Overworked doctor trying to focus.

Graduating from medical school in 1978, I started my hellish internship while reading Samuel Shems 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 disillusioningbut 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 Shems new book, Mans 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 thingscorporate greed and electronic medical records, which are like conjoined twins. Theres 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 Shems writing.

In the olden days, for example, I used to graph out when each antibiotic wasstarted and stopped on the TPR sheetthe hand written graph the nurses charted the patients 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 didnt 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 Ive 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 hospitals 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 Ive 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 patients 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 dont take a temperature, you cant find a fever.

Those EMRs were problematic, but nothing like the new generation.

Epic and newer EMRs

HAMILTON, MA - JULY 2: The pop-up on this fictitious patient's electronic health record shows ... [+] drug-disease interactions. Dr. Hugh Taylor , with Family Medicine Associates, in Hamilton, talks about records, on Wednesday, July 2, 2014. (Photo by Pat Greenhouse/The Boston Globe via Getty Images)

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 cant 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 Mans 4th Best Hospital is HEAL, described by its President Krashinsky, For billingwe monetize.As protagonists Dr. Roy Basch and Berry reminisce,

The choice in medicine back then? The Fat Mans 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. Its also unclear how Lancaster General, the other hospital in town, can absorb the additional patientsas well ashow 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 Armys AHLTA; I hear pretty good things about the VAs 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. Theyd become more disconnected; less likely to see and help one another, and often less able to.

Man's 4th Best Hospital cover

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,

Its not burnout. Its placing doctors in a moral bind. Its like being in a war you dont believe in. That kind of thingIts abuse of doctors, simply put. Because we cant practice the way we want to. Were 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,

its our job, being with patients at the crucial times in their lives, yes, illness, old age, and deathwell suffer less, spread less suffering around andheal. 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 Mans mantra, that sometimes Less is more.

The Laws of Mans 4th arent 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.

Read more:
Electronic Medical Records, Burnout, And Mans 4th Best Hospital - Forbes