Happiness in this World

Reflections of a Buddhist physician

How to Survive a Hospitalization

The greatest danger in being hospitalized isn't what you think.

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Just two weeks ago, my hospital went live with a full ambulatory electronic medical record. Though the roll out wasn't without its challenges, the software is simply outstanding. There is almost nothing about a patient's medical history I can't now access with a few clicks of a mouse button. Not only do physicians have more technology than ever before with which to diagnose and treat patients but also, at my hospital at least, we now have access to all the data our technology provides without ever having to leave an exam room. When physicians talk with patients, taking their histories and examining them to figure out what's wrong, questions immediately begin arising: Could this be heart failure? Could this be emphysema? Could this be interstitial lung disease? Now I can answer these questions potentially within seconds simply by navigating our computer system to see if they've had an echocardiogram, a lung function test, or a chest CT.

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Not only that, but if those tests haven't been ordered previously, I can now order them through the computer with the click of a button. No longer must anyone struggle to read my handwriting. No longer are paper requisitions at risk of being lost and tests not scheduled in a timely way. Further, when I order these tests, the computer reminds me of relevant lab results and allergies. Did I forget my patient is allergic to contrast and needs pre-medication before the CT scan? No problem: the computer flashes a warning to remind me.

Further, I no longer have to keep track of what tests I've ordered. When results are ready, the computer sends them to me. I can not only batch review the result of every test I've ordered on every patient I see (including looking directly at x-rays on the computer screen) but also respond to each appropriately: I can send Mr. Jones his normal results electronically, I can order an additional test on Mrs. Smith electronically (which my clinic coordinator schedules electronically), and I can prescribe Mr. Black a medication electronically that's ready at his pharmacy by the time I call him to let him know he needs it. It all sounds a bit like science fiction, but in 2012 it's become standard operating procedure.

But.

Though the literature shows we are indeed all safer in many ways with the advent of electronic medical records, there exists a dark side many don't recognize. Especially on the inpatient wards, the implementation of electronic medical records may have led to an unintended consequence that makes hospitalization even more dangerous: it seems to have cut down on the amount of face-to-face communication that occurs between providers.

In his book Imagine, Jonah Lehrer discusses Steve Jobs' view that innovation comes from interaction. That is, the more that different people talk with one another face to face, the more creative the solutions that will result. Which is why apparently Jobs wanted the buildings that housed his employees to be designed in such a way that forced them to talk with one another on a daily basis. Bathrooms, for example, were only located centrally.

In medicine, too, communication has never been more crucial. With the explosion in our understanding of disease, our ability to diagnose it, and our ability to treat it, no one provider is now likely to have at his fingertips all the knowledge required to provide gold-standard care. Most of us need our colleagues' help much of the time—especially with patients sick enough to require hospitalization. But never before have we all had to work so hard to be able to get it.

Why? Because the electronic medical record has made it harder for us to run into each other physically. In the past, consultants had to document in a paper chart by each patient's bedside—the same chart in which the primary service wrote their daily progress notes. It was an enormous hassle tracking that chart down. But in making the effort, we often ran into each other and talked. And when we talked, we asked each other questions. And from the dialogue that ensued, all parties involved obtained greater understanding of the others' perspective and ideas. And plans were often hatched that wouldn't have been had we each only read one another's notes.

This was such a big deal when I used to attend on the inpatient ward that whenever my team would ask a consultant for help with a patient, I would insist my residents not just read the consultant's note but actually talk to them about their recommendations. Almost every time when such conversations happened, it changed the way we understood the consultant's note and as a result changed our plan.

Now, however, with the advent of our electronic medical record, consultants can enter their thoughts and recommendations from anywhere in the hospital. And the primary service can read and implement them from anywhere else. Never before have the teams of providers that roam hospital corridors been less likely to run into each other, and therefore less likely to dialogue about the patients for whom they're caring together. Unless other attending physicians do what I did—insist their teams make the effort to talk to other teams—that communication isn't going to happen nearly as often as it should.

This is actually alarming. Yes, we've cut down on prescribing errors. Yes, we're far less likely to give a patient a medication to which she's allergic. But we're also, I believe, less likely to benefit from the collective knowledge of the entire medical establishment, a benefit that's never been as imperative to obtain. We may not be as likely to harm patients as we once were, but we may also be less likely to figure out what's wrong with them if what they have is unusual because we in the medical profession are simply not talking to one another as much as we did.

This is the thing that scares me about being hospitalized the most. I always recommend that people bring with them an advocate when they're hospitalized, a family member or close friend who can help make our system work for the patient when the patient is too sick to make it work for himself. But now I also tell that that person's top priority should be ensuring that all the members of the patient's medical team—not just the consultants, the radiologists, and the pathologists, but also members of the primary service itself—talk to one another in person on a daily basis. I now believe that if there's any one intervention anyone could make in 2012 to increase your chances of not only surviving a hospitalization, but also of being given the right diagnosis and the right treatment, that's it.

 

Dr. Lickerman's book The Undefeated Mind will be published in late 2012.

Alex Lickerman, M.D., is a general internist and former Director of Primary Care at the University of Chicago and has been a practicing Buddhist since 1989.

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