Day in the life of Dr. Joe

Introduction:

(My daughter asked me to write seven blesings for her marriage ceremony....)

Marriage is a grafting of one family tree to another to create a new and unique family. The new branch has the strengths of the trees of origin, and wondrous new possibilities all its own.

Marriage is a special set of promises made sacred by the public declarations of love and commitment.  All who attend the ceremony hold the promise and all present are part of the marriage.

Marriage is unique in the hopes, possibilities, and opportunities it creates.

We hereby ask for the fulfillment of these blessings inherent in marriage:

May your marriage be always a space and a time of safety and security, protecting you from dangers within and without.

May you marriage provide you with encouragement to do all you must and be all you can, nurturing you to be strong and resilient.

May your marriage make you tingle with excitement and thrill  with stimulation of each other,of your dreams and of your world.

May your marriage always be  the place you can share your hearts, your minds, and your experiences, as well as your fears, your angers, and your disappointments, in secure intimacy.

May your marriage every day be source of joy and peace.

May your marriage be the fertile soil for the growth of your future selves and your future partnership, blossoming in your individual and joined lives.

 May your marriage be from today into forever, standing upon the lines of your family and continuing for generations to come.

On October 1, 2015, the government of the USA mandated the use of the International Classification of Diseases version 10 (known as ICD-10) for all diagnostic coding.















A patient came to see me recently, after October first, having a soccer injury: he was cleated on his right great toe. Examination showed he had a minor, fracture of his right great toe and a painful subungual hematoma (blood under the nail). The coding starts out easy: W21.31XA: "struck by cleats, initial encounter". Then it proved more difficult: S92.424A: "Non-displaced fracture of right great toe, distal phalanx, initial encounter, closed". It was s much more difficult in that there are tens of thousands of fractures in the list. Sorting them is a Herculean task. The last code proved impossible. There is NO specific code for a subungual hematoma. None. Internet research showed that many toenail diagnoses are all listed under L60.8 - “Other nail disorders”:

Acquired nail displacement
Acquired nail discoloration
Congenital clubnail
Congenital koilonychia
Congenital malformation of nail
Hemorrhage of the nail (subungual) (HERE IT IS!)
Leukonychia (punctata)
Leukopathia unguium
Onychophosis
Onychoptosis (pitting)
Congenital flat nail - platonychia
Acquired remnant nail
Fngernail shedding
Spading nail  

These diagnoses have no biological, pathological, diagnostic, therapeutic, or any factor in common, other than they have to do with "nail". No mention is made of right or left, finger or toe, number of digit, or anything else that clarifies to a level parallel to that provided for fractures. They are all classed under one code. It is unfathomable how this clumping of unrelated diagnoses could ever serve research, teaching, patient care, or standardization of the medical record.


And yet we are mandated to use this system. Billions of dollars have already been spent. A divide in data-continuity has occurred: all the data prior to 11/1/15 is obsolete and does not map into ICD-10.  I may just set my water-skis on fire, jump off, and see what happens!

(This is a first draft. If anyone cares to comment I will expand on the idea)


My fellow Americans.  I come before you today to delivery my State of the Union Address.  I have two versions of the speech with me. In my right pocket is the version prepared by my speech writers. It tells of the success of the Affordable Care Act, the success of our military, and our success at revitalizing the economy.  In my left pocket is the speech I wrote last night, late into the night.  I may look tired to you: I got little sleep. But I feel my heart is lighter and my eyes brighter, for I have resolved to tell you the truth and to shed the cloak of politician and to assume my robe of responsibility, for the position to which I was elected, as the leader of the greatest nation ever on this earth.

Before I describe the State of the Union and my intentions for the future, let me address the lessons I have learned.

The Affordable Care Act, known to all as “Obama-Care”, is a spectacular example of the failure of our government.  Intended to provide affordable health care for every American, it has already succeeded in raising the cost of health care by thirty five percent. Our federal budget will be increasingly difficult to balance without Draconian cuts in the number of hospitals and the services they provide. Experienced physicians are retiring ten or twenty years before they had intended, and medical school is no longer a goal for our best and brightest.

