Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Sunday, November 29, 2009

The Plural of "Anecdote"

Not offering an opinion of my own about the state of the economy based on the observation that the King of Prussia mall made a zoo look sedate this weekend, but comparing and contrasting some other proffered opinions from around the blogosphere:

From The Well-Timed Period:
On Broadway early this morning, all the stores on the Upper West Side--Loehmann's, Barnes&Noble, etc.--were open but the traffic was puny. The one notable exception was the new Apple store, it was packed. But, the odd thing was that half the people were store employees. There was almost a 1:1 ratio of shoppers to red shirts.

Couple the observation about store traffic with the fact that I just saw, for the first time ever, an "Apartment available" sign on both West End Ave. and CPW and my sense is that we still have a way to go with this economic recovery.
From Happy the Hospitalist:
I snapped this picture [picture of checkout line wending perhaps 30 yards from store entrance; can't really tell much from it] while waiting in the checkout line at Shopko during the greatest recession in more than 50 years. Based on the number of people waiting in this checkout alne, I'd say the recession is over.
There you have it.

(Then again, considering the sources I'd have to say the economy is still in big trouble, given that HH is reliably full of shit.)

Tuesday, November 24, 2009


Dear DenverDaughter,

Your father and I have been together now for eight and a half years. As you know, we have been trying to work our way through the accumulated detritus of the past. Thanks in part to the huge shipment we sent you, we've finally gotten rid of the garage-sized storage locker, though the last few boxes wound up in our living room. Now I'm going through them one last time, ruthlessly culling, even as I take care to preserve the important stuff.

What counts as important? Photos. Several albums have found their way into boxes that will remain on readily accessible shelves. Pictures aren't going anywhere.

I also came across the sign-in book from your grandfather's funeral in 1965. As you know, he died when your dad was 15, so neither of us ever met him. Still, as I leafed through it, I was impressed to see page after page after page of signatures of friends and relatives. Clearly, he was loved. I slipped the book alongside the one from your grandmother. It's not going anywhere.

Then I came across a small bag, silver-and-white striped, containing several things:
  • Six unopened, unused boxes of "Thanks for your expressions of sympathy" cards.
  • An unused, unburnt shiva candle
  • Three large manila envelopes stuffed to overflowing
  • A silver-and-white striped box holding another book from another funeral, this one from 2001.
As you know, it was for your mother. That book isn't going anywhere.

As for those overstuffed manila envelopes, they held all the cards and letters sent to you and your father after she died. When I saw what they were, I stopped what I was doing and went to find your father. I sat down facing him, took his hands, and asked simply, "Do you want to keep the cards from the funeral?" He sighed heavily as he considered. Finally he said, "Nine years is enough. They can go."

I pulled those stacks of cards and letters out of the envelopes and held them in my hand. There were a lot of them. They formed a stack at least six inches high:

I spread them out over the kitchen table. They covered it easily, several layers deep:

You have told me in no uncertain terms that you are not sentimental; that you have no use for stacks of old papers and cards filled with cliched platitudes. Neither does your father. Never fear: they have not been put into the mail to you. They have been duly discarded, as requested. Their purpose has been served. Hopefully, they brought you comfort at the time.

But know that each piece of paper, each bit of card stock, each tattered envelope, represents someone who loved your mother; someone who thought well enough of her to set pen to paper and stamp to envelope just to let you know that. Know that there were so many of them, they covered a kitchen table; spread out, they would easily have covered a banquet table.

Your mother was loved. By you; by your father; and by many more other people than you probably realized. The cards may have been discarded, but that love will always live on. And I now have the unfathomable good fortune to be the subsequent recipient of your father's love. Know that I will spend the rest of my days trying to be worthy of that, and to love him back with every fiber of my being. I'm not going anywhere.

If you are ever moved to doubt, just enlarge that picture of all those cards spread across the kitchen table, and know that you are loved too.

All my love, always.

Monday, November 23, 2009

Count Me In

I received an email from a needlephobic friend acknowledging my generally negative stance toward quackery alternative medicine, but asking me to make an exception for this:
Dark Chocolate: The New Anti-Anxiety Drug?

The results of this new study are intriguing and shed more light on the biochemical basis behind dark chocolate’s health benefits.
Okay; I'll bite (pun deliciously intended). The idea that consumption of dark chocolate could have a favorable effect on high-anxiety individuals seems plausible. Theobromine and other compounds found in chocolate are structurally similar to other psychoactive compounds such as caffeine. Thus, the hypothesis isn't completely out there. However the study was very small, comprised of only 30 subjects. In the face of these promising preliminary findings, I think the only responsible response is to call for further study.

