It’s sacrilege to not want to be the OR if you’re a surgeon, or a wannabe.

I’m guilty of it this rotation. Not only am I not actively seeking out the OR, I’m attempting to avoid it. And today, spending the day in it against my wishes, I’m peeved.

My disdain is multifactorial. Some of the reasons for avoiding scrubbing in are personal and beyond discussion here. But, in part, the fact is I’m tired of general surgery. I want to be a neurosurgeon and if I never see the inside of an abdomen ever again I would be beyond comfortable with that. Even agreeing that any operating time is good learning experience I can’t shake that sentiment.

Toss me anything with a neurosurgical faculty, an osteoma or a shunt or a trauma crani, and I would be there with glee. But I just cannot shake my distaste for what I’ve been doing over the past seven months or for what I had to do today.

Despite my own misgivings about scrubbing in, I can’t understand future general surgeons refusing general surgery (or its subspecialties) cases. I faced such today.

There was a single OR running today with four cases.

There are five residents on my service. It is highly over staffed. Four of the residents want to be future general surgeons. I’m the lone outcast. One was on call, I understand him not wanting to drive across town to scrub in. That left three others, all of whom are seeking to impress the faculty, to garner a good evaluation from this rotation. I’m alone in having my evaluation bear no impact on my future. I’m alone in not wanting to be a general surgeon. And yet I was sent to scrub in.

My response was frank annoyance, hardly professional, but I figure hardly misplaced in full.

It’s true I’ve managed to avoid the OR but for a handful of times and left the responsibility (and may I opine, privilege) to the general surgery wannabes on the services. I imagine them figuring I needed to shoulder my share of the ’scrub in burden’. But what a ridiculous notion. The fact general surgery residents figured scrubbing in as a burden; essentially refused several general surgery cases out of what I can’t help but call laziness is bizarre and worth criticism.

My own avoidance of operating experience is something of laziness although my reasons on this particular rotation, as I said, are complex. But if anyone could be afforded an excuse for such it’s myself; with nothing at stake on this rotation unlike all the others.

And while throwing ones fellow residents under the bus is something of a shameful act I have to ask about today, “What the hell?”

The one guy with the most legitimate (at least I feel so) excuses for not going into the OR is prodded in so everyone else can take a lazy breather?

I’m annoyed.

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If I’m ever in an acute care setting I want to be the specialist. I want to be hidden behind the wall of a consult. I don’t want to be the front line guy.

As much as I love shift work, detective work, immediacy in medicine I was turned off of specialties like emergency medicine because of scenarios like this:

That is pretty much how it happens.

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HT to reddit for linking to the OB&G in turn linking to the following appearance on Anderson Cooper and to Paul’s effort to prohibit a health insurance mandate and to his effort to give a 100% tax credit to all Americans for health care expenses and to his effort for national tort reform.

To call Dr. Paul’s ‘Comprehensive Health Care Reform Act’ reform, as the word has become common lexicon in Washington, would not be fair. The tax credit Dr. Paul proposes would probably do little to broaden health care access for those with current mediocre care. Even with the tax credit we probably don’t reach a place where most Americans can continue to fund an increasing percentage of their health care out of pocket. As well, as with most of Dr. Paul’s impressive proposals, it is a political non-starter. I think cutting government spending by dramatic levels is a noble goal, and such would be required to give all Americans 100% credits for every health care dollar they spent, but it certainly isn’t politically feasible. No matter how many Tea Parties are hosted.

It doesn’t mean that the proposal isn’t a good one. As I’ve said I’m not sure our goal should be increased coverage; that we should be so fascinated with these kind’ve global health care outcome measurements. That health care should be a social concern. Certainly it shouldn’t be one with a government vested interest.

Essentially reform, as it is thrown around in Washington, calls for a trade of liberty for some ill defined right to health care. I’m not comfortable with that. And I understand, and concede, that only government intervention will improve these utilitarian metrics used to grade ours and all health systems. I understand, and concede, that only government intervention will further health on a population scale. But what it is going to cost, in terms of a further broadening of the role of government and an erosion of the right to property, to get that ‘universal’ access and to improve these numbers is unacceptable.

