Automated Malpractice and Digital Dishonesty

Posted on March 30, 2014 by ergeller57

Quite a few years ago, I was conducting morning teaching rounds on the surgical service of a university teaching hospital. Teaching rounds are a combination of patient care and education, the educational aspects directed at the bevy of residents and medical students in attendance. We stood outside the room of a postoperative patient who wasn’t doing well. Either was the senior medical student struggling to explain just what was the reason that the patient’s health was failing.

“What’s the white count this morning?” I asked the man. He was an over-achieving rotator from another school, doing a senior elective on our service. He suddenly blanched.

“I’m sorry?” he said.

“Don’t be. Just tell us the white blood cell count of the patient this morning.” I waited. He looked at his junior resident. The junior resident looked at the senior resident. The senior resident looked at the chief resident. The chief resident looked at me. He shrugged sheepishly. “No one knows the patient’s white count this morning?” I asked. Everyone looked at their shoes. “Did you operate on this patient?” I asked the student. He nodded. “And though the patient trusted you enough to let you operate on him, you just don’t care if he lives or dies at this point?”

“I care,” the student replied, indignant.

“Just not enough to check his white blood cell count, is that it?” I asked. The student wisely said nothing. “It would be reasonable to suspect that your patient is suffering from an infectious complication from your operation. If you do not make the diagnosis soon, he will die from your operation. I suggest that you check his white blood count.” Everyone nodded assent. We moved on to the next patient.

Twenty-four hours later, we all stood once again in front of the same patient’s room. The patient had spiked a high fever overnight. “White count?” I asked the same student.

There was the briefest pause before the medical student said, “Twelve point two.” Which was a lie. He was a pretty good liar, looking me straight in the eyes as he said it. I had checked the patient’s white blood cell count before rounds.

“Take this dime,” I said, handing a coin to the student, “and call your mother. Tell her there is serious doubt about your ever becoming a doctor.” All twenty members attending rounds looked at me with a blank, uncomprehending stare. “Really?” I asked. “Nobody’s ever seen The Paper Chase?” They all shook their heads. The student had gone beet red with embarrassment. “Look,” I said. “You screwed up. I told you to check this patient’s white count. You didn’t. You have a responsibility to this patient.” The student, his resident, and the chief resident started to explain about all the traumas cared for overnight, about how busy the service had been saving lives. I held up my hand. “I don’t care. You screwed up. You all screwed up, by letting him screw up. You are failing this patient. But that’s not why I’m pissed. We all make mistakes, every one of us. Every day. Can’t be helped. But you can’t lie about it. You can’t stand here and pretend that you did something that you didn’t. You can’t give me false information, information that may lead to my decision regarding the care of this patient, just because you’re too weak to admit that you didn’t do what you should’ve. What this patient needed. That’s not acceptable. You can’t lie. Not to me, not to this patient, not to your fellow residents or students. Because if I can’t trust you, I can’t let you take care of my patients. Worse, you are lying to yourself. If you can’t trust that what you wrote in a chart last month was actually something you did–and not just something you made up because you didn’t have the time to actually check–you will hurt your patient. Lawyers can lie. Accountants can lie. Stockbrokers can lie. Surgeons can’t lie. Surgeons who lie kill patients. Go check the patient’s white count. And while you’re at it,” I said, turning to the senior resident, “book the patient for reoperation this afternoon. Because his white count this morning is 22,000 and I think your patient has an anastomotic leak.”

The embarrassed, hotshot medical student went on to be a very good orthopedic surgeon. I like to think that he learned something that day about patient care and responsibility. I don’t know for sure. I am sure, however, that it no longer matters. Every physician is now systematically dishonest on a daily basis. Every one of us.

During the past two years, hospitals and medical practices across the country have been required to implement an electronic medical record system. Every single health care practitioner has been falsifying patient records on a daily basis as a result. Not by a desire to be dishonest, or any lack of effort on behalf of our patients. It is now a systematic requirement. Which is particularly ironic, because the intention of the electronic medical record mandate was to increase the quality and accuracy of medical record keeping. The result has been the exact opposite.

