Don’t Just Do Something, Stand There

(If I fellow could keep his head and not get caught up in the hysteria surrounding health care, if he could just keep his mouth shut and his eyes open he might see the real problems in the system without being blinded and deafened by the usual propaganda from the usual suspects using Health Care as a fulcrum to leverage their way into political power. Unfortunately, the solutions being proposed to solve the problem of increasingly expensive health care and the so-called “lack of access” are going to compound the very problems they are supposed to fix.-PB)

The Paper Mill

In a proprietary process understood by few but a marvel of unintentional design, living patients are turned into paper. I read the chief complaint and open the chart, already primed with fifty pages of seed paper, and go to work sifting through the catalogue of promises, obligations, and warnings, every action of mine laying the groundwork for the creation of even more paper. From the Diversity affirmations to the pre-printed discharge instructions that nobody ever reads, the chart is a masterpiece of bureaucracy and wasted effort. The HIPAA section alone spans nine pages that no patient has ever read and could be Proust for all they care. And yet to not initial and sign where appropriate will cause the heavens to weep and the hospital attorneys to gnash their teeth in fury.

I would not be exaggerating in the slightest if I said that for every hour of direct patient care, things like obtaining a history, doing a physical exam, and performing procedures, I spend three hours manufacturing paper, some of which is necessary documentation but most of which will never be used for anything and will end up mouldering in the crypt known as medical records until the sun should fail and the sea shall give up her dead. That is, unless it is dredged from that antediluvian mire as evidence for a spurious lawsuit against a doctor who was only guilty of doing the best he could with a patient who would have made William Osler himself cringe and the Great Galen’s blood run cold.

In fact, there is no part of the hospital or the clinic not primarily dedicated to the paper trade. Ask any nurse and she will tell you that most of her time is spent sorting through the increasingly arcane compliance and safety documentation which is the delight of bureaucrats and thier familiars but contributes nothing to the medical care or safety of patients. Twenty minutes here to fill out a medication reconcilliation sheet, fifteen minutes there to document that she has had her hand washing refresher training and pretty soon we’re talking hours that could be used for direct care of the increasing numbers of patients they tell me are clogging our hospitals.

Judging by the incredible cost of in lost productivity as well as the very real opportunity cost of treating paper instead of additional patients, the most expensive phrase in the history of the world has to be “If you didn’t document, it wasn’t done.”

What does this mean, anyways? That good medical care wasn’t delivered if you didn’t spend an hour writing pointless notes? That because you didn’t meticulously copy lab values from the computer onto another piece of paper that you didn’t look at them? Or does it mean that if you didn’t document that the surgical field was “prepped and draped in a sterile manner” that you ate a taco over the incision?”

What it really means is that the legal environment has become so stifling that nobody trusts anybody and huge amounts of money are wasted covering our asses. Forget the money awarded to plaintiffs and their attorneys in malpractice suits. Forget the cost of defending against lawsuits where the defendant is held harmless. As our lawyer friends are eager to point out in order to distract the public from their depredations, these direct costs are chump change. Even malpractice insurance, although it can be as high as a quarter of a million dollars for an obstetrician in Florida (and is a cost, like most business expenses, that is passed on to the consumer, whether private of government) does not come close to the cost of the bureaucracy which is necessary to keep the inquisitors at bay.

It is a difficult problem to correct. Like vultures to carrion, lawyers will follow the cloying smell of money rising from the hospital. Lawyers run government and unlike physicians who have real jobs, a lawyer can make a career blocking meaningful tort reform and get paid for it, not to mention winning the adulation of people who on one hand view the right to sue as inviolable but on the other would have no problem appropriating private property (the doctor’s time and labor) and as much of other people’s money they can possibly steal to pander to their own narrow interests. As for Alexander Hamilton’s great beast, the people, they are unfathomable. The number of people who have hit the malpractice jackpot, winning big awards after a bad neurosurgical outcome for their wino uncle who they ignored until he was found unconcious under a bridge, must be very small and yet appeals to the greater good, cheaper more efficient medical care in exchange for a cap on compensatory damages, fall on deaf ears.

Apparently, nationalizing health care under the false flag of Single Payer and redistributing several trillion dollars a year through the federal sausage mill is easier than passing a few legal reforms.

Somewhere in the rat’s nest of paper originally created by your hospital’s risk managers but now continuously growing as if alive is your patient, protected from your depredations by paper; the sword, the shield, and the strong arm of the bureacracy.