 Previously uninsured young people are now strapped with insurance policies that they will never use with no coverage for the health care they actually use: the average uninsured twenty eight year old, before Obama-care, would have less than $300 per year in health care expenses, and for the next decade, a total of under $3000.  Now at a cost of $4,000 per year and a deductible so high it will never be met, the ten year cost to the young adult for insurance they will unlikely use is $40,000: nothing is left for paying the bills.

The regulations generated by the Affordable Care Act now exceed the length of all other regulatory agencies rules.  Compliance is an impossible burden on the industry attempting to deliver quality health care.

Why did this happen?  The political process is corrupted by reliance on the wrong advisers.  I did not listen adequately to the American people or the true experts in health care, the doctors and the nurses.  I listened to the insurance companies, the only part of our culture that will profoundly benefit from the Affordable Care Act.  In my dream of protecting the American people I made government much bigger and the middle-man much profit. I now see that we have hurt the ancient science and art of medicine. I pray it is not irrevocable damage.

The Law of Unintended Consequences rightfully predicts that the more far-reaching and complex the changes made, the greater the number and impact of the unintended consequences.

How do I fix it?  I am not wise enough or informed enough to have that answer.  I know now I need to go outside government for advisers to guide me. 

Let’s turn to the economy and education.  Yes: my right-pocket speech correctly states that more Americans are working today than before the recession.  But it does not tell the whole truth.  Well educated Americans, with decades of experience in industries requiring highly technical training and experience, have lost their jobs and are now working at jobs for half or less of what they previously earned, with no need of their education or experience.  Fresh college graduates are having a hell of a time finding rewarding jobs. Advanced degrees are no long a promise for fulfilling employment in any field of expertise.

My right-pocket speech promotes higher education, but the reality is the time and expense for attaining advanced degrees does not provide good vocational training,  and, sadly, is decreasingly good education for broad knowledge or critical thinking.  We must seriously reevaluate our educational system and our priorities.

As the president, I must seriously consider the role our government has played and should play in the future of education.

The three hundred richest in the world have more money than the poorest three billion.  That is 0.00000004% of the world has more combined financial wealth than 40% combined.  We cannot fix the world: we are not empowered to even consider it. But the top 1% of all Americans control more wealth than the combined 99% .  Middle class Americans, the new “poor”, contribute 20% of their earnings to taxes.  The top earners pay nothing.  Maybe this is fair, but it surely does not seem so.  On the face of it, a flat tax rate of 5% on all the earnings of all Americans living above the poverty level would allow us to balance the budget and to carry on all our good work.  A family earning $65,000 per year would have $10,000 real dollars back in their pocket every year.  Halliburton’s CEO would still go home with over $30,000,000, but would contribute $1.5 million to the tax coffers!

It is not the government's job to equally distribute wealth, but it is our creed to be fair and equitable. Real tax reform, returning to simplicity and justice, seems imperative. 

In the past century, with our successes in the two World Wars and the establishment of the United Nations, we have taken on the job of being the policemen for the world.  With our might and our successes in all fields we have become the envy and the enemy of many.  September 11, 2001 brought the terrorists effectively and horribly to our great land.  Since that time there has been a steady increase in worldwide terrorist strength. Armies, no longer isolated terrorist cells, are rising and arming.

Above all else, the central government of this country is charged with  protection from foreign assault.  This must be a central goal.  I believe that our best effort will be to use our intelligence and resources to get to the root of the problem and work to regain the trust and respect of the world.

In the past century, the world population has gone from little over a billion human residents to over seven billion.  In the next fifty years, probably less, the number will exceed fifteen billion. The worldwide basic infrastructure of food, clean water, and energy will never sustain these numbers. We need to be in action now.  The consequences of failure will be famine, illness, and death.  And war.

Climate change is an inevitable reality.  Our best efforts to change human behavior may slow down but will not stop the inevitable.  We need to be in action now to be prepared for the inevitable.  If we do not begin to shift the direction of our attention to remediation and not delay, we will be caught underwater.... and worse.

My fellow Americans: I have learned a lot during my presidency, and my time in office is not yet over.  I hereby declare that I am no longer a politician. I will live and breathe every moment to be leader to the best of my ability.  I am sure I cannot fix the problems that I have outlined, but I will endeavor to change the culture of the office of president of the United States.  I will listen widely and seek out the informed dissenting views. I will work to make government smaller at every turn to avoid the unintended consequences of our over-reach.  I will work to inspire the confidence that has been the hallmark of the American people.  I will work to truly protect our shores, protect our people, most specifically the most needy, and I will work to set America as the shining beacon to all peoples of the world.

