I’ve written several times before about my love/hate status with my EMR. While I enjoy using mine, I long for it’s usefulness to get to the next level. While the EMR is useful at tracking data, it’s greatest handicap right now, is that it can’t talk to other systems. Data is still locked in individual systems and can’t be shared across platforms. This lack of inter-operability has thus far been the EMR’s greatest handicap, and I have longed for the time when EMRs are able to share data.

But as I see more and more systems being employed in my area and talk with other physicians about their experiences, I am becoming increasingly concerned that  the inexorable march forward is going too quickly.

Shouldn’t we get these systems right before introducing interoperability into the equation?

The administration and the public are now clamoring that the information in these systems should be able to be shared among providers. In effect, that the information should not be “held hostage” by each providers respective system. These are fair and reasonable requests that should be expected in the long run. To that end, some EHR vendors have agreed in principle to begin writing standards that would allow inter-operability between systems.

The unfortunate problem here, and one that the public does not understand, is that these systems are not like the  computer operating systems that they accustomed to using. It’s easy to forget that Microsoft, Word, Windows, Powerpoint, and Macs are more than 20 years old.  They’ve gone through several generations and hundreds of billions of dollars in development by the worlds most talented programmers. All to now finally be at a point where the program does not routinely stop working for some unknown reason.

In December of 2012 Microsoft made $21 billion in revenue. In the same period, Cerner, one of the largest health IT outfits just made 3% of that. How could anyone reasonably expect that  Cerner could put out a system in it’s first generation that is anywhere near as well thought out and user friendly as a current Microsoft or Apple product?

The $27 billion that the administration put aside in the 2009 stimulus bill included certain stipulations in order for EHR’s to qualify for government subsidies. These stipulations, also known as “Meaningful Use”  are being rolled out in several phases. They include several measures of functionality in order to document and track health care quality measures with the hope that they could be used to improve patient care. Among these measures were financial penalties for physicians who did not adopt the systems.

From the time the bill went into effect,  the race was on. Health IT companies have cobbled together a growing healthcare IT infrastructure which is being adopted by physicians on a massive scale. To the EHR vendors, it’s been a buffet. All they had to do was create systems that met those specific “Meaningful Use” targets that the government had created, and physicians would have no choice but to purchase them. Unfortunately several important parameters were not included among these targets.

For example there was no requirement that the systems be good.

There was no requirement that the systems be intuitive, or time saving, or reliable. There was no requirement that the systems should not stop working inexplicably, or that they work with your printer, or your fax machine.

Don’t get me wrong, I’m relatively happy with my system, I never want to go back to the days of dictating every patient encounter in the office. But my system was in place long before the government got involved, and we’ve had years to refine it to our specific needs. Most other physicians have not had that luxury. Furthermore we are a small office with only a few users, not a large hospital or hospital system which must apply the technology on a large scale to be used by thousands of people.

In places like those, and in small physicians offices where physicians are new to the technology, things are getting pretty ugly.

Most physicians are not happy with the systems currently in place. They knew that these would be first generation systems which would need to be refined. But they expected that at least the systems would be designed around physicians, and be intuitive.

Instead many physicians now  feel that they’re being forced to buy overpriced, sub-standard, half-baked systems designed by polytech school dropouts.

What is it like to use these systems? Put yourself back in 1990 in front of a  Windows 3 machine, to give yourself a good picture of the (hate to use the word)  “modern” EHR experience.

So to go back to the title of this post: Should EHR’s talk to each other? Yes, absolutely. But they have to work first.

Related Posts: Daily DocBlock (EHR Style);       My EHR Tells me I’m a Bad Doctor;    Snowbirds and the Unfulfilled Promise of Electronic Medical Records;

Dear Nurses, Thanks for Everything You Do!

-Originally posted at scrubsmag.com

Related Posts: Be Nice to Nurses. . . Or Else!

If you don’t know this about me by now, I need to confess something, I’m a bit of a geek. I love  Star Trek (all of em), and I regularly check the NASA website  to see how the Voyager pairs are doing. And yes, of course  I follow the Mars rover’s twitter feed, who wouldn’t?.  So as I was perusing my issue of Chest recently, there was a study that really got my attention. It wasn’t only because of the incredibly important  issue of Cystic Fibrosis and identifying what causes exacerbations. It was the novel way that the authors identified air pollution as a factor that contributed to CF exacerbations.

Air pollution has long been thought to play a role in leading to lung disease. Air pollution is also thought to contribute to exacerbations in people with known lung disease such as asthma, COPD, and Cystic Fibrosis. However, these correlations have been difficult to show,  and have primarily depended upon looking at admission rates for people with exacerbations  of lung disease during periods where there is a known environmental anomaly or excess pollution. Unfortunately such conditions are not very predictable.

A study published in this month’s issue of  Chest showed an intriguing relationship between  air pollution and exacerbations of cystic fibrosis. What was intriguing to me about this study was not only that the authors showed a relationship between CF exacerbations and environmental pollution, but also how they set about demonstrating an association between the two.