Next: Charles Ponzi Would be Ashamed

29 thoughts on “Don’t Just Do Something, Stand There

  1. You cannot imagine how scary all this sounds to an ordinary patient-type. But I’m not surprised to learn that paperwork is consuming far more of the medical staff’s time and energy.

    I hired on as a Social Worker for a state’s children’s services in 1979. For the first three years I spent no more than 10 hours weekly on paperwork and committee meetings. Four to six hours a week was spent in courtrooms. Maybe six hours a week coordinating with other type service providers on behalf of my clients. The other 30 hours weekly was devoted to direct client contact, usually in their homes rather than in my office.

    By the time I quit in 1996 paperwork alone was consuming 25 hours a week; committees ate up another 5-8 hours; coordinating with the schools, medical doctors, treatment centers, psychologists, psychiatrists, etc, stayed about the same; the court work remained about the same. Seeing my clients face-to-face, as you can tell, got the ‘overtime’ evening hours. We weren’t paid overtime, we were allowed to take those hours ‘off’. But no one ever did. The paperwork increased at the behest of the feds who supplied much of the money supporting this state agency.

  2. It’s the same as with government. Paperwork is exactly like entropy: it can remain static or increase, but never decrease. Naturally, then, over a period of time it slowly creeps upward. There is no escape. Presumably (in the pea brained mind of the retarded administrator who came up with it) that spiffy new form for each rx will serve some great purpose. Then they float on to subtracting value from some other organization but their legacy lives on, soon to be built upon by a new pea brained administrator with exciting ideas (forms) of their own. There is no escape.

  3. Let me tell you something else, except if you don’t meet certain minimal standards as a resident, many service on which you rotate would rather you were a good paper-pusher than a good doctor (although you can certainly be both). In other words, you can make all the right decisions, provide excellent care, but if you show a distaste for paperwork and “write outside of the boxes” you will gain a reputation as a troublemaker.

  4. Panda,

    You could be like Henry Reardan in “Atlas Shrugged.” Too bad you don’t still have that M-16….

    Or do you?

  5. Every business has gone the way of paperwork hell. I could wall paper my living room in the amount of paper generated from one client for one mutual fund sold. In financial services we have to document every time we take a $hit. I promise the NASD is every bit as nuts as medicine. We did ce on a friggin weekly basis!

  6. very colorful way of stating the transition of medical care from a patient care based treatment to a cover my ass type of documentation. “here mr soandso, can you fill out this 10 page sheet with every possible symptom that you could possibly have for your great toe pain. regardless of what your xrays show, we’ll get an MRI, CT, and bone scan. i would that you pain may be due to melanoma, because i read it may happen in the toe even though there is now pigmented area.”

    this cya mentality drives me crazy. you touch on the topics of paper work which i partially brought on by the malpractice situation and the current payer that drives most medical documentation today, medicare (HCFA). so all of my patients get the full documentation: HPI, ROS, complete PE, and I/P. why? because i don’t want those @ssholes to say you over coded because i did not document the family history on a patient who has a radius fracture.

    ok, i feel better now. 🙂 thanks for listening

    nice post

  7. Yes, I do own several military rifles and support fully the right of the people to keep and bear arms, reason number 225 I will never live in California, a state where every rifle I own would make me a criminal.

    No, I will not argue the second amendment on this blog and I’m going to delete any comments that are not strictly informational and are not of the type, “Gee, Panda, I have a keen Springfield Armory M1A1 (the semi-auto version of the M14 and my rifle Holy Grail) and that summbitch is a tack-driver.”


  8. any chance that making all of this stuff electronic could diminish the amount of time you spent on paperwork?

    Is this paper trail more of an issue when you rotate outside of the ED or is the ED included? because when I shadowed an EM attending for a while, he did not spend a whole lot of time on paperwork. The residents looked like they were a lot busier than him, but he didn’t have to fill out too many forms as far as I could tell.

  9. Good reference to ‘Atlas Shrugged’, Justin. I’ve found myself saying with many of Panda’s blogs, “Who is John Galt?” As we’re driven ever deeper into the bowels of mediocrity and apathy by small-minded politicians and lawyers who posses more power than brains, I fear our dirction leads directly to Ayn Rand’s frightening world. We’re being destroyed from within, and I can’t imagine a worse fate for the strongest nation in the world.

  10. @TheProwler:

    “the attending didn’t do very much paperwork, but man those residents looked busy!” ???