So I’ll continue to cheer on proposals like Ron Paul’s.

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It’s A Big One

There’s something gut wrenching about being an intern in July. You’re a ‘doctor’ in name but there’s nothing magical that happened when they handed you your degree.

To be fair, I would argue that the data leans heavily that patients receive no worse care at teaching hospitals in July, when new interns start, than any other month of the year. As well major teaching hospitals, where residents are involved intimately with patient care, consistently provide better care than non-teaching hospitals.

But that’s all a sidetrack. The fact remains that being a new doctor is not without some butterflies.

Every once in a while however you do something of effect. Opportunities to truly help patients often arise from the fact that as an intern I’m probably the physician who lays eyes on our patients the most.

I was two weeks into my intern year when I first ‘caught’ something with a patient. I was in the Surgical Intensive Care Unit. Late one day the ENT resident caught me to tell me about a post op patient they had put in SICU admission orders for. I can’t remember what he had had done but he had been a tough intubation and didn’t have an air leak when they were done with the procedure. So they kept him intubated and ventilated and dosed him with some steroids.

On a ventilator, of course, he was going to require an ICU bed.

I went down and visited him in the Post-Anesthesia Care Unit. There was a good chance he was going to spend the entire night down there as there were no ICU beds open. At that time he was hanging out. I put in some standard ICU orders, talked briefly with his wife, wrote a note and headed back up to the ICU.

About two hours later I get a call from the nurse in the PACU that the patient is agitated.

Something made the experienced nurse caring for him sit up and take notice when this patient began to pull at his restraints, rather than just turning up his Versed drip. As such I probably shouldn’t be calling this ‘my’ catch.

In anycase, I get down there and the guy is tachycardic on the telemetry monitor. I’m an intern so my modus operandi is to order every test in the book for every little thing and I’m already thinking about a PE protocol CT scan with this guy. But first things first, the nurse and I get an EKG. I’m admittedly surprised at how classic it looks.

The EKG Looked Something Obvious Like This

I remember MONA, call the cardiology fellow, fax over the EKG, call my upper level, call the ENT resident and the patient ends up in the cath lab with a clot pulled from his LAD.

The patient ended up in the MICU and I’ll be honest I don’t know how he ended up. Hopefully well. For me, this patient taught me some valuable lessons; he taught me to respect what the nurses have to say about patients, to lay eyes on patients whenever there’s any change. Things I need to keep in mind as I get along in my residency.

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I’ve been working some hours of late as my fellow intern is taking vacation and there really wasn’t afforded anything in the schedule to mitigate that. Not to get all ‘I walked uphill in the snow both ways to get to school each day’. I know residency used to be something tougher. Maybe.

While I haven’t gotten into the operating room I’ve gotten some cool procedure, gotten pretty proficient at chest tubes and pigtails and generally had a pretty good weight towards actual patient care this rotation considering the bureaucracy of medicine that falls to residents at academic centers. So don’t number the above as a complaint.

But the amount of time I’ve spent at the hospital has got me thinking about the way the ACGME polices residency rules. So much centers on self reporting. And there’s huge pressure to not report violations. When residency programs get in trouble with the ACGME there are consequences for the residents. A residency program shutting down can be disaster for residents. You could be searching for a new program, leaving a program you love, maybe even switching specialties or moving across the country.

The medical community does some to help in situations when programs are lost. In many specialties other programs traditionally give preference to those residents who have lost their spots. And the ACGME and most RRCs are helpful in giving residency programs exceptions for extra residency spots when programs shut down. In reality those concessions and that assistance are small potatoes.

Scrambling for a new spot that has funding for you, moving, acclimating to a new environment is major trauma. That is assuming you even get ahold of a new position.

There are major incentives for residents to keep their programs in good standing, including to lie about their hours worked.

Some research indicates almost half of residents lie about their duty hours. And you have to believe that is a remarkable under reporting of the situation.

