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Editorials

Last 50 Editorials

(Click on title to be directed to posting, most recent listed first)

More Medical Science and Less Advertising
The Need for Improved ICU Severity Scoring
A Labor Day Warning
Keep Your Politics Out of My Practice
The Highest Paid Clerk
The VA Mission Act: Funding to Fail?
What the Supreme Court Ruling on Binding Arbitration May Mean to
   Healthcare 
Kiss Up, Kick Down in Medicine 
What Does Shulkin’s Firing Mean for the VA? 
Guns, Suicide, COPD and Sleep
The Dangerous Airway: Reframing Airway Management in the Critically Ill 
Linking Performance Incentives to Ethical Practice 
Brenda Fitzgerald, Conflict of Interest and Physician Leadership 
Seven Words You Can Never Say at HHS
Equitable Peer Review and the National Practitioner Data Bank 
Fake News in Healthcare 
Beware the Obsequious Physician Executive (OPIE) but Embrace Dyad
   Leadership 
Disclosures for All 
Saving Lives or Saving Dollars: The Trump Administration Rescinds Plans to
Require Sleep Apnea Testing in Commercial Transportation Operators
The Unspoken Challenges to the Profession of Medicine
EMR Fines Test Trump Administration’s Opposition to Bureaucracy 
Breaking the Guidelines for Better Care 
Worst Places to Practice Medicine 
Pain Scales and the Opioid Crisis 
In Defense of Eminence-Based Medicine 
Screening for Obstructive Sleep Apnea in the Transportation Industry—
   The Time is Now 
Mitigating the “Life-Sucking” Power of the Electronic Health Record 
Has the VA Become a White Elephant? 
The Most Influential People in Healthcare 
Remembering the 100,000 Lives Campaign 
The Evil That Men Do-An Open Letter to President Obama 
Using the EMR for Better Patient Care 
State of the VA
Kaiser Plans to Open "New" Medical School 
CMS Penalizes 758 Hospitals For Safety Incidents 
Honoring Our Nation's Veterans 
Capture Market Share, Raise Prices 
Guns and Sleep 
Is It Time for a National Tort Reform? 
Time for the VA to Clean Up Its Act 
Eliminating Mistakes In Managing Coccidioidomycosis 
A Tale of Two News Reports 
The Hands of a Healer 
The Fabulous Fours! Annual Report from the Editor 
A Veterans Day Editorial: Change at the VA? 
A Failure of Oversight at the VA 
IOM Releases Report on Graduate Medical Education 
Mild Obstructive Sleep Apnea: Beyond the AHI 
Multidisciplinary Discussion (MDD) in Interstitial Lung Disease; Some
   Reflections 
VA Administrators Breathe a Sigh of Relief 
VA Scandal Widens

 

For complete editorial listings click here.

The Southwest Journal of Pulmonary and Critical Care welcomes submission of editorials on journal content or issues relevant to the pulmonary, critical care or sleep medicine.

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Monday
Jan282019

More Medical Science and Less Advertising

A recent article appeared in JAMA Open Access reporting that wait times to see a provider in the Department of Veterans Affairs (VA) have improved (1). You might remember that in the not so distant past the VA was embroiled in a controversy for reporting falsely short wait times (2). The widely publicized scandal was centered in Phoenix and led to the firing, resignation or retirement of a number of administrators in VA Central Office, the Southwest Veterans Integrated Service Network (VISN) and the Phoenix VA. What was not as well publicized, but perhaps even more disturbing, was that up to 70% of VA facilities also were reporting deceptively shortened wait times (3). Congress appropriated additional money for the VA to fix the wait times but it is unclear how the money was spent (2).

Now the VA reports that the wait times have shortened and compares favorably to the private sector. The VA’s history has to lead to some skepticism about the data. Is it true? Is it accurate? The short answer is that we do not know because the VA data is largely self-reported. The VA used a different method, the secret shopper approach, for the private sector assessment. In this method a caller requests a routine appointment with a randomly selected care physician in a given health care market. The reported VA data may not be representative of the VA as a whole. Only some metropolitan areas were selected and did not include non-metropolitan facilities and no facilities from the Southwest VISN where there was a known problem. Furthermore, the data is only for new patients requesting a primary care, dermatology, cardiology, or orthopedic appointment. Data for wait times to see other specialties is not reported.