Lots of it. Study, that is. With chocolate. Dark chocolate. Very dark chocolate.

Furthermore, because of the debilitating nature of anxiety and the vital importance of following up on any possible breakthroughs in its treatment, I would even be willing to volunteer for these very important studies.

As long as there is lots of chocolate.

Thursday, November 19, 2009

Prevention is in the Eye of the Beholder

I saw a new patient the other day for a physical. No complaints, he said. He was very healthy, he said. Wellness was very important to him, he said. He was interested in being as proactive as possible about his health.

Wonderful! What more could a primary physician ask for than a healthy patient interested in being proactive about wellness?

I begin by taking a complete medical history and performing a physical examination.

Any medical conditions? No.
Ever been operated on for anything? No.
Allergic to any medicine? No.
Family history? Nothing.
Do you smoke cigarettes? Yes.

Wait, what? Health; wellness; prevention; smoker??

You will all be very proud to hear that I was in fact able to keep a straight face.

Next up is the physical, which begins with the measurement of vital signs:

Weight: 210 lbs.
Height: 67 inches
Body Mass index: 32.9
Temperature: 98.7, orally
Pulse: 74
Respirations: 12
Blood pressure: 160/100

Remainder of physical examination was completely unremarkable.

Okey doke. So what we have here is an obese smoker with an elevated blood pressure. My proactive wellness recommendations would be to stop smoking, begin an exercise program, and lose weight with a reduced-calorie diet.

It turns out that what the patient's idea of proactive wellness is a chest x-ray and an EKG.


Yes, he's aware that smoking increases his risk for lung cancer, which is why he wants the chest x-ray. This kind of makes sense (not really) but the mind-boggling thing is that he doesn't want to quit smoking.

I try to wrap my mind around this illogic (it's tough when one's brain is trying to ooze out through one's ears) and turn to the other major cardiovascular risk factor I have identified: his elevated blood pressure.

Yes, he knows that high blood pressure can lead to a heart attack. This is why he wants the EKG. No, he has no chest pain, shortness of breath, exercise intolerance, or any other acute symptom of coronary insufficiency at this time. And no, he is not particularly interested in changing his diet or exercise habits; and he doesn't think he'd be willing to take any medicine for his blood pressure (if it's still high after two more readings). He just wants the EKG. Because he's so proactive about wellness.

See what I'm up against?

Wednesday, November 18, 2009

Whose Medicine is it Anyway?

Hypertension, or high blood pressure, is one of the most commonly diagnosed chronic conditions seen in this country. What many people don't realize, though, is that a single blood pressure reading is not enough to make a formal diagnosis of hypertension. Technically, you need three readings on separate occasions -- preferably different days -- to make the diagnosis. Because I like to use sports analogies, I tell my patients that the diagnosis of hypertension doesn't happen until you have "three strikes."

What I usually do when I first measure a blood pressure higher than 140/90 is to explain this to the patient. I also discuss the role of weight loss, exercise, and sodium restriction in reducing it. Then I ask them to come back in a month to re-check the blood pressure. With any luck -- and with aggressive lifestyle modifications on the patient's part -- a mildly elevated blood pressure can respond before I ever make the diagnosis, coincidentally sparing the patient the official record of a "pre-existing condition."

I saw a guy the other day with "strike two". His blood pressure was still about 150/100. He wasn't all that overweight and his diet was already pretty good, so I started trying to prepare him for the fact that he would likely require medication to control his blood pressure. Like many people, he wasn't keen on that idea. He scowled as he said, "Okay, we'll give it one more month. Then I guess I'll take your damn medicine."

I thought, "What do you mean, my medicine?" My blood pressure is fine (as are my cholesterol and thyroid, thanks to better living through chemistry). I'm talking about medicine for you, Mr. Patient. Which got me to thinking:

Whose medicine is it anyway?

As prescribing physicians, we often talk about all the medications at "our" disposal. Is studying, understanding, recommending and writing for drugs enough to invest us with their "ownership"? Or does filling the prescription, paying for and swallowing the pills carry more weight?

I guess that's the source of the expression, "to take one's medicine."

