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A Day in the Life of Sir William Osler

Snowed in by a fierce Nor’easter, with our clinic as well as every other outpatient facility within 100 miles closed for the day, I stoked the fire in our wood stove, pulled up my high back chair and read for a couple of hours.

I returned to my treasured, signed copy of Harvey Cushing’s biography of Sir William Osler, the father of modern medicine. On page 431, under the subheading ’He Knew Not Idleness’, Cushing quotes a senior assistant’s account of Osler’s daily routine.

This description may be surprising to those who only know Osler by his famous quote, “Look wise, say nothing and grunt”:

“At 7 he rose; breakfast before 8. At a few minutes before nine he entered the hospital door. After a morning greeting to the superintendent, humming gaily, with arm passed through that of his assistant, he started with brisk, springing step down the corridor towards the wards. The other arm, if not waving gay or humorous greetings to the nurses or students as they passed, was thrown around the neck or passed through the arms of another colleague or assistant. One by one they gathered about him, and by the time the ward was reached, the little group had generally grown like a small avalanche.

The visit over, to the private ward. For the many convalescents, or the nervous invalid whose mind needed diversion from self, some lively, droll greeting or absurd remark or preposterous and puzzling invention, and away to the next in an explosion of merriment, often amid the laughing but vain appeals of the patient for an opportunity to retaliate. For those who were gravely ill, few words, but a charming and reassuring manner. Then, running the gauntlet of a group of friends or colleagues or students or assistants, all with problems to discuss, he escaped. How? Heaven only knows!

A cold luncheon, always ready, shortly after one. 20 minutes’ rest in his room; then his afternoon hours. At 4:30, in the parlor opposite his consulting room, the clans began to gather, graciously received by dear ’Mrs. Chief’, as lady Osler was affectionately known. Soon the chief entered with a familiar greeting for all. It was an anxious moment for those who had been waiting on for the word that they had been seeking with him. After five or 10 minutes he would rise, and perhaps beckon to the lucky man to follow him to his study. More often he slipped quietly from the room and in a minute reappeared at the door in his overcoat, hat in hand. A gay wave of the hand, ’Good-bye’, and he was off to his consultations.

Dinner at seven to which impartially and often, his assistants were invited. In the evening he did no set work, and retired early to his study where, his wife by the fire, he signed letters and cleared up the affairs of the day. Between 10 and 11 o’clock, to bed. Such were his days. Three mornings in the week he took at home for work. He utilized every minute of this time. Much of his summer vacation went to his studies. On railway, in cab, on his way to and from consultations, in tramway, and in the old ’bobtailed’ car that used to carry us to the hospital, book and pencil were ever in his hand, and wherever he was, the happy thought was caught on the wing and noted down. His ability at a glance to grasp and to remember the gist of the article that he read was extraordinary.

His power to hold the mastery of his time was remarkable. He escaped as by magic, so graciously, so engagingly that, despair though one might, one could hardly be irritated. No one could speak consecutively to Osler against his will. How did he do it? I know not.”

(W.S. Thayer, ‘Osler’. The Nation, N.Y., Jan. 24, 1920.)

It makes me reflect:

Time, my old arch enemy, is always on my mind. Over the years, I have managed to adopt a somewhat Oslerian persona, which tries to make every minute, and every brief encounter, count in the mind of my patients and in my own pursuit of forward movement in each clinical case I encounter.

But most days I don’t know that I am anywhere nearly as skillful as the old master in navigating through it.

He probably capitalized on his larger-than-life reputation and position in the world of medicine. I have only a local reputation and the position that career longevity and mature appearance bestows me, like my silver haired temples and my wrinkled hands and face.

But the one thing I know and sense every day in the clinic is: If for a single moment my love of my profession or the connection I feel with my patients and my coworkers is clouded or briefly forgotten, the pace of my workday becomes almost unbearable.

It is only when I am carried by the momentum of my greater purpose that I can make every one of my brief encounters with my fellow human beings count and be healing in any sort of way.

Dropping the SOAP Note

The SOAP Note isn’t what it used to be, and what it has become needs to be scrapped, because it has made the office practice of medicine cumbersome and unsafe.

In simpler times, when medical records were written by and for doctors, the SOAP Note represented a significant leap forward in terms of expanding and organizing office notes, and also notes from emergency rooms and walk-in clinics. Prior to that, notes sometimes only documented the diagnosis and the treatment, not how those were arrived at.

With S for Subjective, O for Objective, A for Assessment and P for Plan, the reader could instantly find exactly what he or she needed to know from a colleague’s medical record entries.

These days, medical records contain a lot of data that is mandated by outside parties – CMS, ACOs, PCMH/NCQA, the Joint Commission, and now even local states, like Maine.