An accompanying editorial by two VA investigators does a good job in explaining the nuances of the study (4). Editorials in response to a specific article are often authored by the reviewers. If these editorial authors were also the article’s reviewers, they can hardly be blamed for saying nice things about the manuscript since “biting the hand that feeds you” is usually a dangerous practice. However, why JAMA published the article in the first place is puzzling. Certainly, lack of timely access to healthcare is very important and lack of access has been associated with higher costs and worse outcomes (4,5). However, this article reports nothing about how the VA achieved this improvement in access. Was it by hiring additional physicians to see the patients or by hiring additional scheduling clerks or additional practice extenders such as physician assistants or nurse practitioners?

The VA data could be easily manipulated. If access by a limited number of new patients is all that is being reported, there may be a tendency to underfund other areas. What about other specialty areas such as oncology, nephrology, pulmonary, neurology, general surgery, ENT, audiology, and ophthalmology to name just a few? What about established patients? What about financial incentives? Were the administrators given bonuses for improving access in these highly selected areas but none or less in others? This is the system the VA used during the wait times scandal and likely contributed to the falsification of data (6).

As it now stands the manuscript represents more advertising than medical science. Medical journals owe their readers better. Hopefully, we at the Southwest Journal are doing a better job of publishing articles that allows the practitioners to better care for their patients and not administrators make their bonus.

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Penn M, Bhatnagar S, Kuy S, Lieberman S, Elnahal S, Clancy C, Shulkin D. Comparison of Wait Times for New Patients Between the Private Sector and United States Department of Veterans Affairs Medical Centers. JAMA Netw Open. 2019 Jan 4;2(1):e187096. [CrossRef] [PubMed]
  2. Wagner D. Seven VA hospitals, one enduring mystery: What's really happening? The Arizona Republic. October 23, 2016. Available at: https://www.azcentral.com/story/news/local/arizona-investigations/2016/10/23/va-hospitals-veterans-health-care-quest-for-answers/90337096/ (accessed 1/25/19).
  3. 60 Minutes. Robert McDonald: cleaning up the VA. Aired November 9, 2014. Available at: http://www.cbsnews.com/news/robert-mcdonald-cleaning-up-the-veterans-affairs-hospitals/ (accessed 1/25/19).
  4. Kaboli PJ, Fihn SD. Waiting for Care in Veterans Affairs Health Care Facilities and Elsewhere. JAMA Netw Open. 2019 Jan 4;2(1):e187079. [CrossRef] [PubMed]
  5. Roemer MI, Hopkins CE, Carr L, Gartside F. Copayments for ambulatory care: penny-wise and pound-foolish. Med Care. 1975 Jun;13(6):457-66. [CrossRef] [PubMed]
  6. Robbins RA. VA scandal widens. Southwest J Pulm Crit Care. 2014;8(5):288-9.

Cite as: Robbins RA. More medical science and less advertising. Southwest J Pulm Crit Care. 2019;18(1):29-30. doi: https://doi.org/10.13175/swjpcc005-19 PDF 

Cite as: Robbins RA

Friday
Jan252019

The Need for Improved ICU Severity Scoring

How do we know we’re doing a good job taking care of critically ill patients? This question is at the heart of the paper recently published in this journal by Raschke and colleagues (1). Currently, one key method we use to assess the quality of patient care is to calculate the ratio of observed to predicted hospital mortality, or the standardized mortality ratio (SMR). Predicted hospital mortality is estimated with prognostic indices that use patient data to approximate their severity of illness (2). Examples of these indices include the Acute Physiology and Chronic Health Evaluation (APACHE) score, the Simplified Acute Physiology Score (SAPS), the Mortality Prediction Model (MPM), the Multiple Organ Dysfunction Score (MODS), and the Sequential Organ Failure Assessment (SOFA) (3).

Raschke et al. (1) evaluated the performance of the APACHE IVa score in subgroups of ICU patients. APACHE is a severity-of-illness score initially created in the 1980s and subsequently updated in 2006 (4,5). This index was developed using data from 110,558 patients from 45 hospitals located throughout the United States, and encompassed 104 intensive care units (ICUs) including mixed medical-surgical, coronary, surgical, cardiothoracic, medical, neurologic, and trauma units. The final model used 142 variables including information from the patient’s medical history, the admission diagnosis, and physiologic data obtained during the first day of ICU admission (4). Although it subsequently has been validated using other large general ICU patient cohorts, its accuracy in subgroups of ICU patients is less clear (6).