Now I’ve never lied about my duty hours. And I can’t say I know directly of anecdotal episodes of categorical residents lying about their duty hours to protect their programs but you have to believe it happens. It is just not something that will ever be spoken to. If the ACGME wants residents and others to self report violations; if truthful reporting is going to be the centerpiece of review then it needs to give residents more protections. I’m talking about an extreme shift. I’m talking about emergency funding for residency spots when programs run into trouble, about guaranteed spots for residents whose programs fail including about requiring all programs to agree to participate in helping to take on displaced residents, about relocation expenses.

I’m thinking program violations for all sorts of things must be vastly, vastly, vastly under reported. ACGME policies don’t have a lot of teeth when weighed against the future of your training.

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A traumatic subdural with a pretty good shift deteriorates on his transfer from some rural area, gets to your hospital as a GCS of 7 and needs to go to the operating room emergently. His next of kin rode on the transport to your hospital. Other family members are en route by car but are some distance out.

You try to consent his next of kin using phrases like ‘emergency,’ ‘right now,’ ‘life and death’. The response is a lot of waffling, a request to wait until the rest of the family gets to the hospital, and calls to those same family members seeking advice.

I seem to have run into the above, or the equivalent, several times over my still young intern year. Not every night or every week, but a few times. Too many times.

I understand such situations are incredibly stressful for those presented with a decision for an emergent procedure (or not) for a loved one. I understand a lot of information is presented to them in a short period and they’re asked to digest it under stress and make one of the most important decisions of their lives.

I’m not sure it excuses trying to skirt the responsibility.

The most frustrating instances involve those legally responsible asking you as the provider to seek the opinion of other family members and to have them decide.

“Oh, I just don’t know! Can you call his sister and have her decide?”
“I’m happy to talk to her and anyone else in the family, but this is something I really need consent from you for.”

Admittedly it could be me. I don’t think so however. I think I present the situation generally with the proper sense of urgency and yet lay out the decision to be made and the options and the consequences of each option in a pretty down to earth and understandable way. The few times I’ve run into this, others – my residents, fellows, faculty – who have come along to talk to the family after me have had the same problem.

True, maybe as the first to attempt consent I’ve spoiled the whole pot for all who follow. More likely the commitment and responsibility owed to a loved one breaks down under the spotlight of the situation for some.

Decisions under time pressure, with limited information, with a loved one at stake are incredibly difficult and I try to check my frustration. However, a sense of responsibility is just sometimes lacking from those asked to choose to either put the pen to the consent form or to refuse to put the pen to the consent form.

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Life as a healthcare provider is privileged. You get to see a lot of humanity. The good, the sad, the humorous.

Probably two weeks into being a physician I had to push neostigmine on a patient. Neostigmine is a powerful cholinesterase inhibitor that among other things causes…significant bowel contraction. Which is why I was using it. My patient had come into the trauma ICU following, literally, a nose bleed. Early onset dementia had left the patient in a nursing home and following a fall at that nursing home no one had been able to stop his epistaxis. Down in the ER they had literally stuck foley catheters deep into his nostrils and inflated them to apply pressure and stop the bleeding.

Typically Doesn’t Go In The Nose

He had a lost a lot of blood and had a lot of comorbidities and was at high risk for rebleed and so he ended up in the ICU. Easily, supposedly the least sick patient in the trauma ICU.

He had significant deconditioning on presentation and likely had some generalized ileus. Being in the ICU and further bedridden didn’t make his condition better and his belly started to grow. A KUB sometime into his stay showed a pretty significant generalized ileus without evidence of obstruction. Enemas and other efforts didn’t do a lot to decompress him. So my resident sent me in to give the patient neostigmine.

Neuostigmine isn’t always a benign drug. ‘Side effects’ include bradycardia and, that persisting, arrest. So my resident had me go into the room to administer the neostigmine with a syringe of atropine should I require it. The rest of the team, in a telling move, stood outside peeking into the room; they feared the consequences of rapid bowel contraction.