Friday, November 13, 2009

One Quick Question

One quick question. What could be wrong with one quick little question? Just this: if I hear the words, "I just have one quick question" one more time, someone will be ripped limb from limb and fed slowly to the great Sarnack to be slowly digested over a thousand years, while I set my hair on fire, yank my fingernails out one by one, and shriek for mercy to the heavens above. Also, I may get a little upset.

Here's why.

It's flu shot season. This means that in addition to scheduling patients for regular visits, we have people coming in just for a flu shot. We pull the chart (so we can document the flu shot), but they're squeezed in and around the other patient visits. Given that it takes me about 15 seconds to draw up a flu shot and literally less than one second for the actual injection (not counting however long it takes them to roll up sleeves/remove jackets/unbutton shirts/whatever it takes to get to bare skin), we usually get these folks in and out pretty promptly. In fact, we count on it.

So when they start in with other stuff, like "I need a couple of prescriptions," or "Can you check my blood pressure?" or "Can I just see what I weigh?" or the infamous, dreaded "Can I ask one quick question?" my blood pressure starts to rise, as do the hairs on the back of my neck, and my hackles.

It sounds (and feels) so petty to say, "NO! You're just here for a flu shot. Not a blood pressure check; not a weight check; not for prescription refills; and certainly not for a visit, which is what we call it when you have questions -- quick, slow, long, short, whatever -- that require my professional expertise to answer. I mean, that's why you're asking me, right?" So I don't say that. Even if I'm thinking it; I somehow manage not to say it.

Instead, I swallow hard and say, "Sure."

And they ask their question, which often needs an office visit, which I try to get then to schedule. And I'll write a prescription or two; if there are more, I'll ask if they can come back later; they're usually okay with that. But I won't weigh them or check their blood pressure when there are other patients waiting for scheduled appointments. Mostly, they understand. I hope.

Because one quick question is seldom quick.

Tuesday, November 10, 2009

By Request

An email received from one of my two readers (who aren't related to me):
So - post something about the new health care legislation!!!

Excuse me??

Um, what exactly are you talking about???

There was a ridiculously large, abstruse bill passed in Washington that no one actually read all the way through which included explicit provisions for payment for pseudoscientific religious nonsense (Section 125) along with financial incentives to states for not trying to address the issue of tort reform, among other provisions that don't actually mean anything until some unelected bureaucrats write the rules that will actually be implemented.

Once actually written and implemented, though, nothing in this bill does or says anything about health care. Rather, what is attempting to be reformed is payment for health care. Please note that I am even refraining from using the word "insurance" in this context, because "health insurance" as commonly used in this country at this time is not actually "insurance" in any linguistic meaning of the word. What we call "health insurance" is actually brokered payment for health care services.

Nothing about actual health care anywhere to be seen.

My bottom line response to the passage of this bill and other shenanigans currently being perpetrated in our nation's capital: move on; there's nothing here.

Sunday, November 08, 2009

Saddest Words Ever

Overheard in a hotel lobby:
Obama makes sense, until you hear Rush Limbaugh and Sean Hannity explain what he really means.
That's it. We're doomed.

Thursday, November 05, 2009

Tweaking the Tail of the Home Birth Tiger

Science Blogs has a new contributor: Dr. Amy Tuteur, an OBGYN who elicits, shall we say, very strong reactions among her readers.

Dr. Amy's debut post trumpets "The Tragic Toll of Home Birth!" (The exclamation point isn't actually there, but doesn't it sound like it should be?) Reading through it, though, sounds more like a screed against midwives -- specifically those who are not CNMs (Certified Nurse Midwives) -- than home birth per se. She includes this nifty chart to demonstrate her point:

Let's see. According to these numbers, non-CNMs do indeed have higher neonatal mortality rates than either MDs or CMNs, however MDs have nearly double the mortality rate of CNMs! Wow. If I really want to be safe, I should go to a midwife.

Then again, that table doesn't actually say anything about home birth. It just breaks down mortality figures by birth attendant. As it happens, the database Dr. Amy links is ridiculously easy to navigate. (Go and play with it.) In fact, I was able to come up with this breakdown of home birth vs. hospital birth, by birth attendant, using the same remaining parameters as Dr. Amy (2003-2004; white women, 37+ weeks, ages 20-45):

[Sorry I can't manage it in a nifty table format]

In Hospital:
CNM: Deaths: 107, Births: 292,422, Deaths/1,000 births: 0.37
MDs: Deaths: 2,118, Births: 3,498,447, Deaths/1,000 births: 0.61
Other Midwives: Deaths: 2, Births: 4,323, Deaths/1,000 births: Suppressed

Not in Hospital:
CNM: Deaths: 6, Births: 11,853, Deaths/1,000 births: Suppressed
MD: Deaths: 7, Births: 2.689, Deaths/1,000 births: Suppressed
Other Midwives: Deaths: 20, Births: 16,613, Deaths/1,000 births: 1.20

(Note: Rates are suppressed when the numerator is less than 20, because the figure does not meet the NCHS standard of reliability or precision.)

