Monday, November 30, 2015

Information Systems, Good Medicine and the Search for Black Swans

Many years ago, when I was in medical school, learning the art of the physical exam, I was taught that the exam should always be done in the same order each time, starting with the skin, moving to the head and then working your way down, leaving the rectal exam and the exam of the genitalia for last (more for the comfort and the dignity of the patient).  It was drilled into me that it must always be done from the right side of the bed or exam table.  That consistency and discipline in performing the physical exam the same way each time was considered a critical element of good medicine. 
While the idea of a physical exam in general may be seen quaint and outdated in our era of telemedicine, scans, apps that can monitor bodily functions and other imaging technology, the discipline of the physical exam and even the emotional impact of that exam is hardly outdated.  Abraham Verghese, the esteemed author, physician and educator has written and spoken about the importance of the physical exam in both a ted med talk and in the medical literature and his words are worth reviewing.  Verghese emphasizes the ritual part of the physical exam, and the importance it holds in bonding the physician and the patient.  He writes,

“…….the ritual of the bedside examination involves two people meeting in a special place (the hospital or clinic) wearing ritualized garments (patient gowns and white coats for the doctors) and with ritualized instruments, and most importantly, the patient undresses and allows the doctor to touch them.  Disrobing and touching in any other context would be assault, but not part of this ritual which dates back to antiquity.”
He goes on to say,

“We propose that if the ritual is short changed, if it is done in a cursory fashion, if it is not done with skill and consideration, if its sacredness seems to be violated, then the transformation (which in this case is the formation of the doctor-patient bond, the beginning of a therapeutic partnership and the healing process) does not take place.”

His words reflect the way a good physical exam helps form the basis for the doctor-patient relationship.  However that is not what I will choose to dwell on in this post.  Rather I want to discuss the ritual itself.  The very rote and disciplined way the examination is done each and every time a physician, especially an internist or family physician sees a patient. 

Back in medical school, I was taught to perform the exam very precisely each time for a simple reason.  I was told that if I did the exam the same way each time, it would make it more likely for me to notice anomalies.  I would notice something that was not like the thousands of other exams I had done.  In many ways, medicine is extremely repetitive.  Because of this repetitive nature of practice, it is very easy for physicians (and nurse practitioners) to go on auto pilot – to become reflexive in their actions instead of remaining cognitive with every patient and through every exam.  At the same time, high quality medicine is all about finding the needle in the haystack: noticing the unusual exam finding that might suggest an illness that could turn into tragedy.  In order to find that “black swan” (defined as an unpredictable or unforeseen event or diagnosis, typically with extreme consequences) one must sift through thousands of exams that are very usual and very common.  One must feel a lot of normal livers and listen to many normal hearts to find the one that is indicative of a disease.  It is so easy not to notice!  It is so easy to take shortcuts and not go through the discipline of the exam. 
The result can be a missed diagnosis and ironically a more expensive evaluation, as unfocused diagnostic evaluation often called shotgun medicine, requires numerous tests which are unnecessary if instead the exam is thorough.  An example is the 50 year old patient who comes in with chest pain.  On the basis of that history and a lax approach to the physical exam a cardiac evaluation would be done which could include stress tests, and even cardiac catheterization.   If one however does a physical exam and notes that the pain is in one dermatome (an area of the skin supplied by nerves from one spinal root) and that small vesicles can be seen, the diagnosis of shingles is made and no further evaluation is needed. 