EMR vendors have inserted these mandated items in sometimes very illogical places in the medical record, and they have also infused bookkeeping items where they probably work best for billing purposes, but definitely not to document clinical thinking.

Some examples:

I see many ER notes that don’t clearly state the patients “Chief Complaint”. I see that they got there by private vehicle, gave the history themselves, didn’t need an interpreter, had already had all their baby shots and were not yet ready to quit smoking, but I’ll be darned if I can figure out what brought them out in the middle of a snowstorm to see somebody in the emergency room.

In the SOAP Note, anything observed during the visit instead of told to us, such as vital signs, heart sounds, blood tests and in-house X-ray findings would go under Objective. Tests ordered but not expected back until later went under Plan.

In the EMR I work with (or under?), there is no Objective and no Plan. There is Exam and Treatment.

That difference isn’t subtle.

The tests I do in-house are ordered and resulted under Treatment, after I have already stated under Assessment what the diagnosis is. That makes no sense. A chest X-ray doesn’t treat anything. The antibiotic I prescribe goes there, too, so at least that makes sense. But essentially, the logical and chronological order of my notes has been hijacked by non-clinicians.

More static items like past medical history, family and social history used to go on the inside left of paper records, where they could be referenced and updated on the fly. Now, just like in a hospital admission note where the patient is presented as if they had never been seen before, they are prominently displayed in every single office note.

That is one of the fundamental differences between a paper office note and an EMR note; the former is pertinent and the second is comprehensive, because the note presumably has to document that the doctor mentally went back over known historical facts and considered their possible relevance for the problem at hand with the speed of expertly trained thought and hard earned experience.

It didn’t seem enough to keep the background data separate and simply state “I considered the Past Medical, Surgical, Social and Family history in handling the patient’s issues in today’s visit”.

Even if someone I stitched up ten days earlier just comes back to have the stitches removed, the second office note reads as if a stranger just walked through my clinic door.

In such a case, a visit that lasts less than five minutes from the doctor’s point of view requires verification of all the data that isn’t likely to have changed in ten days, and the office note is just as long as the original note about the chainsaw cut or their first get-established visit – seven pages of 99% irrelevancy for a simple suture removal.

The mandated add-ons’ presence in every single office note has created a clear and ever-present danger that time-pressured clinical staff and physicians will miss critical information and put patients at risk for clinically incomplete care, even though I’m sure the non-clinicians’ intent at some point was to ensure the opposite.

All these additions have inflated and cluttered up the SOAP note to the point where I think it is high time we reclaim a space, however small, inside the office note for strictly medical documentation that is immediately pertinent.

This nugget notation needs to be near the top of our computer screen, so we don’t have to scroll, even to get from the beginning to the end of it.

We must accept that the office note serves the needs of many people and bureaucracies, but if we don’t make it serve us better, we’ll drive ourselves into the ground and at least some of our patients into their graves because we might miss critical things in the overinflated medical records of today.

Friday’s Lessons

My colleague, Dr. L.T. Kim, was off this week and I covered for him.

Friday afternoon I dealt with two of his patients and learned, or relearned, two important lessons.

I saw a man with thoracolumbar back pain. He had fallen off a ladder a few years earlier and suffered from recurring bouts of back pain, sometimes with tingling in both legs. He had been to the emergency room after a particularly bad episode. Dr. Kim saw him in followup and ordered an MRI of his thoracic spine.

I saw him to review the results. The MRI showed more or less garden variety degenerative changes, but nothing that would explain all his symptoms.

“I’m feeling much better, but this very sore spot is still here”, he said and asked if he could point to the corresponding place on my back.

I asked him to remove his shirt and palpated my way down his spine.

“Right there. You got it”, he said.

I marked the spot with an X, using my green ink rollerball pen, sat down at the computer and ordered PA and lateral lumbar spine films. My tech taped a metallic marker over my X and a few minutes later I saw on the screen that his pain centered on his second lumbar vertebra, just below where his expensive MRI had ended.

A call to Cityside hospital’s MRI department verified that they couldn’t just go back and look a little lower on their images, which only included a small fraction of L2. Our patient needed a whole new, lumbar, MRI.

In case I had any temptation to feel a little smug that I had realized something Dr. Kim hadn’t, I learned another lesson at 4:55 pm.

“I’ve got a sodium of 123 on one of Dr. Kim’s patients”, our lab manager said as she entered my office with a lab printout in her hand. “If he saw this he’d probably have the patient go to the ER by ambulance”, she continued.

“Well I don’t usually worry quite that much about sodium levels”, I said. “I’ll take care of it.”