To benchmark whether the APACHE IVa performed sufficiently, Raschke et al. (1) employed an interesting and logical strategy. They created a two-variable severity score (2VSS) to define a lower limit of acceptable performance.  As opposed to the 142 variables used in APACHE IVa, the 2VSS used only two variables: patient age and need for mechanical ventilation. They included 66,821 patients in their analysis, encompassing patients from a variety of ICUs located in the southwest United States. The APACHE IVa and 2VSS was calculated for all patients. Although the APACHE IVa outperformed the 2VSS in the general cohort of ICU patients, when patients were divided into subgroups based on admission diagnosis the APACHE IVa showed surprising deficiencies. In patients admitted for coronary artery bypass grafting (CABG), the APACHE IVa did no better in predicting mortality than the 2VSS. The ability of APACHE IVa to predict mortality was significantly reduced in patients admitted for gastrointestinal bleed, sepsis, and respiratory failure as compared to its ability to predict mortality in the general cohort (1).

The work by Raschke et al. (1) convincingly shows that APACHE IVa underperforms when evaluating outcomes in subgroups of patients. In some instances, it did no better than a metric that used only two input variables. But why does this matter? One might argue that the APACHE system was not created to function in this capacity. It was designed and validated using aggregate data. It was not designed to determine prognosis on individual-level patients, or even on subsets of patients. However, in real-world practice it is used to estimate performance in individual ICUs, which have unique cases mixes of patients that may not approximate the populations used to create and validate APACHE IVa. Indeed, other studies have shown that the APACHE IVa yields different performance assessments in different ICUs depending on varying case mixes (2).

So where do we go from here? The work by Raschke et al. (1) is helpful because it offers the 2VSS as an objective method of defining a lower limit of acceptable performance. In the future, more sophisticated and personalized tools will need to be developed to more accurately benchmark ICU quality and performance.  Interesting work is being done using local data to customize outcome prediction (7,8). Other researchers have employed machine learning techniques to iteratively improve predictive capabilities of outcome measures (9,10). As with many aspects of modern medicine, the complexity of severity scoring will likely increase as computational methods allow for increased personalization. Given the importance of accurately assessing quality of care, improving severity scoring will be critical to providing optimal patient care.

Sarah K. Medrek, MD

University of New Mexico

Albuquerque, NM USA

References

  1. Raschke RA GR, Ramos KS, Fallon M, Curry SC. The explained variance and discriminant accuracy of APACHE IVa severity scoring in specific subgroups of ICU patients. Southwest J Pulm Crit Care. 2018;17:153-64. [CrossRef]
  2. Kramer AA, Higgins TL, Zimmerman JE. Comparing observed and predicted mortality among ICUs using different prognostic systems: why do performance assessments differ? Crit Care Med. 2015;43:261-9. [CrossRef] [PubMed]
  3. Vincent JL, Moreno R. Clinical review: scoring systems in the critically ill. Crit Care. 2010;14:207. [CrossRef] [PubMed]
  4. Zimmerman JE, Kramer AA, McNair DS, Malila FM. Acute Physiology and Chronic Health Evaluation (APACHE) IV: hospital mortality assessment for today's critically ill patients. Crit Care Med. 2006;34:1297-1310. [CrossRef] [PubMed]
  5. Zimmerman JE, Kramer AA, McNair DS, Malila FM, Shaffer VL. Intensive care unit length of stay: Benchmarking based on Acute Physiology and Chronic Health Evaluation (APACHE) IV. Crit Care Med. 2006;34:2517-29. [CrossRef] [PubMed]
  6. Salluh JI, Soares M. ICU severity of illness scores: APACHE, SAPS and MPM. Curr Opin Crit Care. 2014;20:557-65. [CrossRef] [PubMed]
  7. Lee J, Maslove DM. Customization of a Severity of Illness Score Using Local Electronic Medical Record Data. J Intensive Care Med. 2017;32:38-47. [CrossRef] [PubMed]
  8. Lee J, Maslove DM, Dubin JA. Personalized mortality prediction driven by electronic medical data and a patient similarity metric. PLoS One. 2015;10:e0127428. [CrossRef] [PubMed]
  9. Awad A, Bader-El-Den M, McNicholas J, Briggs J. Early hospital mortality prediction of intensive care unit patients using an ensemble learning approach. Int J Med Inform. 2017;108:185-95. [CrossRef] [PubMed]
  10. Pirracchio R, Petersen ML, Carone M, Rigon MR, Chevret S, van der Laan MJ. Mortality prediction in intensive care units with the Super ICU Learner Algorithm (SICULA): a population-based study. Lancet Respir Med. 2015;3:42-52. [CrossRef] [PubMed]

