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.