I slowly push the neostigmine and I stand there, vigilant, grim waiting to have to urgently give the atropine if needed. I’m tense. I’m a two week old doctor and my resident has made this out to be a serious medication.

Suddently my patient starts with, “I have to go. I have to go. I have to go.”

“Okay, sir, we’re getting you a bed pan,” I say. It does nothing to temper my poor demented patient, “I have to go. I have to go. I have to go.”

The nurse runs out of the room to get a bed pan; an admitted oversight for everyone involved in this endeavor. “I have to go number two!”

“It’s okay, sir,” as we slide a bed pan into position. “You can go if you need to.”

I’m watching his heart rate on the monitor and then the patient starts throwing in a new phrase. At first I think he’s saying, “I hate you.” But as I strain to listen it’s clear, “I hate poo. I hate poo. I hate poo.”

I almost lose it. Sitting there with atropine in hand should this patient have a crisis and brady down, I have to turn around and walk to the corner trying to stop myself from laughing.

I refuse to call it unempathetic; there was something endearing and worth a non-condescending chuckle about what we were putting this man through to treat him and help him. It’s the humanity of practicing medicine.

“I hate poo. I hate poo. I hate poo.” Me too.

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My last residency interview was a couple of days ago. I’ve rarely been so relieved to be done with something. Walking out after hours of being holed up in a hospital conference room and of talking with faculty and researchers, I felt a real big weight leave my shoulders.

Interviewing for any job can be stressful. Residency interviews may be on a whole different level.

Residency has been caricatured by shows like Grey’s Anatomy and Scrubs. It is that time in a physicians life after they have graduated after they have graduated from medical school and gotten that M.D. after their name; when they are getting training in a medical specialty.

Can’t Wait For Graduation Day & The Diploma

But getting from where I am now, to where the characters of Grey’s Anatomy are requires navigating the residency interview and match process. It isn’t quite like any other job search out there. Although most of my interviews were get-to-know-each-other type of affairs I was, at times, ‘pimped’ on clinical scenarios, asked to read CT and MRI scans, and even had my dexterity tested. All more than fair. But except for select technical jobs – say engineering or computer programing work as examples – not exactly the type of oral test most job applicants face.

Those type of clinically relevant questions are important and not wholly unique. What may be more unique and grueling is merely the length of the whole process. Last year, in the specialty I’m trying to enter, the average medical student went on more than 14 interviews. Like for in many job interviews, each residency interview is a full day, often a multi-day affair. 14 job interviews is a lot. Perhaps more telling, it isn’t unheard of to talk with 15+ individuals at a single interview.

Let’s say the average number of faculty you interview with at any program (this is specific for the specialty I’m trying to enter) is 7 or 8. Let’s say 7.5. That seems like a reasonable number from my experience. If you went on 14 interviews you would’ve talked with more than a 100 people by the time the interview season was over.

That’s answering the same questions 100 times. That’s asking the same questions 100 times. That’s the same small talk 100 times.

Don’t get me wrong, it is important. This is your future as a graduating medical student. This is their future as a program. And the interview is often a very narrow window to get a feel of where you want to spend the next several years of your life. But boy, I think everyone can imagine how draining such a process could be.

And you do get such a small window of what programs are like. If my future was working in a cubicle, I could get at least a sense for the day to day mechanics of a corporation, of it’s bureaucracy, of what a typical day is like during a couple of days of interviewing. Residency interviews can rarely afford you that. Ten applicants, crammed into a day of interviewing cannot go spend time down in the clinic or go scrub into the operating room or round with the residents.

True, many programs, especially in some of the surgical specialties, encourage ’second looks.’ They encourage interested applicants to come back and see how their residency program runs in a real day situation.

But there’s another kicker with that. The entire interview process, including any potential second looks, is largely self funded. Applicants applying to competitive specialties and going on many interviews can easily spend upwards of ten or fifteen thousand dollars. That is borrowed money and in actuality will end up costing the applicant much more than that.

It’s an investment in your future of course and so I think most applicants take the debt with grace. And most medical students are used to debt; another $10,000 is just something to shrug at…unfortunately. Still, it is a little eyebrow raising.