Cite as: Medrek SK. The need for improved ICU severity scoring. Southwest J Pulm Crit Care. 2019;18:26-8. doi: https://doi.org/10.13175/swjpcc004-19 PDF

Monday
Sep032018

A Labor Day Warning

Today is Labor Day, a public holiday honoring the American labor movement and the contributions that workers have made to the strength, prosperity, laws, and well-being of the country. Though this holiday dates back to the end of the nineteenth century, the concept of organized labor is under increasing attack. While many of the physician and nurse readers may think that “labor” does not apply to them, after all they are professionals, management would likely disagree.

In Arizona v. Maricopa County Medical Society in 1982, the Supreme Court ruled that when physicians negotiate collectively with insurers about fees, and as a consequence do not compete with one another, such negotiations represent a horizontal agreement among competitors to fix prices (1). This was based on the concept of physicians being independent from hospitals or healthcare systems. However, more physicians are now hospital employed which has been in no small part due to cuts in physician compensation by Medicare with the insurers rapidly following. This increase in physician employment has been associated with increased billings leading to increased profits and decreased physician compensation (2,3).

The Nation’s largest healthcare system is the Department of Veterans Affairs (VA). The pace of VA hiring has not kept pace with the growth of patients leading to prolonged wait times first reported in Phoenix (4). Two recent decisions will likely affect physician hiring and retention at the VA. First, President Trump announced cancellation of the the planned salary increase for civilian employees (5). Second, VA Secretary Robert Wilkie, cancelled collective bargaining rights when it comes to professional conduct and patient care by VA providers (6). In the private sector, hospital employed physicians seem to becoming increasingly discontented because of 1. Having to deal with a lot of rules; 2. Having to deal with a large bureaucracy. 3. Not having a staff under their control; and 4. Having little control over compensation models (7).

All in all, this does not bode well for physicians or patients. The data suggest that the Medicare has helped destroy independently employed physicians while over compensating hospital employed physicians whose fees are collected by the hospital (7). This trend will likely continue until Medicare realizes that the existence of the independent practitioner keeps healthcare costs down. By financially squeezing the independent practitioner Medicare’s actions lead to decreased competition and increased healthcare costs.

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Halper HR. Arizona v. Maricopa County: a stern antitrust warning to healthcare providers. Healthc Financ Manage. 1982 Oct;36(10):38-42. [PubMed]
  2. Lowes R. Hospital-employed physicians cost Medicare more, study says. Medscape. November 16, 2017. Available at: https://www.medscape.com/viewarticle/888772#vp_1 (accessed 9/3/18).
  3. Kane L. Medscape physician compensation report 2018. Medscape. April 11, 2018. Available at: https://www.medscape.com/slideshow/2018-compensation-overview-6009667#12 (accessed 9/3/18).
  4. Davidson J. VA doctor shortage fueled by management issues, poor pay The Washington Post. July 16, 2018. Available at: https://www.washingtonpost.com/news/powerpost/wp/2018/07/16/va-doctor-shortage-fueled-by-management-issues-poor-pay/?utm_term=.070275d06e2a  (accessed 9/3/18).
  5. Liptak K. Trump cancels pay raises for federal employees. CNN. August 31, 2018. Available at: https://www.cnn.com/2018/08/30/politics/trump-cancels-federal-employee-pay-raises/index.html (accessed 9/3/18).
  6. Department of Veterans Affairs. VA secretary clarifies collective bargaining authority for patient care. August 29, 2018. Available at: https://www.managedhealthcareconnect.com/content/va-secretary-clarifies-collective-bargaining-authority-patient-care?hmpid=cmlja3JvYmJpbnNAY294Lm5ldA== (accessed 9/3/18).
  7. Mertz GJ. Physicians employed by hospitals. Medscape. January 01, 2018. Available at: https://www.medscape.com/viewarticle/891120#vp_1 (accessed 9/3/18).
  8. Lowes R. Hospital-employed physicians cost medicare more, study says. Medscape. November 16, 2017. Available at: https://www.medscape.com/viewarticle/888772 (accessed 9/3/18).