They first went back and identified  2204 individual CF exacerbations that occurred at their institution in Belgium. Using the patients’ home addresses, they  calculated concentrations of  particulate matter, ozone, and nitrogen dioxide the patients would have been exposed to around the time of their exacerbations.

How were they able to estimate pollutant concentrations for individual  addresses?  They used interpolated data derived from the Belgian regional telemetric air quality networks which  creates four-by-four kilometer grids. Data on air quality in each individual grid  was was  taken from satellite imaging from the European Environmental Agency.  Together these data could be used to estimate relative concentrations of particulate matter, NO2 concentrations, and ozone levels for individual locations on any given day. The authors then looked at the days that their patients developed CF exacerbations as well as the relative concentrations of various pollutants at their address in the days preceding the exacerbations.

And Voila! Merging the satellite and patient data together, they were able to show  a significant correlation between C.F. exacerbations and  ambient concentrations of air pollutants.  In fact, the risk for exacerbation increased by 11.6% for each 10 microgram/cubic meter increase in ambient NO2.

Reading a study like this reminds me of something that’s easy to forget as i slog away clicking check-boxes and trying to meet quality metrics on my fantastically slow EMR. It reminds me that technology is good. Technology is helpful. Technology, applied in innovative ways can revolutionize health care.  So as night falls and our satellites sentries begin their next watch,  I can’t help but think that somewhere, just maybe, Captain Kirk and Bones are smiling.

Social Media and Medical Education: Access Denied.

-By Rebecca Hastings, D.O.

I have never been very computer or tech savvy.  I’m not up-to-date on the latest technology, but I do have a smart phone and a laptop which I use for their very basic purposes; and I do admit I have a Facebook account, mostly for keeping in touch with friends and family and, you know, the daily grind.  Up until recently, I had no idea how to “Tweet” or what Twitter was really all about.  A physician mentor of mine suggested that I start a Twitter account and take advantage of the vast amount of knowledge floating around in Twitter world.  I was hesitant at first since my free time is limited and I didn’t really need any additional distractions from my fellowship.  Plus, I definitely didn’t need to join another social media network to share pictures and read about everyone’s daily happenings.  But, I trust my mentor and appreciate his guidance, so I signed up.  And WOW!  Information overload at my fingertips!!  Within a few minutes, I became a “follower” of JAMA, Chest, Cleveland Clinic, Johns Hopkins, New England Journal of Medicine, the Annals of Internal Medicine and numerous other large medical journals and institutions.  Granted, I may have also become a “follower” of a couple fitness magazines and my beloved Kansas Jayhawks, but the majority of my Twitter thread consists of these professional organizations.  I had immediate access to hundreds of tweets from these prestigious institutions across the world.  These world-renowned entities were “tweeting” about medical information, both past and present.  They were sharing everything from major review articles to personal reflections and comic strips.  Not only were the major institutions sharing these, but other physicians were sharing their professional opinions and other articles that they found important and interesting.  By signing up for Twitter, I had opened my eyes to a whole new world of medical education.

At first, I mostly just browsed articles and topics that were posted.  But the more I read, the more I wanted to share.  I felt like others were helping me, so why not share the knowledge.   One afternoon, I sat down in the fellow call room on a break.  I had been browsing my Twitter feed on my phone and there were a couple of interesting articles and commentaries I wanted to read.  But low and behold, when signing in, a big red box comes across the screen stating “Access Denied.”  Ok, so I know Twitter is technically considered social media, but why can’t social media be used as an educational tool?  Large renowned institutions and organizations are tweeting valuable information pertaining to my livelihood and I can’t access it “on the job” where I’m supposed to be gaining an education.

I completely understand the philosophy of “internet censoring”.  I mean, who wants to see Johnny Five post 15 pictures a day from his iPhone about what he had for lunch while he’s supposed to be getting paid to do his job.  There is a time and a place for social media.  But why not allow some social media in the workplace as an educational tool? Why not allow residents and fellows the opportunity to access this information in their downtime?  Twitter, and/or other social media networks, could be viewed as a great opportunity for medical professionals to share information with one another.  Why not start a “Pulmonary and Critical Care fellow’s page” and fill it with all the landmark articles, recent advancements, personal stories, financial advice, and multiple other topics important for fellows to become well-rounded physicians?  Not only do you have access to scientific information, but also personal stories and advice that humanize medicine.  Other healthcare professionals’ comments encourage you to think about topics in a way you might not have done so previously.  This allows you to grow, not only professionally, but personally.  Wouldn’t it be great if residents, fellows and physicians started tweeting about their experiences, and sharing information they found useful for their practice? After all, medicine is an art.  The beauty of the network is that you have the power to choose who you follow and what you read based upon your professional needs.  It’s a way to stay up-to-date on current medical events, to network with other professionals, and to follow what other medical professionals are reading; things that you should probably be reading, but just didn’t really know existed.

In this age of technology, healthcare social media is becoming an all new important and emerging part of medicine.  One that until recently, I didn’t even realize existed.  Training programs all across the country, at least in my neck of the woods, are censoring how their residents and fellows are using their resources.  What do you think about unlocking their social media access while at the workplace and opening this up as an avenue for education and growth?  In this new generation of healthcare social media networking, maybe “access denied” isn’t just prohibiting trainees from posting their favorite Harlem shake video on hospital time.  Maybe it is actually prohibiting the the expansion of educational opportunities in the modern age. It’s time that medical education answer the call of this tremendous opportunity.