(Links:  The US Constitution
              The ACTUAL State of the Union Address )

I.

In horror I read of the three guns carried by the Connecticut mass murderer. One gun was not yet identified in the press. The other two were a Glock handgun and a Sig Sauer semiautomatic rifle, favorites of military and law enforcement and gun enthusiasts for their “stopping power” and reliability. I visited the link to a gun enthusiasts’ video on the Sig Sauer, capable of firing faster than ten shots in a second and firing a bullet that causes a half inch entry wound with an exit wound the size of a basketball.

I could not help but see in my heart and mind the bodies of schoolchildren dead with exit wounds the size of basketballs.
It is very hard not to die when shot at close range with a Sig Sauer or a Glock.
I then searched for “constitutional legal arguments against gun control” and read several long legal briefs published in a number of law journals and reviews. I was impressed with the erudition. I was surprised by the gist of the arguments: our right to bear arms is historically necessary.
When the Bill of Rights was written, we had just triumphed in a war for independence from the rule of a perceived tyrannical king of a vast empire. We the people had no established army: we were a rag-tag rebellion, primarily fighting as militias, armed with our own firearms. True, an army and even a navy were cobbled together, but the war was fought by citizen soldiers of local organized militias.
When the Bill of Rights was written, we feared tyranny and we feared that a clever tyrant would protect his reign by limiting our ability to defend ourselves. Lest we fall prey to homegrown or foreign tyranny, we insisted on the necessity of militias. We needed to be able to arm ourselves to protect ourselves. The second amendment to the constitution gives us the undeniable right to bear arms so that we can form militias to protect ourselves from such an eventuality.
And so that she could be part of a militia to protect we the people, the middle aged mother of her matricidal and innocent-murdering son owned three or more weapons of great firing speed and reliability and stopping power in order that she be at the ready to ward off tyranny and protect the American Way?
I do not think so.

• We do NOT have the constitutional right to own guns for individual self-protection.
• We do NOT have the constitutional right to own guns for hunting for sport or food.
• We do NOT have the constitutional right to own guns for a pretty collection.
• We do NOT have the constitutional right to own guns just because we want to own guns.

We DO have the constitutional right to own guns so that we may form militias.
Militias may exist to protect us from the government if it were to become corrupt and threaten our liberties or our lives. Militias may exist to support the government if the formed military is inadequate to the task of protecting us from outside threats.
I, for one, cannot see that these beliefs are at all central to the belief or practice of the vast majority of gun owners.
I, for one, cannot see and that this precept is at all meaningful or at all viable in the United States of America of today.

GIGO

Part 2 of "The Medical Record"

"Garbage in, garbage out", GIGO, is a term that computer geeks have used since the early days of computer mainframes in the 1950's. Computers make impressive charts and graphs. Computers make impressive data displays. If the information entered is wrong, so is the output.

I am concerned about the methodologies used to enter data into the electronic medical record. While the old handwritten chart was prone to human error and illegibility, the new record seems to magnify the errors and present them legibly and authoritatively.

I currently have a patient in the hospital admitted (as most are) through the emergency department. The ER is the first department in the hospital to have doctors and nurses notes computerized. In the very first doctor entry in her chart, the ER doctor's note, in the very first paragraph, she is described as in "no distress and well hydrated", as well as being "grey, comatose, and with dry mucous membranes" (a cardinal sign of severe dehydration). How can she exhibit all these contradictory findings?

The answer is twofold: templates and checklists.

Of course, in the end, it is the responsibility of the physician to ensure that that notes are not only sensible, but truly reflect his observations and understanding.

The computerized record, however, allows and enables, if not encourages, GIGO.

There are far too many men who have medical records recording their pelvic exams and make note of their previous hysterectomy, as well as women who are recorded as having normal testicular exams. Why? Surely, not because of an epidemic of hermaphroditism, but, rather, a rash of checklists. GIGO.

Despite the epidemic of obesity, and the documentation of patient weights, the record nearly always describes the individual as "well nourished". Why? Surely not because of a hesitancy to label the 400 pound patient as obese, but, rather, templates. GIGO.

