Why Your Doctor Doesn’t Look at You Anymore
Should you treat the chart, or the patient? Increasingly over the past decades healthworkers of all stripes – doctors and nurses, therapists and technicians – buff the chart first. Legal, insurance and regulatory requirements have burgeoned to overcome the concerns of health.
Checklists work very well in military and surgical conditions. You really want to check a checklist when you’re shooting an F-16 off a carrier deck or closing up an appendectomy. They can aid public health by placing attention on major problems like hypertension and diabetes. Yet they can also cloud out judgement, humanity and ultimately health. The end results are more than exhausted, frustrated health care workers and furious patients. The waste of time and money – easily tens of billions of dollars a year – is remarkable.
Here are a few problems with checklist medicine:
1. Tunnel vision. It really is important to consider blood pressure and glucose levels in many medical encounters. But on the checklist version of the electronic health record, the only things that count are what’s on the checklist.
What if that back pain is caused by depression? Probably not on the checklist. What if the elderly patients can’t read the labels on their medicines? Don’t expect to see that on the checklist.
With checklist medicine, if “the numbers are fine” so are you. And whole dimensions of health – your lifestyle, your social support, work stresses – are rarely on any checklist. You may feel awful and that nothing meaningful has been done – but the chart looks good.
2. Deforming Clinical Decision Making – if you treat by the checklist, you look for checklist diagnoses. Keep doing it, and you become inured to thinking out of the box.
Common things are common. So you end up looking for common things – often exclusively.
Yet the body is supremely complicated, and continually fooling even the most thoughtful doctors. Diseases and drugs intersect, interact and interrelate in manners unpredictable or even – by checklist measures – unfathomable.
But clinicians are trained by checklists to see things along the same railway track. To think, to look around, discuss and consider, takes time. It also often means evading or violating checklist guidelines. Rare events get missed.
But it’s recognizing and treating the rare events that people are paying for.
3. Time Wasting. Health care is expensive. Thanks to checklists, lots of it takes a lot more time.
Some estimates are that charting and other paperwork take up more than 40% of ER docs’ time. Even if the numbers are half that among other clinical workers, is charting worth 20% of healthcare worker time? Do the numbers. You quickly see that present charting, checklisting and paperwork may cost over $100 billion a year – before considering its clinical effectiveness. Is that economically or clinically justifiable?
4. Repetitiousness. Much of the charting done, even by the “efficient” electronic health records, involves inputting the same stuff over and over and over again. By any industrial standard, that is highly inefficient.
It is also highly frustrating. Many physicians, particularly internists, claim they now spend an extra 1-3 hours a day fitting through their checklists for notes and treatments – and they still can’t access critically important material, like the weights of congestive heart failure patients. No wonder the British spent $15 billion on an electronic health care system and then junked it – among other things, it just wasted way too much time.
5. Money Versus Clinical Effectiveness. As a form of social control, checklist medicine is highly effective. If talking with patients, putting down complicated histories, pays vastly less than doing a quick procedure – people will be “trained” by insurance companies and clinic and hospital administrators to “do the efficient thing.”
6. Further Wrecking the Doctor Patient Relationship. The doctor is a drug. A large part of effective medical care occurs through placebo effects. If you feel your physician, therapist, or nurse cares and is competent, you do better. But if your internist is always spending her time pumping in clicks on her keyboard, how connected do you feel with her? It may be hard to define just how deleterious this change is, but the effect on clinical effectiveness is much larger than most people think.
7. Lack of Security. Checklists are great in generating numbers. The electronic health records they connect to are, however, are not great at keeping secrets.
When Anthem announced that 83 million records had been hacked, people should have been up in arms. They weren’t. That may change when folks realize their most personal information is out there available to the highest bidder – and often the price is quite low.
There are many other reasons why checklist medicine worsens healthcare and health results. For health should be the issue – physical, mental, social and spiritual wellbeing of the population – not how many clicks you need to make to generate a 16 page report that moves easily through the giant American health insurance racket.
It’s time for proper clinical trials of checklist medicine. How does it affect diagnostic accuracy? How many, and what kinds of records really are necessary? How do they affect patient results?
We don’t know the answers. But the waste, inefficiency, frustration and absurdity of the present system demand we find out. It’s time to do the real numbers – and find out if checklist medicine is worth it.
