Medical Practice Nightmare

It was like I was in a dream. I was referred a woman with symptoms of near fainting and dizziness. She came to me with a sheaf of papers from another hospital. I read through test after test, after test, MRA of the abdomen, MRA of the chest, of the neck of the head, MRI of the brain, echocardiogram, extensive blood tests.   The radiology reports lacked clinical impressions. I thought the last paragraphs of the reports with the doctor’s conclusions had been left out, but no, there weren’t last paragraphs. 

I did have clinical evaluations written by physicians, but they lacked diagnostic impressions. There was only no real history or physical exam. The write-ups mentioned plans for more tests. I found no evidence of clinical reasoning. 

The patient saw me looking through this mass of paper.  I’d been lead to believe she spoke no English. Then she said clear as day, “Wow Doc, I feel for you.  You have to go through all those medical records.” 

There was no note addressing the particular problem this lady needed to have solved. Digging through all that paper I came upon the likely trigger for the referral. The MRI showed a large pre-pontine cistern. Could it be a cyst causing pressure or was it just an incidental finding? It seemed to me it was a benign incidental finding.

That was time-consuming. I looked at the images myself being convinced there was nothing on the scan of any importance, then took my own history, the first detailed history that as far as I could tell, entered her medical record.  She communicated in English well enough, was articulate even, and I examined her.  It seemed this was the very first time she’d been subjected to a full history and exam. She’d only been briefly spoken to and sent for test after test. 

Only a few days later I had occasion to see another referral from the same facility. A man who had a reaction to a protamine infusion, a drug known to cause severe reactions, had his blood pressure drop to near zero. He had become sweaty and lost consciousness. The man’s wife saw the event.  He never stiffened or shook in the manner of a seizure. He too was tested extensively and everything was normal. Yet the neurologist who evaluated him,  apparently believing it was possible he had a seizure, felt duty bound to report the patient to the department of motor vehicles. His driver’s license was revoked for six months. It happened that the man was an inspector who needed to drive to make a living. That didn’t matter. Neither did the fact that he’d reacted to an administered drug and there was no evidence for any tendency to have seizures. 

After a review of tests and documents and exam, I filled out the required motor vehicle papers endorsing the man’s ability to drive. I could only apologize for the egregious behavior of his clinicians. 

I felt I’d entered a Twilight Zone where logical thought had been removed from the patient interactions, only,  I was awake and in the real world of medical practice today.

My first thought was that the lack of any clinical thought was unique to this particular place, but I don’t think so.  I’d seen time and again clinicians made into robots having to click and click again on documents and enter data, for their hospital to be paid. Then the doctors sign their name again and again in the form of more clicks to get it all into the computerized record. There is nothing for the clinician to take a history, and examine someone and every encouragement to over test and generate a giant medical bill. I thought I wouldn’t send my worst enemy to this particular hospital. 

But then I thought again. I decided to recommend these cases for review, sending identification of the encounters to the chief medical officer of the institution. I had to assume in such a place that the chief medical officer was as uncaring as the rest of the place. After all, they’d created a culture of the blind adherence to dictates of computerized billing and absence of thought. At the same time, it was incumbent upon me to give them an opportunity to change. 

A few days later, I had an epiphany, profound in its simplicity.  Our computerized medical world could be improved if clinicians were paid, not according to the myriad insignificant details they are made to tick off, such as mentioning the integumentary system in the review of systems. Doctors should be paid to show a logical thought process and intellectual formulation related to a clinical plan.  In the system we have,  there is no requirement for a logical diagnosis and plan, only ticking off little irrelevant details. That is the rub.

The metaphor for medical practice is the 737 Max. The new plane similar to the medical practice computer. The Doctor is, of course, the pilot. The System on autopilot will inevitably crash. A valued experienced human is needed, who knows how it all works and is able to figure it things out. Medicine and Flight are both on autopilot. The difference is that automated flight is a lot farther along than medicine. Our society will be able to afford to dispose of pilots a lot sooner than doctors (sorry, pilots out there). For one thing, doctoring is a lot more personal than piloting.  

Real doctors will not be made into groveling automata.  Doctors show they aren’t robots every time they proudly document their human thoughts.  For example: “The weakness of the iliopsoas  and quadriceps muscles and absence of the knee reflex localize the  lesion to the femoral nerve.”  The physician needs to be rehabilitated and incentivized to think. 

The account above sounds like a dream and a revelation. Sadly, it all happened in our real world of perverse incentives.