-Rebecca Hastings, D.O. is a Pulmonary, Critical Care Fellow. She is on twitter @RR_Hastings.

 -by Matthew Moeller.

Due to the tremendous popularity of Dr. Moeller’s original post as well as some of the critiques and questions it raised, Dr. Moeller has written this follow-up post in response.

Thank you to everyone for the positive feedback. Over 57,000 Facebook “likes”, tweets, and newspaper requests over the past week was quite a surprise. I was especially moved by the multiple tweets from hospices, physician groups, and individuals recommending my article. This article really has hit a nerve and shed light on some of the issues at hand in today’s healthcare debate. I am writing a follow up article to further address some issues.

First, I wrote my original letter to illustrate some sacrifices doctors on the front lines of care make. In order for doctors to continue providing the highest quality comprehensive care, we need our leaders/ lawmakers to understand the perspective we face so that the best solution can be found to care for our population. I do not feel that this particular perspective was voiced on Capitol Hill during the health care reform debate. Yes, there are lobbyists, but they are not those who are treating patients and may not know the nuances that individual doctors can provide. In addition, I am concerned about my colleagues in private practice (specialists or primary care doctors) whose livelihood is threatened because of the potential cuts in reimbursement (up to 26%). This measure could force these doctors out of practice simply because their expenses (which rise yearly) are exceeding their declining reimbursement, which has declined steadily over the past several years already. If this does happen, it may force doctors to stop seeing Medicare patients because reimbursement is usually lowest for this group. It will take away the physician-patient relationship that is needed for great medical care. A recent Forbes article explains this. In my opinion, Congress needs the help of doctors who take care of patients daily to give their advice on possible remedies.

Despite these lingering issues, I nevertheless love my profession and my patients. Becoming a doctor was the right choice for me; I was interested in science since I was a little kid and am thankful that I can use my education to help my patients and their families. I have also learned a tremendous amount from my patients. I cannot see myself practicing any other field other than medicine and I am humbled daily serving my patients. I definitely would do it all over again as well because I feel this profession is my calling and I get an enormous amount of personal satisfaction taking care of those in need. Anyways, who would go into medicine in the first place with its long hours, large debt load, delayed earnings, risk of lawsuits, and daily life and death decisions if they didn’t true care about the human race? I am happy to say that most of my colleagues feel the same way. Our concerns rest on the idea that we may not be able to provide quality care to all patients if the tools and resources we need are reduced.

Second, I was trying to speak for ALL doctors, not just GI doctors. People have commented that I was complaining about my salary and the salary of GI doctors. This article was not intended for GI physicians, but, rather, for all physicians. Not all physicians get paid the same and primary care doctors typically get paid significantly less than specialists. The article was a personal anecdote to illustrate some sacrifices of a typical doctor who is paying off his or her loans themselves. I am not complaining about my current compensation. Doctors do have the highest average salary of any other profession despite the financial sacrifices early in our career. But I am concerned about the FUTURE CUTS that may force doctors to

either stop seeing Medicare patients or encourage them to do concierge medicine (which charges a premium to patients for access to the doctor). I have this concern because most of my colleagues in practices have seen their reimbursement cut and their expenses increase. When these two things happen, one either works more hours in the week to make up the difference or their expenses increase until they can no longer afford to see patients without going into debt. This in turn could lead to the decline of quality advanced health care that Americans enjoy. There are numerous articles out there as well that show concierge medicine is growing).

The way doctors currently get reimbursed is unique to the medical profession. The charges (bills) that patients see in the mail are not what doctors get paid. These are inflated numbers derived from contracts between hospitals or groups and insurance companies. When a hospital or doctor submits a charge (bill), the insurance companies or Medicare/Medicaid depending on the patient’s insurance utilize a fee schedule, which consists of thousands of codes that give dollar amounts for individual procedures or clinic visits (available on AMA website). Each code has a dollar figure and a relative value unit (RVU) to determine how much to reimburse that doctor. This is called a “Medicare fee schedule” and insurance companies will pay a certain percentage of the fee based on Medicare. This can range from 80% to 180% of Medicare depending on the insurance carrier. If a patient has Medicare, however, one can see exactly what that doctor will get paid based on the CPT code (it varies 1% based on geography) by using the fee schedule. This is often called the “allowable charge” in patient’s bills. The revenue the doctor receives is in fact this fee (not the charge) and is set no matter how much the hospital or doctor chooses to charge. To complicate matters, there are usually two different charges in a patient’s bill: a “professional” charge from the doctor, and a “facility or hospital” charge (an inflated charge that only goes to the facility or the hospital, not the doctor). First, the doctor only sees the “professional charge” (not the hospital charge) if he or she works for a hospital. This is the charge for the doctors’ services (e.g. office visit vs. procedure vs. MRI interpretation). Second, the doctor only receives a fraction of this “professional charge” because this is reduced by the fee schedule to the appropriate amount. After all of this, a doctor sees only a small fraction of the original charge (the bill the patient may see) and this does not include overhead expenses the practice incurs (which can range from 30 to 60%). This above explanation is not understood by our leaders (ie. President Obama) as verified in this video discussing foot amputations in diabetics.