Cite as: Robbins RA. A labor day warning. Southwest J Pulm Crit Care. 2018;17(3):95-6. doi: https://doi.org/10.13175/swjpcc106-18 PDF 

Friday
Jul272018

Keep Your Politics Out of My Practice

“Nothing so needs reforming as other people's habits. Fanatics will never learn that, though it be written in letters of gold across the sky.”

-Mark Twain

Politicians have repeatedly inserted themselves into exam rooms and under hospital gowns, telling doctors what they can and cannot discuss with patients; forcing providers to recite scripted medical advice they know to be factually inaccurate; and even instructing physicians to prioritize the financial interests of private companies over the health of their patients (1,2).

In 2011 Florida passed a sweeping law barring doctors from routinely asking patients whether they had guns in their homes, counseling them on common-sense firearm storage measures or recording any information about gun ownership in their medical files. Four states (Pennsylvania, Ohio, Colorado, and Texas) have passed legislation relating to disclosure of information about exposure to chemicals used in the process of hydraulic fracturing (“fracking”). Some new laws require physicians to discuss specific practices that may not be necessary or appropriate at the time of a specific encounter with a patient. For example, New York enacted legislation in 2010 that requires physicians and other health care practitioners to offer terminally ill patients “information and counseling regarding palliative care and end-of-life options appropriate to the patient, including . . . prognosis, risks and benefits of the various options; and the patient's legal rights to comprehensive pain and symptom management.” Still other laws would require physicians to provide — and patients to receive — diagnostic tests or medical interventions whose use is not supported by evidence, including tests or interventions that are invasive and required to be performed even without the patient's consent. In Virginia, a bill requiring women to undergo ultrasonography before having an abortion was passed despite objections from the American College of Physicians. Arizona required physicians to tell women that drug-induced abortions may be “reversible” a claim that is unsupported by scientific evidence. A growing number of states have instituted mandatory waiting periods for abortions when there is no apparent medical need.

Healthcare providers who do not observe with these laws could face fines, license revocation, and even jail time for failure to comply. Fortunately, many have been struck down by the courts. However, a new tact for some has been to allow objection to certain types of medical treatment such as abortions based on the healthcare provider’s religious or moral beliefs. These providers have a new defender in the Trump administration (3). The top civil rights official at the Department of Health and Human Services (HHS) is creating the Division of Conscience and Religious Freedom to “protect” doctors, nurses and other health care workers who refuse to take part in procedures like abortion or treat certain people because of moral or religious objections. "Never forget that religious freedom is a primary freedom, that it is a civil right that deserves enforcement and respect," said Roger Severino, an anti-abortion Catholic lawyer who directs HHS's Office for Civil Rights. Here in Arizona healthcare professionals are not required to provide services that conflict with their religious beliefs, including abortion, abortion-inducing medication, emergency contraception, end of life care, and collection of umbilical cord blood (4).

Two recent incidents in Arizona involving pharmacists have brought this law under scrutiny (5). Hilde Hall, a transgender woman in Arizona, was allegedly denied hormone prescriptions by a CVS pharmacist in Fountain Hills. She was unable to fill the prescription at that location and despite her doctor requesting it, the pharmacist refused to transfer the order. CVS apparently fired the pharmacist. This comes within weeks of the case of Nicole Arteaga, who was denied medication for a nonviable pregnancy by a Walgreens pharmacist in Peoria, Brian Hreniuc PharmD. The Arizona State Board of Pharmacy has agreed to review Ms. Arteaga’s complaint against Dr. Hreniuc.

