He has been my patient for several years. My nurse practitioner colleague told me a few days prior that this patient had been diagnosed with terminal cancer. He came to see me today. He looked remarkably calm for a person who knew he had only a few days to live. After my usual evaluation, I sat on my chair. There was a long uneasy silence.

I wanted to say several things. I wanted him to be off all the medicines he was on for long-term benefits. He had a defibrillator that would shock him if his heart were to stop. I did not want him to get painful shocks from the machine when his heart was ready to go in his final moments. I wanted to ask if he wanted his defibrillator turned off. How do I tell him all this without sounding like I had already given up on him? I painstakingly put together some words to convey all that. His response to all those suggestions was quick and matter-of-fact.

Most of the time, when I am finished seeing a patient, I say- I will see you in six months, three months etc. What do I tell a person who is not expected to live more than a few days or weeks? How do I say goodbye to someone I may never see again while maintaining the hope that I just might?

I came back to my office after finishing with him, slumped into my chair, and started staring out of my office window. I had seen him almost every three months. The thought that I will never see him again gave me an odd, empty feeling in the stomach.

I enjoy listening to my patients’ complaints, processing all that data and coming up with some solutions. I had not done any of that to help him today but this visit had taken a lot out of me. Then I heard the thud of a chart being placed on my desk. Time to go see the next patient.
DrChander.com....Correction through action

How Going Paperless is Making Healthcare More Expensive and Lower Quality

‘Electronic medical records’ is the in thing now days. Going paperless is the mantra of our times. There is a concern that some doctors and facilities are not going paperless fast enough. Here is another twist that has much to do with going ‘dictation-less’ as a step to going paperless. There is a push toward providers typing the notes instead of dictating or writing.
Whenever a physician sees a patient, a proper evaluation includes several steps- asking the patient what is bothering him (history), examining the patient (physical examination), assessment of the situation and devising a plan of care based on the evaluation. After a physician sees a patient, these steps are documented for records. This is done by typing, writing or dictating. In addition to being an integral part of good patient care, these records are a great communication tool. Let us say I have to go see a surgeon. A look at my primary doctor’s notes can give this doctor a good idea about my overall health and other pertinent issues. In the absence of that information, my surgeon may end up providing me less than optimal care.
Taking history is an art, and writing an assessment and plan for a patient is a reflection of a provider’s quality of care. These can only be documented in numerous lines. There is a concern that busy providers’ quality of documentation may suffer if they choose to type the notes instead of dictating them as most can not type as fast they can speak. Here are the issues of concern to some people:
- A hurriedly typed record can become a poor communication document with a potential to lead to bad patient care- even jeopardizing patient lives in some cases.
- There is a concern that some doctors are unable to type line after line justifying their plan for patient care- this is easy to do if you are dictating- so they find it easy to order more tests and more consults which can be done by typing only a few words. This might be leading to more healthcare cost. As an example, compare note 1 and note 2 on the same patient.
Note 1- This patient has chest pain. The pain gets worse on breathing so it looks pleuritic. The patient is not high risk for heart disease. There is no sweating or nausea or vomiting with the chest pain. I do not think we need to do any further testing at this time. I have told the patient that if his symptoms get worse, he should go to the emergency room or call my office.
Note 2- C.P. Stress test. Cardiology consult.
Which note will you type when you have twenty more patients to see, they ask? Which line of patient care will prove more expensive without adding much to quality of care?
Some people say that typing instead of dictating saves transcription costs. A case of penny-wise, pound-foolish?
The point is well taken. Here is my take on it. Going paperless should not mean that providers cannot dictate and must type. Dictating is perfectly compatible with a paperless office. You can dictate, send it to transcription and upload it to your records on the computer without using a single piece of paper.
DrChander.com....Correction through action