    Who do you think was charting? Filling in when the patient was seen (god forbid they wait too long!), what EXACTLY happened (not just “fell and broke arm”), what their past history is, all their meds, a complete exam (everyone gets a medical screening exam, less we miss the “new” murmur on the 10 year old who fell off a swing), all the xray reads, what meds were given, which splint was put on, when they are supposed to follow up and with whom, what to return to the ED for (swelling, pain, etc etc etc)…and that’s just a simple fracture!

    Imagine the 80 year old “weak and dizzy.” The 25 year old OD. The 55 year old chronic belly pain.

    The reason the attendings didn’t look that busy…in my hospital, 2 attendings, overseeing minimum 4 residents at a time. That’s 6 doctors covering a 30-40 (if we’re using the hallway) bed ED. At a non-academic center, you’re NEVER going to have 6 at a time…think 2-3 “attendings” see ALL the patients, and charting on every one.

    As a second year resident, I typically have 10+ patients on my “list” at a time, and end up seeing about 2+ an hour over an 8 hour shift. Think of how many I could see if I all did was go from bed to bed, seeing patients, writing orders, reassessing, seeing more patients…without having to write down every thing I see or do.

    And no, electronic does not diminish it, not much at least…you’ve still got to check all the boxes, REwrite all the meds (“see nurses note”? hah!), etc.

  11. Electronic Medical Records will not fix the problem automatically. In fact, EMR has the potential to generate a huge volume of electronic paperwork because, and this is a bureacratic axiom, if left unchecked, paperwork will expand to fill every possible niche.

    The VA has a great EMR system, called CPRS, but I still ended up spending many more hours in front of the computer documenting than I did caring for patients. This is because the mentality of the bureaucrats will never change, and they will invent work to fill the productive time the computer was supposed to free up. The threat has not changed either and the philosophy of computerized record-keeping is to document even more simply because you can.

    When I was an engineer, we used a drafting package called AutoCAD. It was a lot faster and more efficient to produce engineering drawings on AutoCAD but you had to be careful not to spend as much time or more on a drawing than you would on an electronic drawing simply because AutoCAD made it easy to add detail. In other words, the temptation in AutoCAD is to “Draw the World” even if all you need is a little sketch. (Now, don’t jump on me, we certainly did produce hightly detailed drawings of whole process lines off of which we took details but that’s not what I’m talking about.)

    But Emergency Medicine is at the cutting edge of minimizing paperwork. I guarantee that if we ever had meaningful tort reform such as strict caps on punitive damages, limiting lawyer salaries (why not, all of the leftists think nothing about limiting doctor salaries), decreasing the time in which one may sue to six months, and making attorneys pay the court costs for suits that are dismissed (frivolous suits) the problem would go away.

  12. Home health paperwork is the WORST. They have auditors to send you back documents which need to be “corrected”. It is WORSE than ridiculous—I once had a document sent back to me to correct because I had spelled out the patient’s middle name instead of simply putting the middle initial. I was asked to mark out the middle name and put the middle initial instead….

  13. i wish that bring in tort reform would change the amount of paperwork. the paperwork load and documentation Nazis actually come from government agencies and the guidelines which dictates what needs to be charted for the different E&M codes as well as for certain CPT diagnosis and ICD-9 procedural codes. most of the new electronic data gathering systems are suppose to make meeting documentation requirements easier by using templates (as many ER’s do) or by have a “normal” exam which will fill in all the bullet points.

    even the military has a system very similar to the VA system (and i think part of the original VA system), it is called ALTA. that system is even more cumbersome than the original VA system where you actually just typed your clinic notes.

    the whole system make just taking care of patients less important than the documentation. as far as the resident part, i have to read over every clinic note to guarantee that we meet guidelines. Dr. Bear can you make the pain stop?

  14. Actually, forget tort caps. A much easier sell that would fit our needs is specialty medmal courts. If you have juries and judges that deal with medical issues all the time and (ideally) even have a scientific background, separating actual misconduct from bad outcomes will no longer rest on who makes the better emotional appeal but actual evidence. Random juries and judges are, of course, completely unequipped to evaluate two hired “experts” saying the opposite things. We don’t throw bankruptcy in random courts, why should we with a far more complicated subject?

    I don’t really have a problem with someone getting 10 million because some idiot chopped off their arm for no reason. The true thing that makes medmal such a burden for us is the unpredictability: you have NO IDEA what could be constituted as malpractice; it depends on what sort of cereal the jury had that morning and what kind of eyeshadow the defendant is wearing. If we can limit lawsuits to cases where you actually deviated from the standard of care I don’t really care if the cap is $2 billion. Plus it’s a lot easier to sell to the public.

