A reader writes: “Is there a solution to inefficient paperwork? With such great technological advancement, do you foresee any computerized forms of paperwork to make it less inefficient?”

Sure. We have a great electronic record system at one of our departments (the T-System) which makes documentation and order writing a lot easier than previously. The problem is the temptation to document more simply because we can. Not to mention that so long as there are bureaucrats, there will always be new ways to waste time and, unless it is aggresively cut back like creeping kudzu, paperwork will always spread into every available niche.

In other words, despite great technological advances in information technology, there has been no decrease in the amount of paperwork involved in medicine. The converse is true unfortunately as every year seems to find some new asinine JHACO compliance chore sucking up somebody’s otherwise valuable time. Now, to be fair, most of this stuff is what I call “automatic paperwork” meaning that they put a form in front of you, you sign it, and it vanishes into the mouldering realm of medical records where the evidence of your compliance with the hospital’s ass-wiping policy will be entombed forever. It’s not too bad I suppose but it is somewhat annoying and, just as a vigorous mongol warrior may easily ride down a few peasants here and there until you throw enough of them into his path to seriously impede his attack, so too is the modern doctor’s attempt to secure the medical equivalent of the goats and slave girls severely hampered by the reams of innocuous paperwork between him and his objective.

This is not even taking into account the tangled labyrinth of forms, regulations, and coding required to be compensated for your work in a system where nobody wants to pay anybody for anything and most of the bureaucracy is actively engaged in either deflecting invoices and delaying payments or in trying to get somebody else who isn’t involved, the so-called “third party,” to pay.

It all stems from a complete lack of trust at all levels of both medicine and society in general, a lack of trust engendered or at least encouraged by the legal profession against which most paperwork is directed. The hospital doesn’t trust its employees therefore they are required to complete endless forms foreswearing infractions of things that used to be common sense or to give fealty to their overlords in the diversity theocracy. Doctors don’t trust their patients not to sue so every discharge instruction includes the usual reams of boilerplate instructing the patient on differentiating their ass from a hole in the ground. Doctors don’t even trust other doctors and document in an attempt to drag as many people into the stew as possible under the theory that it’s a lot more fun to fry if you do it as a group. The hospital takes the opposite approach and, to minimize their liability, structure their paperwork to identify the one guy who can take the fall for everybody.

Insurance companies and the government don’t trust anybody on general principle.

The two things that have surprised me the most about medicine? Number one is the severity and number of illnesses people can collect and still grimly cling to their mortal coil. Number two is the absolutely astounding volume of paper generated in a hospital, the great bulk of which is completely useless except that the bureaucrats believe it to have talismanic powers against the legal vampires. That and it supplies work to countless people employed in tending it.

But as far as technology simplifying things, we have a long way to go. I still get a kick when patients from out of town or who frequent some other hospital airily dismiss my attempts to garner a past medical history or a medication list with a casual, “Oh, it’s all on the computer.”

Lady, at 3AM your primary care doctor’s electronic medical records might as well be on Neptune for all the good they can do you.

What do you think about the USMLE Step 3?

I took Step 3 today, or rather finished it, because it is a two-day test. I won’t elaborate on the questions so as not to subvert the exam but I will say that it is obviously slanted towards both primary care and, surprisingly enough, Emergency Medicine. It just seems to me that a surgery resident would have to study for it harder than a Family Medicine resident because I have a fairly good idea that most surgery residents rapidly forget all the primary care they ever knew. Sure, they know how to treat a lot of things tbut they may have forgotten how to handle some of the routine cases that are second nature to a Family Medicine intern who has the various preventative medicine guidlelines beaten into his head every day.

Confess. How many of you surgery residents know what to do with a pap smear?

An unusual feature for those of you working your way up the Steps are the interactive cases, nine of them, on the second day of the exam. Definitely do the practice cases provided by the USMLE before taking the real test because the interface, while easy to use, is not intuitive and you need to know how to handle the mechanics of the computer simulation. If you’re going to screw it up its best to do it honestly and not because you clicked the wrong button at the wrong time.

