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Brave New World

Rosalind Kaplan

I think a lot about quitting medicine lately. A lot.

Then I have a morning like yesterday morning:

I see a patient I’ve known for more than twenty years, caring for him through an adrenal tumor, a major gastrointestinal surgery and now renal failure, for which he needs a kidney transplant. As we review his last set of labs (stable, thank goodness), he is sanguine, hopeful. He may have found a donor, and he might make it to transplant without dialysis. He has to live–he has a wife and a child.

Next, I mess up my schedule entirely by spending more than half an hour with a patient who only came in to talk–not about herself, really, but about her husband who has just been diagnosed with a probably fatal illness. I break all of my own rules and tell her what I’d do if this were my own husband–how to push him to get emotional support, where to go for a second opinion….When she leaves, we hug like sisters.

I examine one of my eating-disorder patients who is fighting hard to recover. We’ve gotten her sodium and potassium stable, but she still can’t bear to see her weight number, so when I weigh her, I have her stand backwards on the scale. We acknowledge that as her eating becomes less restricted, her life does the same.

I love my patients. Along with my husband and my children and my seven-pound rescue dog, my patients are the ones I live for. I may help them, but they also bolster me. The ones who have known me a long time are starting to notice that extra furrow in my forehead, the more serious look on my face.

“Are you okay?” they ask. “How’s your family doing?” Some, having followed me to this practice, which I joined fairly recently, ask, “Do you like it here?”

How can I quit? Why would I leave this?

It’s not the patients. Yes, I’m burnt out; I’m fried, in fact. But it’s not from taking care of the patients. It’s from taking care of the charts, using the Electronic Health Record (EHR), trying to document and bill properly, then dealing with all the other digital accoutrements of medical life.

At fifty-six, I am what most people would call a “digital immigrant.” I wasn’t raised or trained with computers; my younger colleagues are faster and smoother with the EHR. Strangely, before the EHR came along, I thought I was pretty computer-savvy for someone my age, but, three EHR systems later, it turns out that I’m not. I’m not just a digital immigrant; I’m a digital alien.

This is a typical interaction between me and my computer: I accidentally close screens I don’t mean to. I click on the wrong order and spend precious minutes correcting my mistake. After typing in my orders for a patient, I forget to hit “Accept,” and my orders don’t go through; way too frequently, I get locked out of my own account at some critical moment.

I call the help desk. I find the help-desk staff anything but helpful. Sometimes they fix the problem, but never without making it clear that I am at best an annoyance, and at worst an idiot.

On top of the EHR, there’s everything else I do as a faculty member, most of which involves some form of digitalization. A nonmedical person might be surprised at how often we doctors act as data-entry clerks. We do this in order to satisfy programs such as PCMH (Patient Centered Medical Home), PQRS (Physician Quality Reporting System), the ACO (Accountable Care Organizations), MU (Meaningful Use), CMS (Centers for Medicare & Medicaid Services) or other such mnemonics, which require data collection. Then we get computerized report cards on how well (or poorly) we documented that data. For student evaluations, we use a program called New Innovations. To submit expenses, we scan receipts and enter explanations into another program, Concur. We watch mandatory-compliance training videos on Healthstream. Call schedules are posted on Amion.

I struggle through the use of all of these applications; they cost me an absurd amount of time and mental energy. I’m sure there are more, but I can’t think of them right now. In fact, I’m not sure I can think at all anymore. My head is too full of computer-screen icons.

Don’t get me wrong. I don’t think that, in themselves, any of these digital tools are bad. I know that we need data collection and organized ways to deal with student grades and expenses and schedules. It’s just that it all hurts my brain, and I can’t help but wonder if there isn’t some other way.

I do believe that there ought to be a way that doesn’t force me to choose between attending to my patients and feeding the insatiable demand for data–some way that doesn’t just insist that I always do more.

When I’m not being so hard on myself, I remember that some of my truly computer-savvy colleagues say that the computer programs themselves are clunky and burdensome, and that the ones who claim to be flying along are probably lying–even the Millennials. It is, of course, common for doctors to hide any difficulties they are having. But when I’m in the middle of mangling my notes and orders, it’s hard to remember that.

I just bought a T-shirt that says “I miss my pre-internet brain,” a quote from the Canadian artist and novelist Douglas Coupland. I do miss my pre-internet brain. I miss the time when I didn’t think in “point and click,” a time when I didn’t edit in Track Changes. I miss being able to fluidly write down my thought process in a chart, instead of only worrying about which problems I assessed, what their billing codes are and which orders I wrote.

Sometimes my solace is in writing pieces like this. I write them in longhand, with an actual pen, on actual paper. I cross out mistakes and write new words above the old ones. When I’m satisfied, I type them into a Word document. (Yes, I use my computer as a typewriter. I wonder if any of the residents and students I work with have ever even seen a typewriter.)

