hour. Each week. Mandatory. To put things in perspective.

Electronic patient notes, the way they stand now, are dangerous. As physicians wiser and more experienced than myself have noted, they are made for billing, not story-telling and communication between healthcare professionals; and as anyone with even basic literacy in the English language will notice as soon as they read one, they are a barely comprehensible, intelligible, muddled word salad that looks computer generated because, well, in most cases it is.

Why?

For one, they are ridiculously easy to create. Click on a checkbox and every admission note you start will come pre-populated with what the EMR thinks are the patient’s current home medications, prior surgical procedures and such. Have trouble accurately documenting the dozen medications your 72-year-old with systolic heart failure, diabetes, CKD and vascular dementia has? No big deal—the e-patient has at least something listed from an ER visit 9 months ago. You’ll make sure to go back to the admission note later and append it with the correct list when you get it from the family member tomorrow, right? Right.

They also save you from having to type. Click click click, and the review of systems is done. Too much clicking? There is a solution: spend 5 minutes to create a macro, and you will have all your common questions pre-answered as No on all the notes, shaving of seconds of additional clicking. Because asking all your patients the same questions and expecting identical answers is just plain common sense, amiright? Oh, and of course tachycardia is a symptom. It’s right there on the ROS list, waiting to be clicked.

Most of all, electronic notes are the one cure for writer’s block. While in the distant past¹ you had to spend agonizing minutes staring at a blank admission note trying to form a coherent story on why the patient came to be seen, and then try putting it down on paper down without feeling ashamed, you learn from EMR that it is OK to sign a medico-legal document that contains this brilliant turn of phrase:

The reason for visit is: pt missed hd, high bp, n/v. The course was: constant. The exacerbating factor was: none. The alleviating factor was: none.

But why? Medicine residents are, in general, all moderately-to-ridiculosuly smart and ambitious people who should know better.

Well, for starters, some of them don’t. Even in the olden days¹ you had a couple of interns who weren’t the best ever history-takers ⊕ They would be the ones calling the patient “a poor historian”, and were usually correct, although not in the way they intended. Patients are the ones giving a (hi)story, the physician is the historian. and wrote poor-quality notes. Electronic notes, unfortunately, help them obfuscate their deficiencies. It is very easy to see in a one-page note how much useful information the resident has actually obtained. Not so much with computer-generated six-pagers.

Then there is your typical smart intern just finishing putting in orders for her fourth admission admission that day after discussing each one with the supervising resident, all while answering a barrage of pages about the 30 patients she is cross-covering. The first two admission notes are almost done—she has to updated the plan after talking with the resident—but the other two will have to wait until she updates the sign-out and hands off all the patients to the night float. This is arguably much more important than notes as it directly affects the care those newly admitted patients will get overnight, while the admission note is not really needed until the following day during morning rounds. She’s smart enough to prioritize.

She’s also smart enough to know what is expected of her. What she know about writing admission notes during residency she learned from her peers, particularly seniors—who concentrated on efficiency —and that lady at the billing department who gave a noon conference talk on the importance of complete documentation for coding. So The Man wants me to be efficient-yet-thorough, and then he gives me this electronic tool with auto-population, templates, macros and such. Hmmmmm…

Yes, she might get in trouble if her notes are so horrendously bad to significantly impede patient care. From my very limited experience this just does not happen. Or rather, if it does, appropriate documentation is a single bullet in the long list of areas of improvement during an M&M.

What to do?

I don’t care much for spelling or grammar. My native language, Serbian, has no concept of the former thanks to its being phonetic. As for the latter, few people in my home town and the surrounding area cared too much about it, flinging tenses, forms and declinations around carelessly. I proudly continue this tradition.

What gets to me is semantics. Misspelling tachypnoeic is unfortunate; saying that the patient’s head is normocephalic means either that it had grown a head of its own, or that the speaker had no idea what the word they were using signified. Never mind that an average internists sees an abnormality like dolichocephaly once every 10 years—thus obliviating the need to say that someone’s head has a normal shape in each and every admission note. Not that most physicians would recognize dolichocephaly if and when they saw it.

So anyway, lots of big words and a sizable footnote just to introduce something I’ll likely be doing on a weekly basis—complaining about today’s youth and their improper use of medical verbiage. Lets pretend that my entire medical experience thus far does not consist of just over two years of IM residency. Also, English is not my primary language.

Carry on.