Source: United States Department of Health and Human Services (US DHHS), Centers of Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Office of Analysis and Epidemiology (OAE), Division of Vital Statistics (DVS), Linked Birth / Infant Death Records 2003-2005 on CDC WONDER On-line Database. Accessed at on Nov 5, 2009 11:45:58 AM

So what does this really mean? It means that a total of 33 babies who were born at home between 2003 and 2004 died in their first month of life. Yes, more of them had mothers who were attended by non-certified midwife than by a CNM or MD. By contrast, if you add them up, there were 2,227 babies born in hospitals who didn't make it past a month either. The rates for total mortality by place of birth including all birth attendants is 0.59 per thousand births for hospitals and 1.06 for "not in hospital".

Okay, then. Say we admit that, taking all comers, a baby is about twice as likely to die if born at home than in a hospital, or even three times as likely if attended by a lay midwife. Sounds pretty scary, no? Well, no.

It's the age old difference between absolute and relative risk. Take TBTAM's trick of using a piece of graph paper with 1,000 squares, and see what the difference is between having one square colored in, or two (or even three). Combine that with the tiny absolute numbers of women who want to give birth at home in the first place (I didn't want to have to clean up after it, frankly) and the whole thing starts looking more like the ideological witch hunt against midwifery that it actually is, and a whole lot less like a noble call to save large numbers of innocent babies from their mothers' intransigence.

News flash: people choose home birth over a hospital experience for many reasons, and will continue to do so even in the light of these statistics. Why? For the same reason they ride motorcycles, some of them without helmets. They feel that the advantages to them outweigh the risks. How can they best minimize the risk? By selecting a birth attendant with appropriate training and experience, for one. More training for midwives? I'm all in favor. But demonizing the entire home birth community by condemning their "Tragic Toll" is uncalled-for.

If you want to talk about "Tragic Tolls", Dr. Amy, check this out:
The National Child Abuse and Neglect Data System (NCANDS) reported an estimated 1,760 child fatalities in 2007.
Now that's tragic.

Wednesday, November 04, 2009

Bring on the Bets

One or two of you may be aware that there is something going on called the World Series. ("What world would that be?" asks this crotchety old guy in his 80's whom I've known for years.) It's the end of the baseball season, and this year it is being played by (my) defending champion Philadelphia Phillies and the New York Yankees.

As is traditional, the mayors of the two cities involved have engaged in a friendly wager. In past years, this has usually taken the form of a food exchange ("cheesesteaks or cheesecakes"). This year, though, you have to admit that Philadelphia Mayor Michael Nutter and New York Mayor Michael Bloomberg have really raised public service (and from "public servants", no less!) to a new level:

Regardless of the outcome, both mayors will host public arts projects. Nutter would join Mural Arts to paint a mural on the side of a recreation center. Bloomberg would partner with Public Color to paint the interior of a school.

If the Phillies win the series, Bloomberg will travel to Philadelphia to take part in the day of service while wearing a Phillies jersey. If the Yankees win the series, Nutter will travel to New York to take part in the day of service while wearing a Yankees jersey. The mayor of the losing city will also buy the mayor of the winning city and his fellow volunteers lunch.
That's just cool.

What it's really done, of course, is to completely reset the bar for all future mayoral sporting bets. Who's going to have the nerve to offer up a case of the local brew against some regional delicacy after this kind of event? Bravo to both of them!

PS: Breaking news from New York:

Tuesday, November 03, 2009

Suzanne Somers "Total Body Cancer" Debunked: The Cliff Notes Version

I love reading Respectful Insolence. Orac does a wonderfully meticulous job of tearing down all kinds of pseudoscientific nonsense. Go and read -- sometime when you have some extra time on your hands. The more time, the better; although he is good, he does tend to ramble a bit.