I’m done though. Now I merely wait. You see, the final difference between interviewing for residency and your typical job interview is that residency programs don’t really offer applicants positions.

Unlike interviewing for that cubicle job, there was no chance I was going to walk out of a residency interview and a couple of days later get a call offering me a position.

Instead, all applicants and residency programs are bound by contract to go through the residency match.

Applicants have to rank the programs they interviewed at. Residency programs have to rank applicants they interviewed. It all goes in a mysterious box and out comes the results, telling you where every applicant ended up (if they matched at all). In reality the algorithm used to match residency applicants to residency programs isn’t too complicated. Why it is done this way is a matter of history. The match is certainly not without it’s detractors; but that is for another post.

At the least, the match makes for a trying wait. From now until match day is approximately 2 months.

My interviews though are over. That sounds like an excuse for a celebratory beer.

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Sanjay Gupta has been offered, and apparently accepted, the post of Surgeon General in Barack Obama’s incoming administration. It appearsObama holds a special place in his heart for neurosurgeons, which of course brings a smile to my face. I heard on the interview trail that Chicago neurosurgeon, Dr. Gail Rosseau, was close to the Obama camp. Whatever the validity of those claims, apparently she was at least considered for the position of Surgeon General.

Neurosurgeons having their say on matters of public health and health policy is obviously something that interests me and that I have a stake in. But even if that wasn’t the case, Dr. Gupta’s nomination as Surgeon General is something that should be welcomed. That has not been uniformly the case in the media.

Sanjay Gupta Will Have To Grow The Beard

Definitions of both Dr. Gupta and the role of the Surgeon General are probably in order.

Dr. Sanjay Gupta is a Michigan raised neurosurgeon and journalist. He has a significant presence at CNN and has filed pieces and covered everything from public health issues in the United States to international natural disasters to the war in Iraq. Dr. Gupta got his MD and did his neurosurgery training at Michigan with a spine fellowship at UT-Memphis. Not small accomplishments. He holds a faculty position in the Department of Neurosurgery at Emory University.

The role Dr. Gupta would take on as Surgeon General is one with many hats. The Surgeon General heads up the U.S. Public Health Service Commissioned Corps. The Corp has several, sometimes ambiguous, goals but in general works to promote public health. In practice they play a large role in delivering health care to Native American and other underserved populations and providing medical officers for the U.S. Coast Guard. The U.S. Public Health Service Commissioned Corp is a uniformed service and as such shares unique organizational challenges with other uniformed services including the military. Beyond that role however, the Surgeon General’s most important and highest profile responsibility is in communicating public health issues to the public.

The reality is the Surgeon General is vested with little real authority. This is both a challenge and a gift. It has allowed prior Surgeon General’s to voice medically valid opinions on highly politicized topics such as sexuality or drugs of abuse or obesity.

That is where Dr. Gupta’s nomination is so brilliant. As the WaPo piece linked to above notes,

The offer followed a two-hour Chicago meeting in November with Obama, who said that Gupta could be the highest-profile surgeon general in history and would have an expanded role in providing health policy advice, the sources said.

Dr. Gupta would serve a cross appointment in Obama’s new Office of Health Reform directly under new Secretary of Health & Human Services Tom Daschle (who would technically be Dr. Gupta’s boss’ boss as Surgeon General).

I would argue their is no more important skill than communication for the Surgeon General considering his limited influence on policy and the public health of the nation. At least historically. Dr. Gupta is obviously unrivaled as a physician in that aspect. Because of his role on television he has established a relationship with the American public and indeed the world. As a journalist he has proven effective at distilling complicated medical issues down to bite sized chunks that the public can understand and digest.

I have no doubt that Obama intends to use the Surgeon General position as a spokesman not only on matters of public health, as has always been the role of the modern Surgeon General, but on maters of health care policy. I would hope that Dr. Gupta’s position in the Office of Health Reform would be a legitimate one and his voice would be prominent. Apparently he is satisfied as such, as he spoke with Tom Daschle before accepting the position. Dr. Gupta has legitimate experience in the policy arena, he served as a White House Fellow in a previous life. That is impressive.