Templates push square patients into round descriptions.

Checklists enable clickety-click instead of thinkety-think.

I fear that we are becoming unthinking extensions of our technology. The nursing tech recording vital signs enters a temperature of 95.3 into the computer without a second thought, and without a gaze at the flushed red flesh or a touch of the feverish forehead. GIGO.

The Design of the Medical Record
Part 1

The hospital medical record has existed since hospitals began. There are ancient Greek archives of Hippocrates' "Cult of Aesculapius" whose temples were the sites of the first recorded gathering places for care for the ill: primitive hospitals. Hospitals have evolved far in the past two millennia. The medical record evolved.

There was a revolution in hospital care that occurred in the sixth decade of the twentieth century, following WWII and the Korean War. Surgical care had progressed by leaps and in-patient medical care was progressing rapidly. The medical record evolved to serve as documentation and communication tool.

At the end of the sixties, the growth in hospital care was exponential. The entire scope of the medical record was carefully studied and intentionally designed. To a very great degree the medical record was standardized across America. The medical record as a tool of documentation and communication reached its pinnacle in the mid seventies.

The hospital medical record consisted of the following elements:
• Demographics
• Emergency room record
• History and Physical
• Physicians' progress notes
• Nursing notes
• Vital signs
• Consultation notes
• Procedure notes
• Laboratory reports
• Imaging reports
• Therapy reports
• Doctors' orders
• Discharge summary

A separate section of the chart held consent forms.

Each of the elements had its own tab in the binder. Other than the lab and imaging reports and the demographic face sheet the entire chart was hand-written. In some institutions, the doctors and nurses charted in the same progress note section. Sometimes the entire physician documentation, from emergency room, H&P, progress notes, and consultations were all in a single tab, written and stored chronologically sequentially.

What was most striking about the chart was the rigorous way that physicians and nurses documented their observations and their assessments. In particular, physicians delineated their diagnostic thought process and their therapeutic decision making. Everything was communicated and available in a well organized chart.

Granted, there was vast variation in compliance with this model. Physician poor handwriting was already a hackneyed joke. Some doctors just did not respect the value, beauty, and sanctity of the medical record.

The "problem oriented record", formulated by Dr. Weed, and adopted by the entire medical community in the late sixties was at the heart of the structure of the medical record. The chart contained a standardized PROBLEM LIST, with dates of onset and dates of resolution of each problem, with the problem described by the "highest degree of resolution". A problem initially listed as "abdominal pain" might later be resolved to "acute peritonitis" and later to "acute sigmoid diverticulitis with localized peri-colonic abscess". Each progress note referenced the problem list.

The progress notes were in the now famous SOAP format, summarizing the patient's subjective reporting, the doctors' (or nurses') objective observations as well as pertinent laboratory or imaging data, the professionals' assessment of each problem and a problem oriented plan.

The notes were sequential and clearly told the story of the hospitalization. The structure facilitated communication and decision making.

The initial "history and physical" had a structure that dates back to the early twentieth century. It was a careful record of the patients presenting complaint, a detailed history of the present problem, a summary of the past medical and surgical history, as well as family, and social data. A "review of systems" systematically reviewed the patients current reporting of any symptoms not clearly relevant to the presenting problem. Then came a structured comprehensive examination report, followed by a review of all the lab or ancillary data available at the time of admission. Next, the patient's condition was carefully analyzed in the assessment: the problem list was here generated. The preceding data was synthesized and a tentative series of diagnoses recorded. The thought process was delineated. The assessment was followed by the plan: how the doctor intended to proceed with treatment and diagnostics. The rationale was described.

Procedure notes and surgery notes had standardized structure and were included in the sequential flow of the chart.

At the conclusion of the hospitalization, a discharge summary was prepared, summarizing the entirety of the hospitalization.

In the design of a medical record for a new medium in a new millennium, the computerized medical records of the twenty-first century, it is incumbent on the creator to, at the least, maintain the working structures of the paper chart. Since no model has ever proven as valuable as the problem oriented record, it would seem obvious that the design of the electronic record should facilitate the production of an equally valuable record. Perhaps the high structure of database technology could even renew the values of the ideal record that have been lost, abandoned, or made sloppy by the past four decades of medical evolution. It is surely offensive and wrong for the system designer to impose models of data entry, recording, and retrieval that fit some model of program design, but that do not promote a medical record model that has been time honored by the medical profession.