I saw that this older woman had been discharged from the hospital a week earlier and she did run low sodiums there, about 130.

Dr. Kim is an internist by training, and he spent most of his residency years in a tertiary acute care hospital, where only the sickest patients went. In that setting, even small changes in lab values could be harbingers of deterioration, disaster and death. I spent most of my training in small town hospitals and outpatient clinics, where most people got better more or less on their own, and where small laboratory abnormalities often didn’t matter much at all.

I dialed the number.

“Hello, is this Mrs. Weld? This is Dr. D. calling from the clinic with your lab results. Dr. Kim is away this week.

“No, this is her daughter.”

“Her sodium is low so I’m calling to see how she is doing.”

There were several voices in the background.

“Guys, I’ve got the doctor on the phone”, she said and the voices went silent. She continued: “The ambulance is here, I’ll put you on speakerphone so you can talk with them.”

“Hey, Doc, what’s up”, the familiar voice of one of our local EMTs greeted me.

“Mrs. Weld has a sodium of 123, it was 130 a week ago when she left the hospital”, I said.

“What are the symptoms of that?”

“Weakness, lethargy, confusion…” I started.

“That would be it, Doc.”

“So she needs to go back to the hospital. I’ll call the ER”, I said.

“Thanks a lot for calling, Doc. Good timing!”

Indeed. And I thought this would turn out to be just an insignificant laboratory abnormality.

Not On Call

“I am not on call”, Dr. Brian Stoltz said over a lot of background noise through what must have been the speakerphone in his car.

“I know”, I said. “Cityside ER said there is nobody on call for ophthalmology this weekend. I have a 54 year old woman with intense tearing, discomfort and only 20/70 vision in her right eye.”

“And she’s not a patient of our office?”

“No, she has only had to see an optometrist for glasses. I’ve called every hospital within 50 miles and there is no ophthalmologist on call over the long weekend. You helped me once before with a case of dendritic keratitis when you were on call.”

I also remembered Memorial Day weekend last year, I was in the same situation during my Saturday clinic. A young boy, whose mother had just joined the board of our health center, came in with eye irritation. He had a small rust ring very close to the center of his cornea. I had dug out plenty of them, with a special spatula or even with the tip of an 18 gauge needle, but this was a child, who might not have beeven fully cooperative, and the location was critical for his future near vision.

Cityside Hospital had no ophthalmologist on call for that long weekend either, and all my calls to ophthalmologists in the surrounding area were fruitless. He got in to see an eye doctor the Wednesday after the Monday holiday and it turned out that he actually also had a small metallic corneal foreign body. Everything turned out okay, but the wait was uncomfortable and at least a little risky.

A corneal rust ring, even a foreign body, can usually wait a few days, but if this woman had what I thought, acute angle closure glaucoma, I wouldn’t want her to wait that long to see an eye doctor.

“I think she’s got acute glaucoma”, I said.

He was silent. I continued:

“She’s got mixed injection, no foreign body, no fluorescein uptake and I can see her left fundus clearly but I can’t get a focus on her right fundus no matter what lens I dial in on the ophthalmoscope.”

He was silent again for what seemed a very long time. Then he said:

“I live an hour away, but I happen to be in town. If you have her walk out your door right now, I’ll meet her at my office in, what, 25 minutes?”

“She’ll be there. Thank you so much.”

I haven’t heard yet what he found, and I haven’t wanted to bug him, but I am anxious to hear what the final diagnosis was. I do know that an urgent slit lamp exam was necessary.

One postscript:

When I sent my emergency eye patient off with her office note and insurance information to see Dr. Stoltz, her husband said:

“You’ve done well by us. I came in and saw you once with a cauda equina syndrome.”

I didn’t remember him, but he must have had a critical enough pressure on his lower spinal nerves to also have warranted an urgent referral to a specialist.

Disease strikes at inopportune times.

Diagnoses Right Under My Nose

When I read a case report in a journal or whenever a patient comes in to see me about a new symptom, all my senses are tuned in and I know there is a diagnosis to be made.

But on regular clinic days with “routine” follow ups, I find myself not being as tuned in as I would like to be. I know my patients well; we are all growing older together. They change gradually over the years, just as I do. A couple of times last year I have found myself surprised and ashamed that someone else made a new diagnosis in a patient I was seeing on a regular basis.

Stella Sanders world had shrunk since her boisterous husband died a couple of years ago. She had never learned to drive, so without Roy to take her places, she had become virtually housebound. Her spinal stenosis had gone from moderate to severe, and she couldn’t take care of her home in the way she had always prided herself in. She admitted she was depressed, but didn’t want to take an antidepressant and wouldn’t hear of seeing a counselor. Her whole demeanor had changed. She never smiled, and she was less animated in all her facial expressions and body movements.