His experience as a journalist, I would argue, has also made Dr. Gupta, admittedly far removed from some public health issues as a highly specialized surgeon, more than well versed on public health issues. The very issues the Corps is tasked to face.

Dr. Gupta’s nomination is not without criticism however. From what I’ve read the criticisms fall into two categories. Either people question Dr. Gupta’s experience or they cherry pick some commentary he made over the course of his career as a journalist to chide him.

For some the Surgeon General should have some experience in a uniformed service. Dr. Gupta has indeed never served in the military or the Public Health Service. But having donned a uniform in the past, in terms of being able to organize and lead a uniformed service, does not seem an absolute necessity.

Without a doubt, the most famous Surgeon General was C. Everett Koop. Dr. Koop served his time during World War II in the Public Health Service instead of in the military. When he came back to serve as Surgeon General under Reagan, it was to head a Corp he had been a member of. But you will never convince me the Commissioned Corp Dr. Koop came back to, forty years after he had left, was the same Corp he briefly served in during wartime.

Dr. Val over at Get Better Health has an interesting comment from an anonymous source apparently either somewhere in politics or in the U.S. Public Health Service. Here’s what s/he says,

If Sanjay Gupta is confirmed as Surgeon General he will achieve the immediate rank of admiral, even though he has no previous military or public health experience whatsoever. It will be difficult for Gupta to be taken seriously by peers at the Pentagon and State Department.

First, obviously the Surgeon General is required to coordinate and interact with high ranking military leaders but playing the Commissioned Corps of the Public Health Service as analogous to a military uniformed service (as I read the anonymous commenter doing) is a little disingenuous. Let’s draw out that assumed analogy and see why it doesn’t hold up. C. Everett Koop spent a limited amount of time in the lower echelons of the Public Health Service, left for nearly forty years, and then came back to head it. And yet was both accepted and arguably effective (if controversial at times). A similar experience would be a drafted man serving as a private in the U.S. Army through World War II, then leaving and maybe working in the arms industry for thirty years and then suddenly being appointed to head the Joint Chiefs. Impossible, unrealistic and just itching for a disaster.

But that isn’t the case with the Public Health Service. While heading a uniformed service and coordinating with career military and other uniformed service officers, the skills necessary to be Surgeon General and lead the U.S. Public Health Service Commissioned Corp are readily learnable in other careers; making it completely unanalogous to the military.

I understand why those in the U.S. Public Health Service Commissioned Corp would want one of their own to lead them but their really is not something wholly unique about the role of Surgeon General that you must be a career public health servant to be effective.

Second, I think some criticizers are ignoring what the role of Surgeon General has grown into. Let’s be honest, the Surgeon General’s most important role is as a public relations man. Maybe not for the administration, but for something more ambiguous; for public health and healthy living. He or she is the chief medical correspondent for the American public. Dr. Gupta is as qualified as anyone I can think of for such a role.

The other criticisms of Dr. Gupta are more specific. Being a public figure in government is difficult when you’ve put a lot of the record. Dr. Gupta has certainly put a lot on the record as a journalist. He’s put both factual errors and his own opinions, free for others to disagree with, on the record. And even before word of Obama’s choice leaked, and certainly after, critics have cherry picked his work and cited his own words against him.

Here’s what Paul Krugman had to say soon after word of Sanjay Gupta as Surgeon General leaked.

I don

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I’m in my fourth year of medical school. In a matter of months I’m going to be a physician. Until October of 2008, thirty-seven months into my education as a medical student, I had never even seen a paper medical chart. My only rotations were at a county hospital with a strong commitment to EMR and at government sites. I rotated at both VA and DoD hospitals both with strong nationally connected electronic medical record systems. I had also never seen any numbers on the prevalence of electronic medical records and so I assumed that most major hospital systems, at the least ones with integrated physician practices such as in much of academia, must also have full fledged EMR systems.