The Arizona Republic put it well. “The person in the white coat behind the counter should be there to help. To answer questions and ensure that the patient understands what the medicine is, how to take it and is aware of possible side-effects. Not to humiliate, question or refuse to serve the client” (5).  Assuming the accounts in the Arizona Republic are accurate, both pharmacists committed several transgressions of the code of ethics of the American Pharmacists Association including a commitment to the patient’s welfare; protecting the dignity of the patient; serving the patient in a private and confidential manner; respecting the autonomy and dignity of each patient; promoting the right of self-determination; recognizing individual self-worth; and acknowledging that colleagues and other health professionals may differ in the beliefs and values they apply to the care of the patient (6).

Whether the Arizona State Board of Pharmacy will decide to enforce professional standards or uphold a politically motivated law is unclear. At a time when pharmacists seek to extend their scope of practice, the behavior of these two pharmacists make one question who they would serve if given more responsibility-the patient or themselves? Also disappointing has been the lack of condemnation from other pharmacists and pharmacy professional groups such as the Arizona Pharmacists Association. This lack of action makes expansion of the scope of practice questionable. We as healthcare providers are entitled to our politics just like anyone else but the line is crossed when you impose your politics on me or my patients.  

Richard A. Robbins, MD*

Editor, SWJPCC

References

  1. Weinberger SE, Lawrence HC 3rd, Henley DE, Alden ER, Hoyt DB. Legislative interference with the patient-physician relationship. N Engl J Med. 2012 Oct 18;367(16):1557-9. [CrossRef] [PubMed]
  2. Rampell C. Politicians are invading our medical exam rooms. Washington Post. October 19, 2015. Available at: https://www.washingtonpost.com/opinions/politicians-playing-doctor/2015/10/19/7b1af280-769e-11e5-bc80-9091021aeb69_story.html?utm_term=.ae6df6d65643 (accessed 7/22/18).
  3. Kodjak A. Trump admin will protect health workers who refuse services on religious grounds. NPR. January 18, 2018. Available at: https://www.npr.org/sections/health-shots/2018/01/18/578811426/trump-will-protect-health-workers-who-reject-patients-on-religious-grounds (accessed 7/22/18).
  4. Center for Arizona Policy. Arizona religious freedom laws. January 2014. Available at: http://www.azpolicypages.com/religious-liberty/arizona-religious-liberty-laws/ (accessed 7/22/18).
  5. Price TF. CVS pharmacist who refused transgender patient's prescription abused Arizona law. Arizona Republic. July 20, 2018. Available at: https://www.azcentral.com/story/opinion/op-ed/2018/07/20/hilde-hall-transgender-prescription-denied-cvs-pharmacy/809450002/ (accessed 7/22/18).
  6. American Pharmacists Association. Code of Ethics. October 27, 1994. Available at: https://www.pharmacist.com/code-ethics (accessed 7/22/18).

Cite as: Robbins RA. Keep your politics out of my practice. Southwest J Pulm Crit Care. 2018;17(1):42-4. doi: https://doi.org/10.13175/swjpcc096-18 PDF 

*The views expressed are the author's and do not necessarily represent those of the American Thoracic Society or its affiliates.

Sunday
Jul152018

The Highest Paid Clerk

Physicians are the highest paid clerks in healthcare, but we only have ourselves to blame. At one time charts were often unavailable or illegible and x-rays or outside medical records were often missing. How we longed to have searchable records available. Now we have them but digital medicine has come at a cost. For every hour physicians spend with patients nearly two hours are spent with the electronic healthcare record (EHR) (1). Nurses in the hospital spend nearly as much time with the EHR (2). If a picture is worth a thousand words, the drawing by a 7-year-old depicting her visit to the doctor may say it best with the doctor staring at a computer with his back to the patient (Figure 1).

Figure 1. Drawing by a 7-year-old of her visit to the doctor (3).

The EHR has done some very positive things. It has reduced medication errors; it assembles laboratory and imaging information; it allows visualization of X-rays; the notes are always legible; and although introduction of an EHR results in an initial increase in mortality, there appears to be an eventual reduction (3,4). However, EHRs were not built to enhance patient care but to augment billing. Despite the effort that goes into collecting and recording data, much of the data is unseen or ignored (3). Our daily progress notes have become cut-and-paste spam monsters that are mostly irrelevant and nearly impossible to interpret. The diagnoses can be difficult to locate, the documentation for the diagnosis is often incomprehensible, and the plan is unintelligible. Of course, billings have increased but not due to improved care, but because of the electronic gobbledygook that serves as a record. 