http://www.youtube.com/watch?v=SG56B2et4M8

President Obama claimed that surgeons get paid (not charged) “30, 40, 50 thousand dollars” for a foot amputation. Looking at the Medicare Fee schedule, CPT code 28805 states that the surgeon would get paid $738.90, which is the fee before his or her office expenses are considered. This $738.90 needs to cover his or her office space, staffing, medical liability, and years of training to have the privilege of performing this life saving operation. Thus, the doctor actually gets paid 1.4% ($738.90/ $50,000) of what President Obama claimed he got paid. There are other fees for the hospital but these are not related to a doctor’s compensation. This clearly illustrates that doctors payment systems are confusing for patients and creates much anxiety when trying to decipher a bill in the mail. It is apparently even confusing to lawmakers and the President who are trying to modify reimbursement yet do not know how doctors get paid. This needs to be addressed so patients and lawmakers can understand where doctors are coming from. It also shows that doctors are not getting paid what some patients think as evidenced by some of the comments in the blog.

As Dr. Benjamin Carson recently stated, “it is very difficult to speak to a large group of people these days and not offend someone….the PC police are out in force at all times.”  And if we continue to attack minor points and detract from the point of an article, we will never make progress. That being said, I have a tremendous respect for lawyers. Many close friends and relatives of mine practice law and they do noble things for their clients. Nevertheless, I was trying to illustrate how the pay structure for a doctor works and used a lawyer as a comparison as we are both hard working professionals. I could’ve used other professions that get paid hourly as examples as well because the payment system for doctors is still different. A good example of the difference in payment structure is as follows: if a patient has a colonoscopy and the “charge” is $2000, doctors do not get paid this. It is an inflated number as described above. A doctor gets paid whatever the Medicare fee schedule dictates (code 45378), which is the same for all doctors assuming they live in the same region. This payment is a small fraction (10-40% depending of insurance carriers) of what the initial charge may be, and again, this is before practice expenses. Further, if that doctor comes in the middle of the night to perform this procedure, he or she gets paid the same and he or she does not charge extra. Doctors do not collect whatever they want for clinic visits or procedures. In addition, if one procedure takes longer than average or is more complex, a doctor does not collect more for that procedure unlike other professions that are paid hourly. The fee is pre-determined by the Medicare fee schedule no matter how sick the patient is. This is clearly different among other professions like law. In addition, if there is a follow up call or letter after the procedure, this is all part of the one fee and no additional fees are billed. If that patient calls at 9pm that night or the patient arrives 30 minutes late to an appointment, there is not an increased charge. I am not stating the way lawyers get paid is flawed or wrong; I am simply stating it is very different and sometimes this contrast is not noticed. Do I speak with patients at 9pm and do I spend the extra 30 minutes helping patients get the quality care they deserve? Of course, I willingly do this because I went into medicine to help those in need and I get satisfaction from this. I do worry, however, that this may not continue to be the case for all doctors if reimbursement models are not modified and doctors’ fees are not corrected for inflation and practice expenses. They simply will not bring in enough revenue to cover their expenses. Again, doctors’ fees have been declining, are not secure (please read about the erratic nature of the SGR formula), and do not adjust for inflation.

In conclusion, the previous article was intended to show lawmakers what doctors go through before policy changes take effect that make it more difficult to provide quality advanced care. We are already seeing a trend towards concierge medicine, which likely will increase costs for patients. We as doctors have a calling to help human beings and we take this seriously. However, we feel that Capitol Hill needs doctors from the front lines to discuss our issues so that the best reform possible can be made. A lot of recent articles point to reimbursement to doctors as a reason for health care costs rising. Looking at it more carefully though, there are definitely other issues that could be addressed (and should be reserved in a separate blog), but it will take Congress to seek out doctors with experience on the front lines of care to help them arrive at a fair system that can benefit everyone. And that is my hope. That Capitol Hill realizes this and recruits a diverse group of practicing doctors (not lobbyists or lawmakers) who can shed insight into the current issues at hand.

-Matthew Moeller is a practicing Gastroenterologist. He can be reached on twitter  (@DrMMoeller).

Follow caduceusblog on twitter (@caduceusblogger)

Related Posts: Open Letter to Washington from a Physician on the Front Lines;   Should  a Medical College Dean Take Money From Pharma (while telling their students not to)?;     Doctors Are Being Gagged by Gas Drillers;     Healthcare Armageddon 6: Medicare and Generation X.

Its been a long road to readjusting to my EHR, and for the most part its been worth it. (see previous EHR articles). I’ve fine tuned my typing skills, I’ve become a black belt of check boxes, a jedi of templates, I whip through e-prescriptions and referral letters like Liam Neeson through eastern European bad guys. Yes, I am Neo, the promised one, of the EHR world. But a recent EHR update had me making yet another change to they way I see patients that I’m sad to say, has tripped me up. This relatively minor problem is that, with this recent update, my EHR takes too long to open after I log in.