Many forces in society, primarily government and financial institutions (third party payers) are placing tremendous pressure on the medical profession to conform to a model of medical practice that is foreign to our science and our traditions. It is fully acceptable for the medical record to serve as a tool for those forces if and only if the principles and values of the practice of medicine are not thereby compromised. Since the same forces are driving the institution of the electronic medical record, it is incumbent on the designers of that tool to honor our medical record.

When I was in medical school I had friends in law school. Late in our first years of training in our chosen fields, I had an epiphany. It was not at all about the information that we were learning, it was about the thought process. The medical students were being taught to think like doctors and the law students to think like lawyers. Both professions are, in most ways, about problem solving. There was a major difference in the problem solving processes taught.

In medicine we gather data, our history, physical exam, test results, and exploration. Along the way we are juggling the data and fitting to patterns. At some point we prescribe or perform a procedure to attempt to fix the problem. If the fix fails, we regroup and try again: gathering data, pattern fitting, trying to solve. All the human players are on the same team, the doctors, nurses, technicians, as well as the patient and the family: the enemy is disease or dysfunction afflicting the patient. Precision and speed are essential. Caring and compassion are essential as well.

In law the process has a different flavor. Although there is information gathering, the process is adversarial. There are winners and losers, and the battle goes to not necessarily to the best solution, but to the the best fighter. Perhaps justice is served, but all the combatants are bloodied. Surely there are "principles of law" that are based on millenia of sorting of human civilizations' wranglings with conflicts between people. But the lawyers thought process is taught about the minutia and techniques that win the battle, not for what is right, but how to win.

I watched as my law student friends became lawyers: arguing their points with ferocity and skill. I watched as my budding medical colleagues became expert in data analysis and complex human bio-psycho-social systems.

Tonight I had another epiphany.

It has been the in last forty-five years, and particularly the past thirty, that health care delivery has shifted and declined. I blame the decline on the shot-gun wedding of government/business with medicine. Under duress, medicine was forced to accept governmental intervention and control and subsequent business interference. The intrinsic thought process of physicians is incompatible with the legalisms of government and the imperatives of the marketplace. The medical model has been supplanted by a business model and legal process. I fear that the new generation of physicians will be taught to think like businessmen, lawyers, and politicians. I see it already.

My generation of physicians are retiring early, unable to practice as the physicians they were molded to be. Few physicians appreciate the interference and control of Medicare and the myriad insurers. The adversarial relationship is foreign to us: it just does not work for us. We are forced to argue with representatives over even the most trivial things.

This morning I was making rounds at the hospital. I needed to write orders, write a progress note, and obtain written consent from a patient for her blood transfusion. I had to search through racks of ninety-six (I counted) different forms to find these three sheets. Of course, half the chart information is not paper, but is in the computer. Despite the computerization there are over one hundred required forms. Thirty years ago there were less than half a dozen forms in the chart. Forms and paperwork are part of the legal mind-set, not the medical world.

I believe the ever-rising cost of health care and the ever-declining esteem and honor of my profession is a direct result of the spawn of that wrong-minded marriage.

I received the thick envelope from Medicare today. They are demanding I repay them because they erroneously overpaid me. The letter details the rules and regulations regarding the necessary repayment. It details my rights for dispute (but makes it clear that such appeal is hopeless). It details the penalty of 10.875% interest on the amount due if not repaid within thirty days. (I assume this is an "annual percentage rate", but it never says that. By gosh! It could be a daily or monthly rate!) If I do not pay by December 3, 2011, they will withhold all my Medicare payments. I am allowed to make an extended payment plan, and I am allowed to certify that I am bankrupt or unable to pay because of other financial difficulty (three more pa ges to so certify).

And then there are the listings of the overpayments.

There are sixty-two incidences where they overpaid me, from February until June of 2010. The amounts of overpayment range from one cent (really! eighteen of the errors were less than a nickel!!) to whopping $1.04. The average amount is forty cents.'

So I am immediately sending them back the $24.63 they demand as soon as I am able (TODAY!) lest I incur the wrath of this bureaucracy!

Their rules. Their error. Their threats. Their ridiculous recouping of this pittance.