Several other recent examples illustrate that doctors are viewed and being used mainly as clerks. I recently, applied to renew my hospital privileges. This involved completing about a 25-page on-line form to including uploaded documentation of all licenses, board certifications, CME hours, a TB skin test and a DTaP vaccination. For this privilege, not only are medical staff dues paid but a $100 fee needs to accompany the application. Pity the poor physician who goes to several hospitals. In our office every piece of paperwork is scanned into the computer and signed by the physician. This includes the insurance forms, notes from co-managing physicians, the prescriptions that I have written and signed, the pulmonary function tests that I have interpreted and signed, the scored Epworth sleepiness scales that the patient has completed and are included in my note, etc.

A recent court decision may further increase the physician clerical load. The Pennsylvania Supreme Court in a 4-to-3 decision ruled that a physician may not "fulfill through an intermediary the duty to provide sufficient information to obtain a patient's informed consent” (5). What this essentially means is that a physician, presumably the operating surgeon, must obtain an informed consent which usually involves signing a piece of paper. However, signing an informed consent form does not assure informed consent and the form’s main purpose is to protect the hospital or surgical center against litigation by shifting culpability to the surgeon. Now a surgeon must not only inform the patient about the operation but must have a form signed to protect the hospital and discuss every adverse outcome and all alternatives, a clearly impossible task. Will it be long before an unintelligible informed consent is required before prescribing an aspirin?

Many physicians, including myself, have resorted to voice recognition software using a template to generate notes due to increasing documentation requirements. Although this seems to decrease documentation time and increase face-to-face time with the patient, a recent article points out that voice recognition makes mistakes (6). Although there is little doubt that this is true, other documentation methods have their problems such as typographical errors, spelling errors, and omissions in documentation. Hopefully, a hullabaloo will not be made over voice recognition mistakes like was made over copying-and-pasting (7,8). Copy-and-paste errors seem to be mostly trivial and the information they contain is mostly for billing and probably does not need repeating in the medical record in the first place.

Physicians have cowered too long to insurer or hospital interests to avoid being labeled as “disruptive”. Many physicians would be happy to carefully proof every note or spend an hour getting the hospital’s informed consent form signed, but only if adequately compensated. Whining about physician lack of autonomy and increased clerical load either in the doctor’s lounge or in the pages of a medical journal will have no effect. The trend of shifting clerical workload to the healthcare providers will likely continue until either physicians refuse to do these clerical tasks or receive fair compensation for their services.

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Verghese A. How tech can turn doctors into clerical workers. NY Times. May 16, 2018. Available at: https://www.nytimes.com/interactive/2018/05/16/magazine/health-issue-what-we-lose-with-data-driven-medicine.html (accessed 7/13/18).
  2. Stokowski LA. Electronic nursing documentation: Charting new territory. Medscape. September 12, 2013. Available at: https://www.medscape.com/viewarticle/810573_1 (accessed 7/13/18).
  3. Toll E. A piece of my mind. The cost of technology. JAMA. 2012 Jun 20;307(23):2497-8.
  4. Lin SC, Jha AK, Adler-Milstein J. Electronic health records associated with lower hospital mortality after systems have time to mature. Health Aff (Millwood). 2018 Jul;37(7):1128-35. [CrossRef] [PubMed]
  5. Fernandez Lynch H, Joffe S, Feldman EA. Informed consent and the role of the treating physician. N Engl J Med. 2018 Jun 21;378(25):2433-8. [CrossRef] [PubMed]
  6. Zhou L, Blackley SV, Kowalski L, et al. Analysis of errors in dictated clinical documents assisted by speech recognition software and professional transcriptionists.  JAMA Network Open. 2018;1(3):e180530. [CrossRef]
  7. Centers for Medicare and Medicaid Services. Electronic Healthcare Provider. December 2015. Available at: https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/docmatters-ehr-providerfactsheet.pdf (accessed 7/13/18).
  8. The Joint Commission. Preventing copy-and-paste errors in EHRs. QuickSafety. February 2015. Available at: https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_10.pdf (accessed 7/13/18).

Cite as: Robbins RA. The highest paid clerk. Southwest J Pulm Crit Care. 2018;17(1):32-4. doi: https://doi.org/10.13175/swjpcc089-18 PDF