More often, my solace is my patients–especially when we talk a little extra, even at the expense of more time spent at the computer later.

Still, I fear that even these consolations can’t sustain me in today’s medical environment, with its ever-increasing technology, its ever-multiplying applications. Sadly, it seems that there’s nowhere else for a digital alien, or her patients, to go.

We clearly can’t go home.

About the author:

Rosalind Kaplan is an associate professor of clinical medicine at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia. She practices internal medicine and women’s health and teaches medical students in the classroom as well as in the office setting. She has also taught narrative medicine to medical students since 2009. “The motivation behind this particular piece is to share the sometimes secret pain that physicians are feeling. We wonder how we got here, and if this is what we worked so hard for. There are no easy answers.”

Story editor:

Diane Guernsey


28 thoughts on “Brave New World”

  1. Beautiful. She has expressed my feelings exactly! I spend more time with the computer than with my patients. Something is wrong here. Just don’t know how to fix it.

  2. David Nathanson

    I resonate with almost every thought and idea in this well-written piece. My computer skills are probably just as bad as Dr Kaplan’s. My training did not include billing. I hate having to look at my computer screen instead of into the eyes of a patient. I have become familiar with ‘templates’ and they ‘populate’ my notes so rapidly that I often wonder if I really did all those things. I hear a recurring theme in Dr Kaplan’s ideas, a theme that we all know to be true: we can resolve a lot of the frustration of modern medical practice by love. When I love my patients, and the staff (even the bad ones!) I want to come to work. I want to help. I’m extremely grateful that I’m in a profession that allows us to enter deeply into the sometimes secret worlds of many diverse people with challenging illnesses.

  3. Well written. You speak for thousands of physicians and medical professionals. I my visits to doctors offices I can see a feel the frustration you are express. Knowing the technology exists for user friendly programs is sad and frustrating. One should not need a degree to enter data.

  4. It is very interesting how the rise of physician burn out as a hot topic and the rise of the electronic record happened at the same time. You are so helpful to name the elephant in the room. Burn out is in large part due to the EHR…

  5. carolyn goldstein

    I am a 71 y/o pediatrician working fulltime. I love my patients, colleagues, and residents. I am married with children, grandchildren, and 2 cats. that’s plenty, but I could never give up medicine. I type with 2 fingers, so I am a typing alien. I can’t even use my cell phone that well! I do not volunteer for things that require more typing. I feel that the computer is the downside of life. the residents and medical students are happy to help me digitally..

  6. Wonderful piece, and it’s sad so much valuable physician time is face:face with a computer and not with patients.
    With regards to students, however, I’ve been teaching medical students longer than I’ll admit here. They all have computers and/or tablets, but many still take notes longhand with multiple color pens, filing notebook after notebook as the year progresses. Then they type (and draw) summaries into their computers. There is still something about the translation of thought into the motor action of writing and drawing that facilitates the encoding of information. And many of them still buy and scribble in paper textbooks because they find it better than the current way notes are done in e-book software.
    Someday technology may replace all of this, but not yet!

  7. This is exactly why I do house calls in a rural area without internet reception, writing notes on paper. It is delightful work, and I don’t miss any of the half-dozen EHR’s I have used. Bravo!

  8. Dear Dr. Kaplan,

    You have touched a nerve, and people are not only feeling your pain but sharing their own.

    We are both Philadelphia Internists, you academic and me in private practice, and we both love our patients. Fortunately for me, I am my own boss. Since computers (I agree with you) work against being creative and patient-centered, I do not have them in my office. Medicare penalizes me financially (although it may cost more to buy and set up and use them than I am penalized), but I do not have to do all the meaningful use, etc. stuff. The Annals study showed that for every hour of patient care, doctors spend 2 hours on administrative / etc. work. Perhaps one day doctors will revolt and refuse to do these exercises in being micromanaged. Imagine that! Doctors (with their patients) taking back control of patient care.

  9. I really resonated with this piece. I am a chaplain in my early 60’s and while quite computer literate, it is not my first language–I am not a ‘native speaker’. Thank you for your honesty. We’ll just keep muddling along….

  10. Your piece about this private struggle really hits home. I have given up checking work emails b/c of the incredible drain on my time. An enterprising friend/FP doctor is experimenting with something called Telemedicine-where a dedicated nurse is remotely viewing and recording the visit into EMR, to the limits that both dr and patient agree upon.
    There’s also Scribes. Perhaps your organiz can look into this.

  11. Thank you, Dr. Kaplan for your honesty on this problem. Believe it or not, patients have trouble with this, too. There is ego in designing software that requires advanced education to deal with its eccentricities and plain faults.

    And scary problems when someone from another dept. does not know how to find my medicine in the computer.

    Someone buys these programs, and goes away. Someone pays for them.

    I fear that only doctors in groups and a few rare administrators can force bad programs out, and errors fixed in programs left in place.