Huge amounts have been written all over the web about the EHR and  how difficult it is to adapt to. To those EHR haters my response has always been this; The EHR is our new reality, if you just get used to the idea that you need to adapt to the computer and not the other way around, and just get on with the process of adapting your typical routine to this new reality, your life will be much better.
But this newest update has me questioning that philosophy. Yes I have adapted my workflow to the EHR, and made all of the changes I mentioned above. Now I have to make another change after a recent update that made only modest changes to the EHR’s functionality. The update has caused a 15 to 20 sec gap from when I log in to the time that I begin to enter information. I’ve tried to fill this time to prevent an inevitable awkward silence, but 20 seconds is a long time to make small talk. Plus I can only ask “how’s the weather outside” so many times per day.
On the other hand if I delve right into history taking, I’m then 20 seconds behind when I do start typing.
So thus far, my interim solution thus far has been to log in first and then go make physical contact with the patient before entering anything in the EHR. This usually involves  a handshake and maybe a few preliminary questions. In some cases, if I’m already familiar with the patient, I may begin my physical exam right away, before I even start entering data. In any case, if you’re one of my patients and you are reading this, I apologize that I am listening to your lungs before I finish getting your complete history, now you know the reason why. I’ll probably keep going with this interim solution until I find a better one, I’m more than open to ideas if anyone out there has any. Meanwhile I’m hoping all future programming updates don’t force me to change my workflow.
Incidentally, a similar problem has occurred at the hospital’s computer system. When logging onto the hospital’s system for the first time of the day, there is about a 30 to 45 sec wait before the program will open.  I now log in, hang up my coat, maybe get some coffee from the machine or check my mailbox, and then come back to the computer.
Either way, suffice it to say, this is getting kind of ridiculous. I am dearly hoping that all future updates will not similarly dictate a change in how I go about seeing patients. . . are you listening Allscripts?

-by Matthew Moeller M.D.

I am writing this letter because I feel that our leaders and lawmakers do not have an accurate picture of what it actually entails to become a physician today; specifically, the financial, intellectual, social, mental, and physical demands of the profession. This is an opinion that is shared amongst many of my colleagues. Because of these concerns, I would like to personally relate my own story. My story discusses what it took to mold, educate, and train a young Midwestern boy from modest roots to become an outstanding physician, who is capable of taking care of any medical issues that may plague your own family, friends, or colleagues.

I grew up in the suburbs of southeast Michigan in a middle class family.  My father is an engineer at General Motors and my mother is a Catholic school administrator in my hometown. My family worked hard and sacrificed much to enroll me in a private Catholic elementary school in a small town in Michigan.  I thought I wanted to be a doctor in 5th grade based on my love of science and the idea of wanting to help others despite no extended family members involved in medicine.  Winning a science fair project about the circulatory system in 6th grade really piqued my interest in the field. Throughout high school, I took several science courses that again reinforced my interest and enthusiasm towards the field of medicine.  I then enrolled at Saint Louis University to advance my training for a total of eight years of intense education, including undergraduate and medical school.  The goal was to prepare myself to take care of sick patients and to save the lives of others (four years of undergraduate premedical studies and four years of medical school).  After graduation from medical school at age 26, I then pursued training in Internal Medicine at the University of Michigan, which was a three year program where I learned to manage complex problems associated with internal organs, including the heart, lungs, gastrointestinal tract, kidneys and others.  I then went on to pursue an additional 3 years of specialty medical training (fellowship) in the field of gastroenterology. The completion of that program culminated 14 years of post-high school education. It was as that point, at the tender age of 32 and searching for my first job, that I could say that my career in medicine began.

Over that 14 year time period of training, I, and many others like me, made tremendous sacrifices.  Only now as I sit with my laptop in the dead of night, with the sounds of my children sleeping, can I look back and see where my journey began.

For me, it began in college, taking rigorous pre-medical courses against a large yearly burden of tuition:  $27,000 of debt yearly for 4 years.  I was one of the fortunate ones. Because I excelled in a competitive academic environment in high school and was able to maintain a position in the top tier of my class, I obtained an academic scholarship, covering 70% of this tuition.  I was fortunate to have graduated from college with “only” $25,000 in student debt. Two weeks after finishing my undergraduate education, I began medical school.  After including books, various exams that would typically cost $1000-$3000 per test, and medical school tuition, my yearly education costs amounted to $45,000 per year. Unlike most other fields of study, the demands of medical school education, with daytime classes and night time studying, make it nearly impossible to hold down an extra source of income. I spent an additional $5000 in my final year for application fees and interview travel as I sought a residency position in Internal Medicine.  After being “matched” into a residency position in Michigan, I took out yet another $10,000 loan to relocate and pay for my final expenses in medical school, as moving expenses are not paid for by training programs.

At that point, with medical school completed, I was only halfway through my journey to becoming a doctor.  I recall a moment then, sitting with a group of students in a room with a financial advisor who was saying something about how to consolidate loans. I stared meekly at numbers on  a piece of paper listing what I owed for the 2 degrees that I had earned , knowing full well that I didn’t yet have the ability to earn a dime. I didn’t know whether to cry at the number or be happy that mine was lower than most of my friends. My number was $196,000.