His current project is a review of the new book nonsense by the original ditzy blonde herself, Suzanne Somers. The problem is that she is too stupid to recognize the utter depths of nonsense she has plumbed in this tome. The "Doctors who are Curing Cancer" interviewed in this book are uniformly quacks whose techniques and treatments are either ridiculously implausible or scientifically proven not to work -- or both. Go and read Orac's archives for more detail. Also be aware that he will be posting more about the book; he's a better man than I. Then again, presumably if his brains explode he has his wife and/or laboratory cleaning personnel to clean them up after him. I have to do it myself, and brains are notoriously difficult to get out of carpet, not to mention all the little nooks and crannies of keyboards.

His most recent post is fabulous, but really long. I thought I would perform a public service by cutting to the chase and revealing what curious readers -- albeit those who have too much to do to peruse Respectful Insolence in its entirety -- are, well, curious about. At least I was.

Apparently in Chapter 1 of the book, Somers states that she was "misdiagnosed with total body cancer." Knowing that there is no such thing, Orac and I wondered what it could have been. Orac, who actually went and read the thing, reveals that it was disseminated coccidiomycosis, also known as Valley Fever. Coccidiomyces doesn't usually cause much in the way of illness in generally healthy, immunocomptetent people. On the other hand, one of the risk factors for dissemination is a suppressed immune system. Manfully resisting Leaving aside for a moment the I-told-you-so temptation (aka schadenfreude) to someone who took fistfuls of supplements supposedly intended to strengthen the immune system, what really was going on with her?

I knew that her supplement list included "bio-identical hormones" like estrogen. I also happen to know that chemically, estrogen is indeed a "steroid" hormone, however its protean effects do not include direct effects on the immune system. Ah, but it turns out that her regimen included "cortisol repletion"! Aha! She was indeed taking corticosteroids (unprescribed and unmonitored by a competent physician; funny about that)! And those can indeed depress the immune system.

The real problem with pseudoscience is that people's bodies neither know nor care what the person inhabiting them believes. Suzanne Somers' belief that she was "cortisol deficient" didn't make her so. She ate cortisone. Her body responded by making less of it, and by damping down its native immunity, thus allowing a usually indolent fungus to spread throughout her body.


There you go: 550 words, give or take, compared with Orac's almost-9,000 word screed. Granted he covered far more material than I -- and I strongly encourage you to go read it -- but the more I think about it, the more I believe I have summarized Suzanne Somers effectively and accurately. In fact, I shall repeat it for emphasis:


Monday, November 02, 2009

The Emergency Department EMR from Hell

Despite the fact that I am almost always available to my patients day and night, day in and day out, weekends and holidays included, there are occasions when they go to the Emergency Department*. Sometimes they call me first. Once I have ascertained, for example, that what they have is an acute surgical abdomen (I have indeed diagnosed appendicitis over the phone more than once), then they don't need me. What they need is a hospital and a competent surgeon, and the most expeditious way for them to connect with those two things is through an Emergency Room**.

Still, there are several other appropriate circumstances when patients head to an ER without calling me first. In these instances, though, it is a generally accepted responsibility of said ER to somehow let me know that the patient was there. A phone call is way above and beyond for routine problems, although there are occasions when it's appreciated (like when a patient comes in dead. It happens.) Failing that, some kind of written notification, either faxed or mailed, serves the purpose nicely.

The first step in the notification process, of course, is the patient admitting letting the ER staff know that I am their doctor. If the patient doesn't give my name when they check in, all bets are off. Once I am on record as their primary physician, though, the ball is in the ER's court.

I've been on staff at two different hospitals; one during my first decade of practice, and the other for the second. Despite the fact that the first one now has an electronic medical record (EMR), nothing much has changed in the notification process: I get a fax of the face sheet of the chart. What that means is that I get the patient's name, the date and time he/she signed into the ER, and all the contact and insurance information that I couldn't care less about. If they are then admitted to the hospital, I get a second fax identical to the first in every way, except that a previously blank space labeled "Diagnosis" is now filled in. If they are discharged from the ER, I get nothing. No idea what happened, what the problem was, the diagnosis, any prescriptions given; nothing. On the other hand, I do have that original sheet, which I leave in the patient's chart. Then the next time I see them or talk to them I'm able to say, "I see you were in the ER on such-and-such a date; what happened?"