I sat once on an airplane next to a psychologist.  He told me that he had been an airline pilot and had developed a psychological test to see if prospective pilots would be good in the cockpit. He left the pilot’s seat to develop this test as he felt his ability to improve airline safety would be greater in promoting widespread use of the test than in his flying planes.  The key to being a good pilot was to be highly intelligent but not too intellectual.  You had to do the same things every time you took off and landed.  On each take-off, you had to make a decision as to whether to abort the take off and it had to be a conscious decision.  You could not allow your mind to wander (in his definition an intellectual is one whose mind does wander) or have the take-off become so reflexive that you don’t notice small differences from the normal take-off.  It seemed to me that the similarities to medicine, especially primary care medicine, were apparent and so it also seemed to Dr. Atul Gawande.
Atul Gawande noticed the use of checklists in the cockpit of an airplane and it led to his writing “The Checklist Manifesto” which advocated for checklists in medicine, similar to the checklists in aeronautics.  In a real sense, Dr. Gawande was only harkening back to the medical school truism of finding ways to do repetitive tasks, such as the physical exam, in such a way that that steps in the processes were not missed and  abnormalities were more easily noticed.  Checklists are a way to highlight deviations from the norm and to ensure that we do everything in medicine in a disciplined way.

However, as we started to computerize our routines, and started to monitor them using modern information technology including EHRs and other electronic tools, we may have lost our way a bit.  The goal of routine leading to more easily noticing deviations from the norm took second place to pure efficiency and blind adherence to protocol.  The idea of the best doctors being those who were complete even compulsive and who found the black swans was replaced by the idea that the best doctor was the one who could prove adherence by having all the computer fields filled and prove efficiency by doing so most quickly. 

Computers allow us to copy and paste and pre-populate fields for the sake of efficiency.  If we do the same exam each time and nine times out of ten the exam is normal, doesn’t it make sense to just prepopulate the normal exam and doctors can then change the results as needed?  However having the areas prepopulated does collide with one of the secrets of medicine, namely that doctors are people and they work towards incentives and towards the path of least resistance as other people do.  When you have a computer record field that is prepopulated, and you don’t think something will be abnormal, and you have a waiting room full of patients, you tend, as a person, to just accept the prepopulated answer and skip the actual exam component.  By doing so, your organization (and more and more physicians are employees of larger organizations) will receive higher reimbursement for a more intensive exam because it is documented that more was done on the exam.  The physician will get a higher report card grade, leading to a better bonus because they did more complete exams or so the computer says. 

By the same logic, in the hospital setting, in which multiple physicians and nurses all having different roles and responsibilities may see a single patient, the ability to copy and paste someone else’s exam since it is likely to be the same as yours, is not seen as dishonesty or poor medicine, only as a way to be more efficient and more productive.    The fact that it removes an internal quality check and that each health professional may notice something missed by another is not factored into the development of the system.  If someone is sick enough to require hospital level care it only makes sense to have multiple checks in place to guard against mistakes that could cost someone their life. 

As an example: for one patient, the head, eyes, ears, nose and throat exam (HEENT) was presumably done because it was pre-populated.   In reality the physician skipped actually preforming that part of the exam.   The patient being seen had known Irritable Bowel Syndrome and came in with constipation and abdominal pain that was not very different from when seen during the previous visit.  The rationale was that the HEENT exam was bound to the unchanged from the previous visit.  But this time could have been different and the good doctor, would have either changed the pre-populated fields to reflect the head was not examined, jeopardizing his or her own job evaluation by the health care organization, or actually done the potentially unnecessary part of the exam, lengthening the appointment in such a way as to either not have time to focus on the problem at hand or run late in the clinic and hurt his or her service evaluation, also harming the job evaluation. 

This is not a problem with the information technology.  These tools can help us achieve and monitor the exam routines I learned more than 40 years ago.   What is missing is the proper design of these systems to support those noble goals of finding the black swans and focusing further testing and therapeutics, rather than the simpler goals of efficiency and adherence to a norm.  Missing from our currently designed systems are the aspects of human engineering that understand how patients, physicians, nurses and therapists really work and think.  We cannot afford to ignore the need for constant diligence to find something unexpected – something unusual that will make the health professional stop and think and perhaps save someone’s life.  It is not an impossible challenge.  It can be done and must be done for the promise of information technology in medicine to truly be met.