$196,000. That was the bill, for the tuition, the tests, the books, the late night pizza. $196,000 financed through a combination of student loans, personal loans, and high interest credit cards, now consolidated, amalgamated, homogenized into one life defining number for my personal convenience.

I then relocated to Michigan and moved into a small condo in Ann Arbor, where I started my residency. As a resident in Internal Medicine, I earned a salary of $39,000. All the while, interest continued to accrue on my mother-lode of debt at the rate of $6000 per year due to the high debt burden.  Paying down this debt was not possible while raising two children. My wife began working, but her meager salary as a teacher was barely enough to cover day care costs. During residency, my costs for taking licensing examinations, interviewing for specialty training positions, and interest on the large loan ballooned my debt further, now exceeding $230,000, all before I began my career as a “real doctor”.

Relatives and friends often ask me, “now that you are a ‘real’ doctor, aren’t you making the big bucks?” While I am fortunate to now be making a higher salary, some basics of finance make my salary significantly less than meets the eye (very in-depth article on how this is so). First, I was 32 years old as I began training and I now had over $230,000 in debt. Had I invested my talents in other pursuits such as law school, I would not have built up this level of debt. Also, as I did not start saving when I was younger, financially speaking, I have lost the past 10 years without the ability to save and invest to earn compounding interest.  In addition, as physicians, though we make more money than many others, we are not reimbursed for many of the services that we provide.
We do not “clock” the number of minutes as attorneys do when we talk with patients.  We do not hang up the phone as attorneys may do if they are not going to get paid. No, we listen to patients and answer their questions, however long it may take.  Even if it is the thirty-second straight hour of work, which happens very often, we listen, respond, and formulate a logical plan.  If it involves calling a patient at home after I just worked 30 hours in a row and just walked in the door to see my family, I do it. I never come “home” from work.  As physicians, we are always available, and have to respond in an intellectual way using the $230,000 rigorous education that we received.   And if we don’t do our work well, we don’t just lose business, but we can lose our livelihood through lawsuits.

You may ask why do we do all of this?  It’s because we have pride in what we do.  We truly care for the well-being of the human race.  We have been conditioned to think, act, talk, and work as a very efficient machine, able to handle emotions, different cultures, different ranges of intellect, all to promote the health of America.  We are doctors.

In reading this letter, one may think that one has to sacrifice a significant amount to become a great physician.  You may think we face physical and mental stress that is unparalleled.   You may begin to think that doctors not only have to be smart, but they have to know how to communicate with others during very emotional times.   You may think that we must face adversity well and must develop very rough skin to handle all walks of life, especially when dealing with sickness and death on a daily  basis.

Now that you see this additional aspect to our career, you may think that we have a tough job to tackle several tasks at once, demanding much versatility.  You may think someone needs a great work ethic to do what we do.  You must think that not only do we have to know science extremely well, we also have to know other areas such as writing, history, math, even law given the multiple calculations we go through in our heads on a daily basis and conversations we have with families. And finally, you must think we know finance, as we have to try balance a $230,000 loan while making $50,000 at age 30.

Now imagine, if you would,  having $230,00 dollars in debt with two young children at age 30 and listening to the news with lawmakers saying that doctors are “rich” and should have their pay cut.  Or that “studies show that doctors lack empathy”.

Unfortunately, we physicians do not have much of a voice on Capitol Hill.  There are not enough doctors in Washington D.C. who can give the insight of this letter while you in Washington, D.C. discuss health care reform.   You may hear from leaders of the American Medical Association, but these are not the doctors on the front lines.   These are the older political voices who were physicians when the times were different, when doctors did get reimbursed fairly for their work, when student loan debt was not this high, and when lawsuits were less prevalent. Many of the loudest voices in the healthcare debate are those of lawyers and lobbyists for special interests. They do not care about the well being of patients; that is what doctors do.

I want to make it clear that this letter is not just another story about the difficulties of becoming a doctor and being successful in medicine.  I do not want you to think I am complaining about how hard my life is and used to be.  In fact, I love my job and there is no other field I would ever imagine myself doing.   My true wish is to illustrate the sacrifices doctors do make because I feel we are not represented when laws are made. These sacrifices include a lack of quality family time, our large student loan debt, the age at which we can practically start saving for retirement, and the pressure we face with lawyers watching every move we make. Yet we make these sacrifices gladly for the good of our patients.

I want to challenge our leaders to address the points I have made in this letter, keeping in mind that this is an honest firsthand account of the personal life of a newly practicing physician.  It is a letter that speaks for almost all physicians in America and our struggles on our arduous yet personally rewarding life.  It is not just a letter of my own journey, but one that represents most physicians’ path on our way to caring for America’s sick.
You may ask how I had the time to write this letter?  As I’m sure many of you do, I made time.  It is now 3:00 am on my only day off this month.  I considered this a priority.  I hope you feel the same.  I just finished my 87 hour week.  Time for a short rest.

Article by Matthew Moeller M.D. who is a practicing Gastroenterologist in Michigan.

Edited by Deep Ramachandran, M.D.

