Terminal man

Nearly all clinicians recognize that providing medical care which prolongs human suffering is anguishing, both to themselves and to the dying patient. more»

Interested readers can now peruse my latest Musings blog at the Journal of the American Academy of Physician Assistants (JAAPA) website.

JAAPA is the official publication of the American Academy of Physician Assistants.

Individuals and types

In a retrospective review of the origins of Antoine Saint-Exupéry’s Little Prince, Edward Rothstein observes that the children’s book might be ultimately “less about individuals and more about types.” It is an aviator’s perspective, sweeping across the landscape, only mildly hampered by earthly ties and human requirements, being guided by the stars. On the other hand, the message of the character of the fox is “far more grounded, empathetic, more concerned with others.”

“Saint-Exupéry may have often been caught between these two perspectives,” Rothstein writes. “He fought against detachment but also relished it, fleeing for atmospheric vistas whenever possible.”

There, briefly stated, you have the same dilemma faced daily by thousands of clinicians in medical practice.

At the outset medical education consists largely of learning how to recognize and diagnose illness. Students are taught to look for disease patterns, clinical signs that when taken together as a whole point to one specific medical malady. Unfortunately this method cultivates an attitude toward human beings as disease entities. Students, residents and even attending physicians are apt to refer to “the cholecystectomy in Room 508,” “the schizophrenic in 212,” “the diabetic in ketoacidosis in the ED.”

Such shorthand nomenclature provides a synopsis of the clinical condition and by implication, a plan for treating it. Yet if we are not careful, referring to patients as diagnostic entities or classifying them as types allows us to dehumanize them. If we come to regard patients as mere disease entities, we are less likely to suffer emotional attachment, more likely to maintain our clinical objectivity; but at what cost?

Patients who perceive that their providers are not interested in them tend to linger longer in the throes of illness than those who feel validated and nurtured as individuals. It has been shown that providing terminally ill patients with good palliative care dramatically improves the quality of life during their waning months.

At some point in their medical education it would behoove clinicians to move toward an attitude of empathy, to take a compassionate stance in dealing with patients entrusted to their care.

Perhaps that is what Saint-Exupéry’s Little Prince has to teach us grownup clinicians who have chosen a career in medical practice.

In the words of the fox: “Here is my secret. It is very simple. One only sees rightly with the heart. The essential is invisible to the eye.”

Full circle

When it comes to systematic medical record keeping, it appears as though we’ve come full circle, as yet another layer has been added to the cost continuum of our healthcare system: the medical scribe.

According to a recent New York Times article, A Busy Doctor’s Right Hand, Ever Ready to Type, the latest trend to surface in medical practice is employing technical scribes to enter salient data into the electronic medical record in real-time, allowing clinicians to maintain eye contact as they talk to their patients.

Dr. Michael Murphy, the chief executive of ScribeAmerica, a company based in Aventura, Fla., that supplies scribes to hospitals and medical practices, estimates that there are nearly 10,000 scribes working in hospitals and medical practices around the country, with demand rising quickly. At his company alone, the number of scribes deployed to clinics and emergency departments has risen to 3,500 from 1,000 in the past three years.

When I first started clinical practice 35 years ago, I learned how to talk to patients. Not only did I talk to them, I spoke with them and I looked at them when I was doing so. I learned to read facial expressions and body language behind their remarks. I learned to look for incongruities that told me something was amiss. Much of what I gleaned during patient interviews held me in good stead when it came time to formulate diagnoses. (Statistics show that after they’ve completed taking the medical history, 85  percent of the time seasoned clinicians have a fairly clear idea of what the diagnosis is before performing the physical examination.)

All of that changed with the advent and subsequent widespread adoption of the electronic medical record (EMR). Clinicians who elect to participate in EMR systems are forced to carry an electronic tablet, notebook or laptop with them from room to room to record the salient points of the medical encounter. But it takes time to enter this myriad data, often at the expense of meaningful human interaction with the patient during the visit.

Advocates of EMR point to the benefits of immediate and shared data retrieval as well as fewer medical errors. Yet anyone who has slugged their way through a day of recording such data understands what a tremendous burden it puts on both clinician and patient alike.

Of course, the bottom line in capturing these myriad extraneous data is that encounters can be billed at a higher level of service. This means more money in the clinician’s pocket and less in the coffers of the third-party payers.

One glitch yet to be rectified is the damper that the EMR places on the numbers of patients seen. Obviously, a clinician can’t work his way through as many patient encounters if he is forced to take the time to record all of the necessary data on the spot. As a result, many clinicians end up taking electronic charts home with them to complete in the late evening hours.

Now we are witnessing the advent of EMR scribes, trained to input data into the electronic medical record in real-time as they follow individual clinicians from one patient encounter to the next. Ironically, this allows clinicians to focus on patients as human beings, maintaining eye contact as they talk with and listen to them. At the same time it allows visits to be billed at a higher level of service; and at the end of the day, no one has to take any additional work home.

One might question the need for yet another person in the exam room. Although her presence clearly benefits the clinician, one wonders what impact it might have on the interaction between the clinician and patient. In addition, in this era of cost containment, one might question the additional fees to pay for the services of scribes.

As a practicing clinician, I never claimed to be able to predict the future; but this time round from where I’m sitting, I think I can read the handwriting on the wall.

Winter walk

"Footsteps, Winter Walk" 2014©Brian T. Maurer

“Footsteps, Winter Walk, 2014”   ©Brian T. Maurer

“In the deepest snows, the path which I used from the highway to my house, about half a mile long, might have been represented by a meandering dotted line, with wide intervals between the dots.  For a week of even weather I took exactly the same number of steps, and of the same length, coming and going, stepping deliberately and with the precision of a pair of dividers in my own deep tracks,—to such routine the winter reduces us,—yet often they were filled with heaven’s own blue.”

—Thoreau, “Former Inhabitants; and Winter Visitors” in Walden