    I wish you well.

  12. Dr. Kaplan, you have all my sympathy. I too long for a pre-internet brain and even perhaps time. Your patients are so lucky to have you as you still listen. So often medical staff are so busy entering things on the computer that the patient does not feel heard. I chuckled over the comments about typewriters as I’m 73 and use my computer like you. Remember the marvel of the electric typewriter! Keep on wearing your tee shirt and keep listening.

  13. So true, so true! Thank you for writing this about this so well. Your patients are lucky to have you as their doctor.

  14. julia mckechnie

    thanks so much for your Brave New Story. I am a nurse in the gov’t health system, & find the increasing demands of data entry & stats & paperwork overwhelming.
    Your writing certainly captures the frustration I ,too, feel when trying to meet client’s needs.
    Thanks for sharing,

  15. As a 67 year old RN and health administrator, I totally agree and understand. And I did bow out, called it retirement but it was really the EHR’s. I miss being able to read the past narrative discharge summary, current H&P, skim the various discipline’s progress note, and have a good sense of this person, their story and how illness affects their life. I can’t do that with an EHR. I can’t figure out how to pull out their story and get a glimpse of their soul.
    Plus it takes me too long to document and it hurts my brain. Hopefully EHR’s will become simpler and easier and friendlier. But it won’t be while I am practicing.

  16. Dr. Lou Verardo

    Dr. Kaplan, I read your piece and thought to myself: Amen. I try to do with patients what you document in your essay, but I am afraid I am too often caught up in EMR problems, or with a general dissatisfaction with how radically the process of patient care has changed over the past 45 years.I want to believe I am better than my complaints; your words provide me with some comfort and strength to keep soldiering on. Thank you for that.

  17. EHRs are in their infancy. Once they are smarter, it will be a great relief. They our most difficult, demanding patient. And we can’t bill for their care. Great essay.

  18. Oh what a well-stated, wonderfully written piece. As a public elementary school teacher, I can so relate. There have been times I have literally wept with frustration at a user-unfriendly site… and look wistfully at my big bookcase of picture books that I so rarely get to share with my students anymore. It’s good to stop and breathe and just unplug it all, if and when you can.

  19. Oh yes! At 68 I struggle with technology, and it will probably contribute too my retiring from a job I love, teaching English at Rutgers-Newark, sooner rather than late…and yet, the human interchanges make all the difference in any given day, and I feel (or like to feel) that my increasingly archaic mindset is somehow needed. As an observer of doctor-patient communication for some time now, and as a teacher of narrative medicine, I note that some doctors use the tools available to them well, and some just hide behind their screens and have almost given up talking to patients. An immense challenge all around. Thank you for your honesty in this poignant piece.

  20. Barbara C. Kligerman

    Really well written piece, Roz. A little more than a decade older than you, I felt much the same way at my publishing job before I retired: the job came to depend more and more on digital agility and familiarity with programs, data bases, and platforms I struggled to understand. The information itself migrated to the Internet, to be used in ways that I did not always comprehend. It was a relief to stop trying to pretend that I was as computer savvy as a twenty-something. I have a full and rich life as a retiree and no longer feel like the dumbest kid in class.

  21. I can soooo relate to your comments! I recently left a big box hospital based medical group and went to a small, private family practice – that yes, is still using paper charts! It is such a relief – I can actually talk to my patients again and look them in the eye. It’s amazing how much “data” you gain in doing that. Yes, I understand the downsides, the loss of certain data sets, the lost revenue, etc. However, the reduced stress and increased satisfaction is ALL very worth it. Interestingly, there are patients who specifically come to us who want someone to “pay attention to them and not the computer.” I read somewhere that the most physicians spend an average of two hours at home on their EMR – that is too much unrecoverable precious, family time! PS – I’m 56 too 😉

  22. I couldn’t agree more. I too am caught between caring for my patients and the ever burdensome computer, I have been an ICU BSN nurse for 39 years and now it is too difficult to care for more than 2 critical patients due to the demands of electronic charting. I too am feeling fried. I hope those who create these programs will eventually make them more patient-care friendly!

  23. Pat Kenney-Moore

    Thank you for this – I feel your pain! its not just docs who are experiencing this – as a physician assistant I’m likewise bound up in this alternate universe that patient care has become. I recently attended a Saturday clinic during which the EHR was offline for “upgrades” and we ran it as a paper clinic. What a joy! I got though the time without being perpetually behind and didn’t have to spend time every visit apologizing for being late. I also recognize the need for data but it has changed the encounter and what it means to me to take care of patients. Thanks for the essay.

  24. I worked in a hospital twenty-years ago and we had entire departments devoted to the clerical aspects of medicine. I am dismayed to learn that the former clerical work assigned to non-medical personnel is now being heaped upon health care professionals in the name of the almighty dollar.

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