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I have it on good authority that it’s not easy being green. But I’m willing to wager that it’s a whole lot easier when you have a lovable name like “Kermit”. Imagine being green (or brown) with a name like “Ramachandran”? Growing up with a name like mine certainly had its disadvantages. While most neighborhoods have a local bully who kicks ass and takes names, in my case, he would typically kick ass, but didn’t bother with the name part because he couldn’t pronounce it. Somehow I found that last part more insulting.

 I’ve long since outgrown the sensitivities about my name (although I still make any telemarketer pronounce it properly before talking with them). For most patients and those with whom I only occasionally associate, I go by “Dr. Ram”, which works fine by me. But perhaps those early experiences left me with an impression about how people can be affected in positive ways by getting the pronunciation of their name right, or at least trying to get it right. As well as the negative ways in which people can be affected by getting the pronunciation wrong, or by not even bothering to try.

So I would like to direct a message to those care providers out there with easy to pronounce names, because this  is something that you probably don’t  know. Getting the pronunciation of somebody’s name correctly (or at least trying to) is important. These people often wave you through that initial awkward part of an encounter, simply because they’ve given up hope that people are going to get it right. They tell you it does not matter only because they have already spent too much time in trying to get the name pronounced properly, only to have it reduced to a few letters. They wave away the mispronunciations because they’ve learned to accept that no one is going to invest the few seconds that it will take to pronounce it correctly. But they do care, and make no mistake, it is very important to them. Not taking the time to learn the pronunciation of someone’s name sends a powerful message. It says “We don’t know you, you’re a stranger here” And doing it repeatedly says “I still don’t know you, and I’m too busy to bother to try”. The subconscious message that the patient takes from these encounters is “these people don’t know who I am”. Conversely, taking the time to try to learn the proper pronunciation of a name  says “I’m listening to you” and “I want to know who you are”.

 So how would one implement this, and what if you’re terrible at pronunciation? Don’t worry, many names can be broken down phonetically. Let’s start with my name, looking at the entire name “ramachandran” can be intimidating. If you break it down into syllables; rama  chan   dran, it’s much easier. If you’re sounding it out right now, you probably got it right! Most people with long or difficult to pronounce names have a system to help people pronounce it properly, whether breaking it down, or using other words that rhyme with it. Keep in mind that no one expects you to roll your R’s like a you’ve been doing it your whole life, and your pronunciation doesn’t  have to be perfect, just close. Remember, the important part is that you’re taking the time to try, you’ll be appreciated just for that.

The next part, and probably the hardest for me, is remembering the pronunciation for the next time that you see patient. This can be especially tough since it may be several months before you see someone back in the office. I’ve found that the EHR can be helpful in this regard. I’ve begun using a system where I include the pronunciation in the HPI part of the history. For example, instead of typing “Mr. Villanueva is a 28 yo male” I might  type “Mr. Villanueva (villain-WAY-va) is a 28 yo male”, I would cut and paste this so that it is always in the most recent note. I’ve also added “pop-up” reminders so that whenever someone from our office opens the chart to call or otherwise interact with the patient, they are also aware of the proper pronunciation of the name.

I feel that instituting these changes lays the groundwork for better communication, improves trust and increases familiarity. In turn, and probably the most important point for medical providers, is that little changes like these can make a medical office truly feel like a medical home and can ultimately help improve compliance. In our increasingly multicultural society, I think that issues like this will take on greater and greater significance. It’s only a matter of time to where, if you want to kick ass as a medical provider, you better be able to get the names right.

I’ve written before about our EHR and all the the things that I really like about it. Add to that list the fact that we can now get incentive payments from Medicare (or Medicaid) for buying and using an EHR (we were early adopters of the technology before the current incentives came out). But in order to qualify as an electronic health record in the government’s eyes, the federal government determined that everyone’s systems must meet certain minimum functionality requirements, what they call “meaningful use”. This is where things are getting tricky. . . because my beloved EHR is telling me that my medical records are are not meaningfully useful, and in fact are meaninglessly useful, or meaningfully useless, one or the other, or perhaps both.
As if that was not enough of a slap in the face after all the love and adoration I’ve showered upon the system, there’s this bitter morsel. I’m being told that the manner in which I’ve been deficient is in the department of documentation of smoking. Can you believe that? Smoking! Me! The super-anti-smoking guy! The one who wrote this article. And then the other one. Plus, remember that other one? Seriously?
Could I truly be deficient in my smoking documentation? Refusing to believe such blasphemy, I delved into the medical records. No, see, there it is? Right there.  Under HPI, “patient has no history of smoke exposure”. And there again, in the next chart, more extensive smoking data meticulously typed into the history. I knew that I was documenting this stuff. What could the problem possibly be?
I spoke with our office’s biller. In order to figure out what the problem was, we delved into the various rigamarole of documentation requirements. Poring through the various reporting requirements and how Megatron (that is what I’ve named our EHR since this incident) reports on them, we identified the source of the problem. As it turns out, it was stupid. Like really stupid.
Ya see, our Megatron has a check box section under social history where smoking can be documented. Even if I type in my own more extensive social history, Megatron does not recognize it.
He wants me to take a specific set of actions every time. In order to illustrate this for you I’ve taken a few edited screen shots from an imaginary patient encounter. Below is our allscripts EHR opened into a patient encounter session. On the upper section there are searchable terms such as cough, abdominal pain, etc. . . If I were to  click on one of these, I would be taken to a check-box system of questions. Since I can type well enough on my own, I prefer to type in the initial complaint history in the field below it, as the person relays it to me. There is where I would normally type in what a person tells me about their smoking habits. However, instead of typing in something like, “The patient has no history of smoke exposure”, I need to click on “History” in the column on the left.

