And the Dander Keeps On Rising

This is número cinco in our series of attempts to shed some of this dander. But it keeps on rising. Here are two recent reports both relating to the life-on-the-ground of North American rank and file physicians, especially as that life increasingly revolves around data entry and digital madness over and above everything else.

Are physicians suffering from acute, maybe by now chronic, PTSD? In the 20 March 2018 number of the important Boston Globe-affiliated newsfeed STAT, Elizabeth Métraux, a prolific staffer and author at the eminent organization Primary Care Progress, gives us another quite useful take on physician burnout. An Iraq War veteran herself, the author gives us a provocative title that
pretty much says it all: "I experienced trauma working in Iraq. I see it now among America’s doctors." Her diagnosis is stark.

[A]s a health care advocate who has struggled with PTSD, it’s clear to me that many of our country’s health care providers are struggling with trauma, as well. And we’re doing little to support them.

Here's another snippet of conversation she recently had with a phyhsician colleague who'd also served in Iraq.

You know, I’d go back to the field any day. Beats practicing in my clinic. ... I didn’t become a doc to put up with billing codes and power struggles. I thought that PTSD would hit when I came home from Fallujah. It’s so much worse when I come home from the office. Truth is, I’ve lost my sense of purpose.

In what she terms "tiny betrayals of purpose," the death of 1000 tiny cuts, she outlines the extent to which the endless obsession by bosses with data entry and charge capture, the eight-minute patient encounter, the constant deflection of attention away from the patient all the while marketing and admin people are trumpeting "patient-centered everything" to their "customers," all of these have taken their toll.

Unfortunately, the usual caveat applies: making the diagnosis is a lot more straightforward than establishing the right therapy for the PTSD viewed by every student who rotates through a preceptor's community office: rapidly driving the best and brightest young physicians away from primary care. The author suggests the patient turn around and ask the physician how she is doing. But much more structural reform will be needed to curb these excesses and reverse these trends. Higher pay would be a fabulous start, not to mention forgiveness of medical school loans.

Less empathic but no less important: revenge of the EHR--more paper records than ever, revealing private information. A fascinating research letter published the same day in JAMA (behind paywall), out of several hospitals in Toronto, Ontario, reveals still more new--but actually, hardly new at all--issues raised by perverse effects of Electronic Health Records. More, not less, paper documents are being discarded because of the EHR. The investigators spent about half a year auditing all the recycling-bound paper from five hospitals. The results are arresting. Here are the key take-aways. Bear in mind the context: these institutions had Protected (Personal) Health Information (PHI) policies; they also had recycling bins and shredders where they needed to be.

• Nearly a ton of paper was examined including nearly 3000 discrete documents.
• The study was multi-institutional.
• Every hospital contained examples--lots of examples--of PHI discarded in both in- and out-patient settings.
• Over 2500 documents containing PHI were found, including over 1000 with highly sensitivbe information (defined as including both diagnoses and descriptions of patients' conditions).
• The vast majority of these documents were found in out-patient settings.
• The highest proportion of PHI-containing documents was found in physicina offices--not hospitals or institution-bound clinics.
• Paper records were impossible--in distinction to electronic privacy breathes--to trace with respect to identifying responsible individuals.
• The authors reported no actual harms accruing to the documents' discovery.

The biggest drawback of this study was its focus on recycling materials, as opposed to other random discards. But recycling does not means properly-disposed-of, so the data are important. Most important is the Revenge Effect, to quote from Edward Tenner's important analysis of technology's impact, of the EHR.

To any of those of us who've lived this scenario, it all sounds drearily familiar. EHR allows managerialism to run rampant in terms of up-coding and adherent to more often than not perverse incentives around Meaningful Use of EHRs. Not to mention outright abuse. But it actually produces all sorts of other perverse effects. One near and dear to our hearts is the "credit" for printed "Clinical Summaries cited as "performed" in EHR databases, but actually abandoned on printers. And, when retried, lacking any information on the clinical plan--essentially only listing medication lists that are often dangerously erroneous.

Now, from Toronto, but we already knew this, we're reminded that EHR didn't do away with paper. Because so much paper comes in and gets scanned to EHR, it is rather more pervasive--but now discarded in the wrong palce--than ever.