It was her neurosurgeon who saw it. He had nothing to offer for her spinal stenosis, but he suggested she talk to me about the possibility of her having Parkinson’s Disease.

I saw her again the other day, and on Sinemet she looks almost like her old self again.

Fred Nystrom’s health had been declining for years, and after going through both an operation for a fractured hip and emergency bowel surgery for perforated diverticulitis last year, he never recovered his old level of functioning. He came back from rehab the second time using a walker. Two months later he was still using it. His affect was flat and he couldn’t keep track of his medications the way he had a year earlier. His enlarged prostate seemed to bother him more and more, and he moved too slowly to always make it to the bathroom.

It was my partner, Dr. Wilford Brown, who made the observation that Fred had dementia, gait disturbance and urinary incontinence – the classic triad of normal pressure hydrocephalus. Fred is going in to have a shunt placed to drain his ventricles at the end of this month.

Our challenge is, in the hustle and bustle of everyday practice, to look beyond the issue at hand often enough to “see the big picture” in each patient, and at the same time keep a constant vigil for small changes that could mean a new disease is evolving.

Doctors Should Be Paid Like Athletes

Think about it, athletes aren’t the ones who document their performance. It’s other people that keep the score. That’s a whole science in itself. People talk for hours after the game or tournament is over about how each athlete did this or that in whatever way they did it and the numbers are in many cases captured by extremely sophisticated electronic equipment.

Physicians work hard to diagnose and treat their patients, and on top of that, we have to do all the work of documenting what we did and how we did it. It isn’t enough that we make a correct diagnosis or provide an incredibly effective treatment. We have to code and document so that accountants, lawyers and the general public can understand what we did.

Our medical charts are now instruments for billing and, sadly, less and less of a tool for us. I suppose it is a bit like if a baseball coach in America had to speak to his/her team so that any Swedes or Martians accidentally present could also understand what was going on. (Baseball is not big in Sweden, or on Mars.)

Now, you might think doctors aren’t worth the millions we pay our professional athletes. I’m not going to argue with you on that one, but I will point out that the medical spending controlled by your average family doctor, through direct care, tests and consultations ordered, emergency room visits and hospitalizations – per capita spending multiplied by the number of patients cared for – is in the ten million dollar ballpark, to borrow a term from America’s favorite sport.

My point is, why do we have to input the data with our own, in my case, two typing fingers, when professional sports doesn’t make athletes keep their own score? The technology is there in other arenas (sorry, the sports terminology keeps popping up), so why not in ours?

Everything Goes Through Me

On an ordinary day last month, I saw patients for eight and a half hours. I addressed a dozen computer messages, took four or five calls from outside providers and held innumerable curbside conversations with medical assistants, case managers and colleagues.

I didn’t get to any of the 100+ lab results or 50+ documents in my electronic inboxes. Consequently, the care for several dozen of my patients didn’t move forward.

Many of them didn’t get the news that their blood tests, mammograms or CT scans were normal; some never got scheduled for follow up visits to discuss options based on their mildly abnormal studies; a few didn’t get their highly abnormal tests acted on. Others didn’t get their annual eye exams logged in their diabetic flow sheet.

This happened because I am the official bottleneck by virtue of the “work flow” dictated by our electronic medical record.

My last office note might say “Follow up to review results”, but if I am late getting through my inbox, the clerical task of scheduling that appointment doesn’t happen.

It’s a little bit like having me answer our clinic’s telephone, or, a presumptuous analogy, the President opening the Government’s mail and then forwarding each item to the proper cabinet secretary.

Because every piece of data in a medical office has an ordering provider or a provider of record, it seemed like an EMR no-brainer to send everything to that person. But I think someone forgot that the current primary care business model is based on each medical provider cranking out as many visits per day as is humanly possible. That makes desk work a money losing activity.

With all the talk about having everyone in the medical office work to the top of their license, I think it is high time we turn the virtual mail sorting work flow on its head:

Have non-providers check incoming reports and lab test against existing treatment plans with cut-offs for when to interrupt providers, and give the provides more time to provide care and make medical judgements. A lot of information comes in to the primary care office just so we can maintain a record of patients’ care. It isn’t necessarily imperative to have the physician read a seven page specialist report to find one relevant medication change that needs to be updated in a patient’s record. That is what we used to call secretarial work in the old days, but that word and concept, dear Health Care Industry Comrades, seems to be taboo these days.

So, back to my reality: Last night, after cleaning the horse stalls, I spent almost two hours going through my backlog of reports. At least I was able to do my work from home, in the company of my horses, but I keep feeling that on a daily basis I am making up for a system that isn’t all that well designed.

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