After clicking on that box on the left, I’m taken to another screen. A new column opens that gives options of entering data on different aspects of the medical history such as social, family, medication history, etc. . .

In this new screen, I need to click on “Social” in the second column, which then opens up the social history field. Under the social history field in the third column, clicking on “Tobacco Use” then takes me to another pop-up screen of check boxes (not shown) which must then be checked. Only if I complete these series of actions will I be considered as a physician who asks people about smoking, and hence using my EHR in a “meaningful” manner.

As you might imagine, I came away from this experience feeling very frustrated. Unless I clicked in the check-boxes, as far as Megatron is concerned, I did not ask about smoking. I felt like I was on a weird Seinfeld episode.
Me: But Megatron, I typed a social history with much more detail that you include in your check-boxes, and I can type it faster than I can click the check-boxes.
Megatron: No soup for you!

I went back to my biller/computer person/assistant office manager/scheduler. “Isn’t there any way we get the computer to just recognize my smoking history if I type it in?”
Her reply: “Dude, you type too much. Just click the damn boxes and quit bothering me.”
Damn, you, Megatron, Damn you!

Related articles:  Snow Birds and EHR;   Where Medical Reports Go to Die.

One of the first posts I wrote here, was a about how pharmaceutical reps provide lunch for physicians while presenting information about a medication that they are promoting.  The post, and others like it, have generated visceral reactions on the part of the public. A similar article to the one that I wrote (also on kevinmd) prompted comments like “Get over yourself and buy your own lunch” and “I’m certainly glad that you are not my doctor”.

The opinions were so strong I was invited to speak on CNN about the topic. In particular, I was asked to speak about all the other extravagant things that physicians get from drug companies. I ultimately did not do the interview on account of me not having any experience with receiving any of the extravagant things they were talking about. It seemed to me that individual physicians receiving lunch was (excuse the pun) small potatoes compared to what happens behind closed doors in the halls of power. While upcoming rules will soon provide the public with a window into the value of goods provided to physicians by drug companies, they will provide little insight about where pharma has its greatest and most effective influence: behind the closed doors of those halls with thought leaders, opinion makers and legislators.

To that point, a story came to my attention recently that reminded me about that fact. The Dean of Weill Cornell Medical College, a prestigious and highly regarded medical school, has apparently kept close financial ties with industry, as reported in the the college’s newspaper.  The college’s Dean, a highly accomplished and awarded physician researcher, has retained positions with a major pharmaceutical company and a laboratory equipment company. In these roles last year she reportedly received about $260,000 from one of the companies and about $277,000 from the other last year. The Cornell Daily Sun also reports that she has apparently received millions of dollars in compensation from both companies over the years as well as more than a million dollars worth of shares and stock options in the companies.

As dean of a prestigious medical college, she must undoubtedly understand that she has the ability to influence the behaviours of thousands of future physicians, and the  power to lead by example. I find it appallingly hypocritical that, while the dean sits on the board of these companies, she is training future physicians who will be discouraged from receiving anything of value from the pharmaceutical industry.

To get a better understanding of the depth of this double standard, take a look at the pharmaceutical vendor policy of the medical college’s affiliated hospital. In an effort to control costs, they have significantly restricted the activities and access that pharmaceutical representatives have in their facility. This is fairly common practice among hospitals, as is the practice of restricting inpatient medications to cheaper generics whenever possible. Hospitals know that the presence of pharma reps increases costs by encouraging physicians to use the more expensive medications. Hospitals thus try to reduce the influence of the reps on physicians both by  removing the expensive alternatives from the hospital pharmacy, and by limiting access to pharma reps.
Like many other hospitals, reps here need to be credentialed and registered by the hospital before being allowed access. They must enter the facility through specific entrances designated for reps, and they may enter by appointment only. Furthermore, the hospital’s policy explicitly states that reps are not allowed to meet with medical students on hospital property. Nor do they allow free drug samples to be distributed by pharmaceutical representatives.

By now it should be exceedingly self evident why telling your students on one hand not to speak with pharmaceutical reps, and on the other taking millions of dollars from the same company would be hypocritical. That we should ask more of our medical educators and health care leaders is also self evident. And I could say alot more, too. I could say how inappropriate this is, and ask that all medical college deans take a pledge to no longer take money from industry. But instead I would like to defer to a simple message which summed up what most people felt about a recent article on drug rep lunches that I think fairly  and accurately sums up this situation as well. The comment, directed at the medical community, said simply and emphatically, “Who’s money do you think you’re spending? IT IS IMPROPER BEHAVIOR!”.