The second hospital is a different story. Back in the olden days, they used a paper system called T-sheets. Every possible complaint had its own sheet, each with dozens of tiny check-off boxes allowing the ER staff to document out their asses in minimal time. They loved it. When the family physicians on staff began demanding requesting that they let us know when our patients were seen in the ER, they responded by faxing us the entire ER chart. This invariably added up to a minimum of 17 pages, of which at least three and up to six were completely blank. (For real; they faxed blank divider pages.) Not only that, but the tiny little print was essentially illegible when transmitted by fax. Usually the only way I could tell what the hell the patient was actually there for was by looking at the pre-printed discharge instructions (that were of course also included in the fax). As has been stated elsewhere, the signal-to-noise ratio of the information in this format was unacceptably low.

Furthermore, there were still many occasions when we didn't even get the 17-page packet of gibberish. The standard answer from the ER docs, recognizing our legitimate complaint, was this:
"Call us."
Um, let me get this straight. If a patient of mine goes to the ER, I don't know about it, and I don't get a report, I should call you. Hmm. So the next time you don't hear a tree fall in the woods, run for cover.

Recently this hospital has spent millions of dollars building a brand-spanking new hospital wing, including a brand-spanking new ER. This brand-spanking new ER also contains a brand-spanking new EMR. Hurrah! Never again will reams of paper be wasted generating illegible notes. This brand-spanking new EMR has the capacity to print out a concise summary of the patient's ER visit, and -- will wonders never cease -- to automatically fax said concise summary directly to little old me. Of course it turns out that although this brand-spanking new EMR can do this, does not mean that it does.

Receiving notification from the ER had been an ongoing issue with this hospital even prior to their multi-million dollar construction project and the acquisition of their brand-spanking new EMR

I recently got a phone call from a patient telling me he had been in the ER three days earlier and was told to call me to schedule a follow-up appointment, which is why he was calling. Because I finally had a situation where I knew exactly when I actually had a patient go to the ER, I called to see what happened to the brand-spanking new report from their brand-spanking new EMR. I actually had a lovely conversation with a conscientious and helpful ER doc, who asked me when the last time was I had gotten an ER report on one of my patients from them.

Because the answer was, "Never," I instead asked, "How long have you had the new system?"

Answer: "Since May."

Okay, then; at least five months.

After some rooting around on the part of the conscientious, helpful ER doc, it turned out that the only way their brand-spanking new EMR system would send me a nifty new easy-to-read report was if all of the following things happened:
  • If I was in their system (I am)
  • If the system had my correct contact information (it does)
  • If the doctor clicked on my name from a pick list while he was writing the discharge instructions. Note: Not before (ie, the information wasn't carried over from the sign-in process when patients are asked who their doctors are); not during the visit (while the doctor was in the process of diagnosing and treating the patient), but SPECIFICALLY while the doctor was typing the discharge instructions.
Maybe that doesn't seem particularly onerous, but I think it's ridiculous. How many other things would I rather have an ER doc thinking about while discharging the patient, especially when MY F*CKING NAME AND OFFICE NUMBER ARE ALREADY IN THE GD CHART!!!

It turns out this brand-spanking new EMR has a few other little minor shortcomings:
  • It doesn't let the physician access the nurses notes
  • It doesn't let the physician access notes from triage
  • It doesn't let the physician access the past medical history, family and social history already gathered earlier.
Um, excuse me, but isn't a computer's major strength its ability to eliminate repetitive actions? Hell, any time I want to order something from a catalog, there's this nifty feature that lets me check off a box that says, "Billing address same as shipping?" instead of having to enter my address again. (Not only that, but once I've done it, there's this thing called auto-fill that allows me to just point and click.) I thought that's what computers were supposed to do best!

But no. Here we have this brand-spanking new EMR -- did I mention that it's one of the largest and most popular EMRs (almost certainly among the most expensive too) nationwide? -- that basically makes the doctor duplicate all the nurses' charting.

Can't they fix this little bug? Surely it can't be all that difficult from a technical point of view.

Actually, it's not. The problem is that because it's such a large, widely used EMR, they can't make changes for just one user. They have to change it for everyone.

So...Why not do that? While they're at it, what's with having to make sure I'm "in their system"? We have these really cool new things called NPIs. The letters stand for "National Provider Identifier". Last time I looked, that first word ("National") pretty much applied to the entire country. So why can't they just incorporate the national NPI database into the system. That way, any time one of my patients went to an ER anywhere in the country, there's an easy-peasy way to identify me as the person waiting with bated breath to read the ER report.

Sorry, came the answer from the conscientious, helpful ER doc. We can't do that right now. So I'll just keep trying to remember to click on your name when your patients come in. I'll also make sure the other docs try to remember to do it too.


* Happy now, Whitecoat?
** Sorry; old habits die hard.