  15. truth as far as medical malpractice, there are specific guidelines for what constitutes medmal. also, not many malpractice claims actually go to jury trial. the problem with the system is the frivolous claims that clog up the system. and cost physicians and the state money to defend against these claims even if they are dropped. sometimes physicians do even have a say in whether to settle or not. that is the decision of the insurance carrier, if it is seen as cost effective to settle whether or not you are at fault.

    as far as the rules of medical malpractice, they plaintiff must prove presence of four elements–duty, breach, cause, and harm–to show that the healthcare provider was negligent?

    Duty arises when you establish a professional relationship with the patient. Once this relationship is established, you have a duty to deliver the standard of care expected of a healthcare provider.

    Breach means the duty or standard of care was not followed. The patient’s attorney must prove that you were negligent–that you failed to use the standard of care a prudent healthcare provider would use under the circumstances.

    Cause refers to the role that breach of duty played in the patient suffering harm.

    Harm, or damages, consists of actual physical damage, and the resulting cost of required treatment and lost wages–both present and future.

    and there you have it.

  16. True, but the underlying issue that allows frivolous lawsuits to be filed at all is the “jackpot” nature of things where even if you didn’t do anything wrong, there’s always a chance the jury will just want to give money to the defendant out of sympathy for their bad outcome. See: John Edwards and his 75 million dollars made on the basis of “This brain damaged baby is speaking to you through me”. Specialty courts would go a long way to ensuring there is no possibility of frivolous lawsuits paying off, which means they won’t be a good threat and won’t be filed.

  17. I just wonder, how are we going to change it? Will it change? How can we get an informed enough public so that they can help themselves and have a clue as to what goes on in the world? Hopefully we’ll get someone like you to start spurring on the change!

  18. It was my understanding that the really really big costs were in filing the forms for reimbursement, and in the constant negotiations with the insurance compaines, and that malpractice costs were pennies in comparison. Though true enough, it’s just more administrative BS.

    I just laugh when my classmates state that all would be fixed if only the GOVERNMENT did everything for us, and adopted a National Health Care System. You wonder if they’ve ever even BEEN to the post office.

  19. I absolutely love the VA’s CPRS system. That is the single best thing about the VA, and it’s pretty sad that the rest of the country is so far behind.

    That said, sometimes the sheer volume of information is overwhelming. Because theoretically, if I have all of that information at my fingertips, then I should be responsible for knowing everything that’s in it. Luckily, if you’re geeky enough to play with the system for while, there are pretty powerful ways of sorting and searching through the notes to quickly get at the info you’re looking for. The remote data is another issue though…

    Another problem is that people don’t adapt their method to fit the system. So often I see progress notes written in the traditional format with all of the labs pasted into it, which is redundant if the labs are right there at your fingertips able to be graphed and plotted and tracked, etc. It just wastes bits.

    end rant.

  20. Old MD girl, the cost of malpractice suits effects the price of medical care in three ways:

    1. The cost of awarded damages
    2. The cost of malpractice insurance.
    3. The cost of defensive medicine which includes excessive documentation of all kinds, unnecessary lab tests and studies, and idiotic things like Press-Ganey.

    Number 3 is the biggest cost and is estimated by some to be as much as 500 billion dollars a year, a huge sum, and all of it contributing nothing to medical care.

    This doesn’t even take into accout the costs of compliance with Medicaid and Medicare or the cost of insurance paperwork. My article barely scratchted the surface of the problem and intuitively, I think that maybe half of all of our efforts and treasure go to treating the bureaucracy, not the patient.

  21. You may have answered this earlier Panda Bear, but if you had to do it all over again would you still go to medical school? Law school is starting to sound like a much better choice to me…

  22. I like Emergency Medicine and I’m glad I ended up in it. And medicine, provided you are in a specialty you like is not a bad job. I just think that in residency, the hours blow and the pay is terrible and there is, for me, nothing more metaphysical to it than that. I can even handle the attempted abuse because I am not the kind of guy people abuse and have developed such a low tolerance for it that I get treated pretty well, even by serial abusers.

    But honestly, if I had known what it was going to be like I might not have been as motivated to run the guantlet of the admissions process which is a minor ordeal in itself.

    Screw law school. Self respect is important too and, while it is not a perfect career, physicians can hold their heads up and say, “You know, despite the crap, I did just save that guy’s life and nothing could be more important than that.”

    Now, realistically, I know some great guys who are lawyers and they are a necessary evil but I just can’t picture myself doing that or anything like “management consulting.”