But over two months, doing away rotations, I learned hard and fast the reality. I rotated at institutions which, like most of the country, still rely on paper charts for the majority of the patient’s record. Sure they often times have lab data on the computers and certainly, nowadays everyone has a PACS. But they’re missing out on so much more.

Over those two months I had to teach myself certain skills which really should no longer be a part of the delivery of health care in this country. I taught myself how to write quick, illegible and uninformative notes by hand. I taught myself how to fight off nurses and social workers for patient’s charts and then hoard them. I taught myself to just give up hope of trying to decipher the handwriting on a consult note and just page the service to hear their recommendations over the phone. I taught myself to memorize my resident’s provider numbers because I knew the nurses were going to be paging to confirm orders which they couldn’t read. I taught myself the most likely places for “missing” charts to be. I taught myself the most likely places for various documents to be filed in the chart.

Nowadays I’m on the interview trail. It is the long and arduous journey to find out where I’ll do residency. And I laugh a little bit inside when residents try to convince the interviewees that it is a good thing their primary teaching sites still use paper charts because it’s “faster and easier” to write notes by hand. That’s novice talk.

The Myth Physician Handwriting Is Worse Than The General Public’s Persists…

Virtually all computerized note writing systems allow templates or, at the least, click at you go note building forms. With three key strokes a resident in my home neurosurgery department can bring up a virtually completed consult note on a patient with any major, common neurosurgical issue. A few buttons on the keyboard to personalize the note for that specific patient and the note is done at least as quickly as if they had scribbled it on a piece of paper down in the emergency room. There is a learning curve and it represents one of the largest non-financial obstacles to the implementation of EMR systems. But I simply refuse to believe, that once the system is known to all and full implemented, that a electronic medical records system does not improve the efficiency of just about any practice environment. From the huge general hospital to the small rural primary care practice.

Beyond efficiency EMRs offer significant patient safety benefits. Poor handwriting or misinterpretation of orders are certainly a source of medical errors. No, electronic order systems, don’t eliminate these in full but they do reduce the risk. Handwriting becomes a non factor. Most major EMRs offer physicians advice on drug-drug interactions, limit physicians’ ability to order too much of a medication and/or check orders against a patients list of diagnoses and try to make sure the physician is ordering what he or she really wants to. Linked dispensary systems, like Pyxis, can limit the risk of nurses or others giving patients the wrong medication. And electronic patient identification (such as barcodes on patient arm bands) can significantly limit the delivery of medication or therapy to the wrong patient.

Obviously there are some major hurdles to the widespread implementation of electronic medical records. Included amongst these are technical issues and of course, in large part, the initial expense of implementation.

But these expenses are far offset by the benefits and most providers who are calculating it otherwise are fudging the benefits.

For hospitals the investment in well designed and implemented electronic medical records pays for itself in pretty fashionable time as some experiences have demonstrated. For private practices the initial overhead can be more daunting, admittedly. But private practitioners shouldn’t delude themselves that the benefits aren’t there. Yes, the patient safety issues for a largely ambulatory practice are less pressing than in the inpatient setting, if still present, but other benefits abound. Consider a new Annals of Internal Medicine study which may demonstrate that physicians who use EMRs may be less likely to pay malpractice claims.

I am a strong proponent of electronic medical records. However my point, in conclusion, is a nuanced one. For major medical centers, especially academic ones with integrated physician practices, to not have full fledged electronic medical records at the present time is inexcusable. For private practitioners, we should be working to bring electronic medical records as a reality. The lifting of Stark law restrictions was a good start, if the current economic conditions mean health systems are currently not as inclined to invest in EMR systems for their physicians as would be ideal. Hopefully federal subsidization will help the spread of electronic medical records into the private sector at an increased pace. Indeed P4P efforts should include the implementation of EMRs for increased reimbursement. Of course we all know how CMS’ P4P plans are doing. Still, I can dream

I’m serious about this issue. Ever residency interview I’m at I ask about the hospitals’ computer interface and what the physicians can and cannot do from the computers. A more substantial roll out of electronic medical records is long overdue.

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