“You can’t be a doctor without a pen,” the adage goes, because the foundation of all medical care is the medical record. This was actually a major plot point in a book by Tom Clancy (may he rest in peace), where the ophthalmologist wife of our hero, Jack Ryan, points out that “if it wasn’t written down, it didn’t happen.” Patriot Games, I think. I could be wrong. Anyways, it’s true. If it happened, you document it. That way, everyone knows what was done, how, and why. Want to know if I removed the appendix while I was inside that patient during surgery? Read my operative report. If I didn’t say I removed it, the appendix is still there. The corollary was also true: If it was written down, it must have happened. If I wrote the lab test down, I checked it. Simple. Patient care depends on it.

Nothing’s so simple anymore. In the era of the electronic medical record, everything is already written down, whether it’s true or not, whether I saw it or not. Prepopulated rubrics, standardized physicals with normal findings documented by default, cut-and-paste patient histories with negative answers already filled in for all those questions the doctor may or may not have actually asked. We can’t trust any of it any more, because we didn’t write it. The computer did. And nobody, no matter how professional or conscientious, can possibly undo all the stuff automatically done by the computer in the name of quality patient care. Except most of it is bullshit. Almost all of it. Even the stuff I did myself, last month or last year. When I look at a physical exam form, I can’t be sure that I really felt the patient’s pulse as it says on the record, or did the computer fill that in and I didn’t take the time to delete it? Patient care decisions are now made on the basis of this flawed type of documentation every day.

It wasn’t supposed to be this way. I was in Washington when the first discussions were being held about implementing an electronic medical record. The advantages are obvious. No more unintelligible doctor writing leading to patients getting the wrong drug. Universal access to critical information on a real-time basis, eliminating repeated tests and procedures. Less waste, greater safety. It was all completely laudable. Government and private industry allied to make health care better, cheaper, safer. First step was to develop ground rules, a basis for all records to be standardized, to be developed by the US Bureau of Weights and Measures. Never happened. Too much money was at stake. The government mandate, well intentioned but flawed in its implementation, was usurped by the greed of private industry. Billions of dollars were at stake. Lives were too, but nobody really stopped to notice.

Last year, I was called upon to be an expert witness in the defense of two emergency medicine physicians in New York. The ER doc’s had heroically resuscitated a motorcycle rider who had suffered a traumatic amputation of his leg. Sadly, the man had died from his injuries. The family sued, alleging incompetence on the part of the treating doctors. As far as I could tell from my review, the doctors had done everything they could possibly have done to save the man’s life. I testified to this opinion in court. With a dramatic flourish, the plaintiff’s attorney projected a ten foot high image of a page from the hospital record. “Explain this, Dr. Geller!” the attorney demands, using his laser pointer to demonstrate where the medical record states that pulses were present and normal in both feet. “These doctors didn’t even examine the patient, didn’t even realize that the patient’s leg was missing!” the attorney declaimed.

“No, not at all,” I had to explain to the jury. “These doctors were so busy trying to save this man’s life, they didn’t have the time to uncheck the boxes on the computer form where it automatically fills in normal pulses for the feet of every single patient.” It took me almost a half hour of explanation to the jury. I thought I sounded like an idiot trying to explain this ridiculousness. In the end the jury understood, and the physicians were acquitted. It’s like something out of Joseph Heller’s novel, Catch 22. Or MASH. But with real dead people.

Publishers on Life Support: An Industry in Decline

Posted on March 19, 2014 by ergeller57

There is no lack of opinion regarding the state of the publishing industry. While I am not a professional insider, my status as a writer-publisher of two novels, as well as my previous experience as an author/editor of a traditionally (Big Six) published nonfiction work, gives me some credibility, I believe, in this discussion. As much as many writing on the topic, at any rate. It is my opinion that traditional publishing is exhibiting evidence of an industry that is deeply moribund.

