By Abigail Zuger, M.D.
October 13, 2014 5:06 pmOctober 13, 2014 5:06 pm
A pedestrian wears a surgical mask as he crosses the street in front of Texas Health Presbyterian Hospital.
Credit Nathan Hunsinger/The Dallas Morning News
Hard Cases
Dr. Abigail Zuger on the everyday ethical issues doctors face.
Will history someday show that the electronic medical record almost did the great state of Texas in?
We do not really know whether dysfunctional software contributed to last month’s debacle in a Dallas emergency room, when some medical mind failed to connect the dots between an African man and a viral syndrome and sent a patient with deadly Ebola back into the community. Even scarier than that mistake, though, is the certainty that similar ones lie in wait for all of us who cope with medical information stored in digital piles grown so gigantic, unwieldy and unreadable that sometimes we wind up working with no information at all.
We are in the middle of a simmering crisis in medical data management. Like computer servers everywhere, hospital servers store great masses of trivia mixed with valuable information and gross misinformation, all cut and pasted and endlessly reiterated. Even the best software is no match for the accumulation. When we need facts, we swoop over the surface like sea gulls over landfill, peck out what we can, and flap on. There is no time to dig and, even worse, no time to do what we were trained to do — slow down, go to the source, and start from the beginning.
On the hospital wards, mixed messages abound. A couple of months ago, I was on the receiving end of a furious, expletive-laden outburst from one sick patient, the printable fraction of which ran, “Can’t you people read?”
This man had by then recounted the long story of his bad leg to three separate teams of doctors and nurses. I was the 14th interrogator by my count, and despite my standard opening gambit (“I know you’ve been over this before”) I was the one to flip his switch: The patient ordered me and my team out of his room and pulled the covers over his head.
Who can blame him for assuming that in this day and age, once told, his story needed only to be retweeted. But medical care requires dialogue. Although we plucked some information from the glut of words in his chart and cobbled together a plan, we didn’t do him justice, not by a long shot.
The fact is that even if all the redundant clinical information sitting on hospital servers everywhere were error-free, and even if excellent software made it all reasonably accessible, doctors and nurses still shouldn’t be spending their time reading.
The first thing medical students learn is the value of a full history taken directly from the patient. The process takes them hours. Experience whittles that time down by a bit, but it always remains a substantial chunk that some feel is best devoted to more lucrative activities.
Enter various efficiency-promoting endeavors. One of the most durable has been the multipage health questionnaire for patients to complete on a clipboard before most outpatient visits. Why should the doctor expensively scribble down information when the patient can do a little free secretarial work instead?
Alas, beware the doctor who does not review that questionnaire with you very carefully, taking an active interest in every little check mark. It turns out that the pathway into the medical brain, like most brains, is far more reliable when it runs from the hand than from the eye. Force the doctor to take notes, and the doctor will usually remember. Ask the doctor to read, and the doctor will scan, skip, elide, omit and often forget.
The same problem dogs other efforts to reduce the doctor’s mundane history-taking responsibilities. For instance: Why not leave it to the nursing staff to ask all those dull questions about smoking, drinking, social activities and recent travel? They will write it all down. The doctors will review.
And then the next thing you know, that unimportant background information explodes all over the nightly news, because the doctors failed to review, or failed to remember what they reviewed, and key travel details simmered unnoticed in the bowels of some user-unfriendly electronic medical record.
Over and over again we are forced to admire the old traditions. As we tell the students, it’s not that complicated. You say hello, you sit down, and you have a conversation.
A few months after our expletive-spewing patient got better and went home, our team went to see a more cooperative young man admitted to the hospital with a fever. This one had gotten sick after a camping trip in California, and the words “camping” and “California” were repeated over and over again in his chart, escalating into the general conviction that he had come down with a serious fungal infection that can be acquired from the soil in some parts of Southern California.
If this patient had refused to talk to us, we might have been tempted to treat him for that infection, which would have been a big mistake. Fortunately, he politely led us through his entire hike, which proved to have skirted the habitat of this fungus by hundreds of miles. We could tell his other doctors to stop focusing on his travels and pay attention to his heart murmur instead, the real clue to his problems.
Like good police work, good medicine depends on deliberate, inefficient, plodding, expensive repetition. No system of data management will ever replace it.
A version of this article appears in print on 10/14/2014, on page D1 of the NewYork edition with the headline: Repeating the Mistakes of History.
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