  23. 1. The world doesn’t need more lawyers

    2. Do not think of medicine and law as equal opportunities. They are not the same (not to say that one is better than the other, but they are very different). If you want to go to med school, think about it and decide whether or not to go. Do the same for law school. Do NOT choose one or the other because it’s a career move. Both scenarios are require too much personal and financial investment to be “stepping stones”.

  24. Med mal courts may not help with the paperwork, but it might cut the costs associated with defensive medicine. If med mal courts, with specially trained judges acting as arbiter (without juries), you’d have a process that would be faster and would throw out frivolous cases (nobody argues gross negligence, which is always a bad thing).

    With less of a time/money penalty for going to court, doctors would not be pushed to settle out of court. Ambulance chasers might head for greener pastures when their revenue stream (% of settlements) dries up. Then docs wouldn’t have to do CYA medicine, as some MBA would quickly note that you could see 2x, 3x as many patients in the same time, and save lots money, if you didn’t have to do as many tests.

  25. Always great for debate, thank you PandaBear. Unfortunately, all these great proposals (tort reform, caps on lawsuits, medmal courts) are just preaching to the choir here. I think almost all docs, med students, and even pre-meds would agree with these changes. The real problem is the fact that doctors aren’t the ones making choices/changes. Instead congress (with one “Dr.” but don’t get me started on Frist), decides what’s good and bad for medicine. Unless some power is given to the AMA, and/or those actually educated in the field, nothing positive will change in medicine.

  26. PB,

    I do not dispute that malpractice costs drive up the cost of health care. However, at a recent lecture given by a well respected health economist (NOT A DOCTOR, I might add), I raised your exact point and was summarily shot down. It turns out that malpractice costs, (in all three ways you mention), do increase overhead, but not nearly so much as paperwork.

    God knows he could be wrong. And I’m not going to argue against the fact that the fear of being sued makes practicing medicine a lot more unpleasant.

  27. He is wrong. Most of the paperwork at the hospital is for the purpose of defense against litigation. Do you think we’d spend fifteen minutes, for example, getting consent for a central line if there was no threat of being sued? Hell, we’s just ask the patient, “Hey, we need better access, can we put in a central line?” and that would be that.

    He shot you down because you don’t have the vocabulary to refute him. How does he know the cost of paperwork? Has he done a study? Does he know the difference between legitmate documentaiton and CYA? I doubt it.

    The cost of defensive medicine, of which increased documentation is a part, is staggering. I see it every day and in every person we admit, for example, because to trust a patient to be responsible for their own follow-up, even if we document their understanding (more defenisive paperwork) would be legal suicide.

  28. A well-designed EMR system most certainly would reduce paper work. But as I learned with H & R Block (God Bless Federal Taxes) the other day, a poorly designed electronic record system will *still* ask you for redundant info. As a computer scientist, I can tell you that the issue is bad design. So we should all support a well-designed EMR – it will help (but it won’t cure) the overload of paper work.

    As for the gun issue, I’m backing Panda 100%. I wish we had conceal and carry laws where I live in California; I’m new here and don’t know the rules, but my guess is that it’s pretty much illegal to even look at a gun, let alone buy and carry one. Yet it’s perfectly legal for motorcycles to drive in between cars in deadlock traffic. California… go figure!

    One more thing: as much as frivolous lawsuits disgust me, my mom, who is a doctor/hospital malpractice defense lawyer, tells me that it is quite rare for completely B.S. cases to go to trial, and even more rare for the doctor/hospital to lose big. Yet she does cite some pretty scary examples of when this does occur, and it is sickening.

  29. This discussion about the obscene amount of paperwork involved in the process of patient care these days reminded me of one of the major maxims I heard as a student of HIM (aka medical records): “Not documented, not done.” After a couple of internships (one in a hospital, the other in a family practice clinic), I can honestly say that yes, there is a ton of CYA documentation in a medical record. The amount of detail in some forms can be staggering…and all the terminology, abbreviations, and such can be completely overwhelming to someone who hasn’t already had plenty of exposure to them. (I was a lucky one in that sense…I already had a ton of background.)

    The fact that medical records are like this is merely a reflection of what I’ve heard called “defensive medicine”, i.e., physicians forced to practice in such a way that they lessen their chances of any sort of litigation being brought against them. EMRs are not yet the answer, either, because there is still so much to learn about how they work, and getting everyone in the healthcare system up to speed will surely prove to be a lengthy and costly process. But hopefully they will eventually replace a lot of the paperwork that piles up and gives us all headaches at one time or another.

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