Since the practice cases are available publicly, I don’t think I’m giving anything away by describing how this section of the test, a section that I rather enjoyed, works. The first thing is to relax. You have been doing this since third year and the only difference now is that you don’t actually have a patient in front of you. After being presented with the history, you are free to write orders, ask for physical exam components as needed by system (which are given to you for the asking), and transfer the patient to any area of the simulated medical center in which you are working. A case might begin in the clinic, for example, and if by history and physical exam you realize that your patient is having a heart attack it’s time to transfer them to the Emergency Department where you continue your management. You manage the patient by writing orders asking for labs, studies, and consults. Some cases seemed (seemed) pretty simple and required simple management with some discharge instruction here and there to stop smoking and lose weight but on one I transferred the patient from the clinic to the Emergency Department to the ICU before my time was up.

You have 20 minutes of “real time” per case plus five minutes at the end to finalize orders and provide a diagnosis. The diagnosis, as I understand from the tutorial, is not part of your grade but can serve to clarify what in the hell you were thinking. The case may span more than 20 minutes of “simulation time.” Within the limits of the “real time” (that is, the limit allowed by the test) you can advance the clock in whatever increment you desire. Sometimes you write your orders and then, with nothing to do, you need to advance the clock to a time when the next lab or study results are available. At other times you advance it to a follow-up appointment that may be the next day or later as you would do in a real clinic when presented with a non-emergent case. One of the practice cases, for example, is a guy with Giardia. I sent him home with lomotil pending the results of his giardia antigen assay and then on the follow-up visit, when it was positive, started him on Metronidazole. I guess this was the correct “play” because on advancing the clock the computer told me that he was feeling better and then abruptly ended the case.

That’s the disconcerting thing, however. You can be tooling along writing orders, managing like a big dog, kicking medical ass and taking health care names when the case, with time still on the clock, will suddenly and without warning come to an end. Naturally this can come as a shock because there may be no feedback. Did I cure him? Did I screw it up? Supposedly the case can end early if you handle it well but some hint would be appreciated. On one case I had no idea what was wrong with the patient and after shotgunning a whole bunch of labs and venturing some treatments just kept advancing the clock until I either killed the motherfucker or the computer decided I was an idiot and put me out of my miseries.

Without boring you with the mechanics, the program recognizes a couple thousand common orders for common studies, medications, and interventions. (I wrote an order to “intubate” and, mirabile dictu, a little window popped up saying that the patient was intubated and on the vent with the appropriate settings without any complications.) It is not necessary to know dosages of drugs but only the name (trade or generic) and the route of administration (PO, IM, IV, etc.). You don’t have to get that detailed with the orders so relax and don’t worry about the esoterica like vent settings and specifying everything you need for an Incision and Debridement. You do, however, need to order the stuff that most Emergency Medicine residents take for granted like intravenous access and cardiac monitors. In the computer simulation world, the nurses still dress like porn stars and don’t do a thing until explicitly told to do so by a doctor.

I guess the object is to show that you know how to manage efficiently and economically. Apparently some of the cases seem simple because they are simple and it is not necessary to admit every upper respiratory tract infection to the ICU. I imagine whoever or whatever grades the test takes points off for over-reacting, maybe putting Emergency Medicine residents at a disadvantage because I often found myself looking for the button labled “Indiscriminantly CT Everything.”

Other than that, all I can say is that like Step 1 and Step 2, knowing “what is the next step” is big. That is, knowing the diagnosis is not as important as knowing what to do about it and when. I don’t think anything came out of left field. Even the things I didn’t know I knew that I should have known. In other words, I knew what the question meant and what I was supposed to know even if I couldn’t exactly remember the details. Some of the answers seemed so obvious that I marked them for review and came back to them just to make sure they weren’t trick questions. You find yourself doubting if those massive ST elevations in the anterior leads are really pertinent to the answer and if the test is really asking you for some subtle, psychosocial management strategy.

Many of the questions are on ethics. Again, I will not subvert the test by giving you specific examples but I think we all know that “Taser the Patient” is probably an answer you can eliminate right off the bat. That and advising your Hispanic patient that “she needs to learn English.” I wasn’t so comfortable taking the test that I could afford to screw around so I voted the straight diversity party line like a good boy.