As a surgeon practicing for over 27 years, I have had the deeply unpleasant experience of witnessing institutional decline and failure. This past decade has been particularly challenging for hospitals. On several occasions, I have witnessed the process of a hospital failing around me. The signs are always the same. The first evidence of a problem is the day that I’m told that some suture or medication that I’ve routinely used during an operation is “not in stock.” While variously ascribed to “vendor problems” or “delayed shipment,” the real reason is that the hospital has stopped paying its bills in a timely fashion and the suppliers are waiting for a check before they send any more stuff. Obviously, this is a problem. It affects the care of my patient, but one finds a way to make do. Next, the clerks start disappearing from the wards and nursing stations. These individuals, while not licensed professionals, are the equivalent of the staff sergeants in the military–the people who know how to get things done. They make everybody’s job easier. But since they have no direct patient contact and are not regulated by the various accreditation agencies that the hospital must answer to, they are first to go as the hospital seeks to pare down its salary expenses (salaries are always the hospital’s highest expenditure). The absence of the clerks doesn’t directly endanger the care of patients, but it makes the lives of the nurses, PA’s, and doctors much more difficult. Suddenly, the care givers must spend time doing clerical duties to get things done for their patients, making everyone less efficient. And it’s not like we have a lot of extra time to take on these tasks, so everybody feels the strain. Hospitals depend on the fact that health care professionals, however, will pick up the slack for the good of the patient. After all, everybody who works in the hospital has sworn an oath to that effect; everyone, that is, except the hospital administrators. But this can only be stretched so far, and eventually, the best staff members leave to take positions at other, more solvent hospitals. The remaining staff, too old or marginally competent to relocate, are left behind in a situation of downward spiraling care. The final phase before the doors are ultimately locked is a deeply distressing period, though patients are often oblivious to the situation.

I see the same thing happening today in the publishing industry. Obviously, traditional publishers are in a financially challenging environment. Their current reaction, it seems to me, exactly mirrors what I describe above. Experienced and talented professionals in the field, some of them my friends and associates, are being let go. Divisions are being downsized or consolidated. Jobs once done by these experienced pros are now done by interns, or not at all. In-house expertise is sacrificed to subcontractors, always the lowest bidder. My recent reading experience has given sad evidence to this trend. Ebooks put out by major publishing houses on Kindle and Nook (I use both) exhibit extensive formatting issues, nonfunctional Tables of Contents, and copy editing errors pointing to a “scan but don’t proofread” approach to converting their manuscripts from print to the electronic format. Even recent print editions, both hardcover and trade paperback books, show the kind of mistakes that shouldn’t be allowed by a professional publishing house that holds itself to a standard above the independent author-publisher. Supposedly.

This is the crux of the matter at hand. The traditional, professional publishing houses are in competition with independently published writers, as well as multiple small presses. The response to this competition must be to turn out an even better product, to provide their contracted authors with a level of support and professional cache that will make for continued loyalty. This has not been in evidence. It seems, instead, that the response is to cut corners as they cut expenses. It’s not going to work. This short sighted approach, like the hospital trying to keep its doors open as it provides decreasing quality of care, leads to failure.

The response of a challenged industry giant must be to use their assets to explore new markets and areas of opportunity. For example, many independents and small publishing houses are exploring the use of “bundles” to provide readers with greater value. This is a natural technique for traditional publishing houses to employ, as they own the rights to huge libraries of previously published material, much of it desirable to readers. It costs almost nothing for publishers to exploit this asset, but there is little or no effort being displayed in this regard. It seems to me that every time I purchase a book written by an author published by RandomPenguinWhatever, I should receive the recommendation to buy a bundle of that author’s previous work, or some part thereof. Not happening.

If traditional publishing houses continue to play defense rather than innovate, to pare down rather than promote those aspects of their industry in which they excel, the downward spiral to institutional failure is inevitable. The best and brightest in the industry–authors, editors, marketing and legal professionals–will leave for the new opportunities which will arise in their stead. These folks haven’t sworn an oath to support their publishers. And readers are not oblivious.