MEDICINE: A culture of mistrust
An extract from Dr. Pamela Weble: https://www.idealmedicalcare.org/how-to-fall-in-love-with-your-emr/
Strong physician supporters trusted this charismatic leader, Lawrence Weed, MD, and his new model of organizing medical records—yet many doctors resisted. Surgeons were most resistant, the internists were ambivalent, psychiatrists demonstrated “damp enthusiasm,” according to the anthropologist.
Culture of Distrust
Most fascinating to me was the obvious culture of distrust in medicine generated by physicians themselves. Doctors back in the day displayed distrust of hospital administrators, nurses, medical students—and even each other! A few quotes from his thesis related to distrust of these four groups—bureaucrats, nurses, medical students, and physicians:
Physician-Bureaucrat Distrust
Ongoing tension between the entrepreneurial and autonomous physician and the bureaucrats has been present throughout modern medical history. Computerized medical records were welcomed by bureaucrats for the “systematizing, auditing, controlling potential” of doctors.
“One of the most common phrases that was used by resistant physicians was ‘the POMR is a conspiracy.’ When questioned further they indicated that it was a conspiracy by those in administration to function as administrators want them to: ‘pushing piles of paper around.’ It was also a conspiracy to ‘get the doctor.’ If the game was to get the doctor, then some requirement that everything must be documented would surely be a useful ploy.” (page 269)
Physician-Nurse Distrust
There was “polarization between doctors and nurses who could now question the logic behind a physician’s therapeutic plans on the computer so the ‘computer was voted out of the ward by a closed meeting of the senior medical staff” because it was “territorially unacceptable to those in power.” (page 80)
The “nurses’ SOAPed progress notes were renounced as “ungrammatical gibberish.” Physicians complained of “non-physicians ‘overstepping their responsibilities’ and were concerned about “who was in control of patient care, exemplified by satirical remarks on ‘nursing diagnosis’” The physicians in both the medical and surgical services spoke of the doctor-patient relationship as being “corrupted by nursing arrogance.” (page 250)
“Within days of the initial physician’s outcry, humorously characterized as ‘who’s writing in my notes?,’ several other physicians used the same ploy to denigrate the nurses.” (page 253)
Physician-Medical Student Distrust
Higher education is about learning and asking questions, yet I’ve found the medical hierarchy methodically oppresses medical students who may be discouraged from thinking independently or questioning their superiors. Some for the first time in their lives fear asking questions during medical training. Our trusted anthropologist writes:
“Within the U.S. medical culture, age, and concomitant status categories (medical student, extern, intern, resident, etc.), usually confer greater authority and greater power. As a medical student, the opportunity to affect peer and faculty behavior is minimal, and the well-documented passage from humanist to cynic occurs. Medical students are low in the professional hierarchy, and behave accordingly. For example, rarely do medical students display disagreement and displeasure to their medical school clinical faculty. As student physicians increase in age, credibility, and credentials they gain the right to assert their opinion. Innovativeness is not customarily rewarded medical student behavior. Only with the acquisition of clinical experience can the opportunity to innovate occur.” (page 145)
Physician-Physician Distrust
The anthropologist found that frequently physicians use “alienating humor” to converse with one another explaining that “much of the humor was at the expense of patients, at other specific physicians or services, at psychiatry or medicine in the surgical domain and vice versa, or commonly placed one physician in a subordinate position. (page 122)
“Internists rarely requested psych consults and had ‘disparaging remarks about the entire psychology and psychiatric services.’” (page 120)
“In medicine, the surgeons claimed that ‘heroic actions are rare in the medical service.’ The surgeons claimed that chronic care is the ‘ballpark of the internist.’ The internists criticized the surgeons as ‘one night stands’; ‘going in and cutting as spectacularly as possibly while we have to do the painstaking clean-up work.’ The ideological differences between internists and surgeons are well known. They begin in medical school, and are strongly reinforced in informal contacts between surgical and medical residents.” (page 253)
“Internists commonly described surgeons as ‘technicians’ and as ‘heroic princes.’ Surgeons referred to internists as ‘boy scouts’ and ‘pill pushers.’ I regret that I did not keep a systematic record of the insulting metaphors that were used by each department; the underlying feeling of division and competition was pervasive in the institution.” (page 141)
After reading the anthropologic study, most shocking to me was the resistance of physicians to befriend one another and how doctors actively attempted to “suppress physician friendships.”
“Many physicians had doubts about the strength, intimacy, and candor of their friendships. Often they mentioned that they worried whether non-physicians were friendly because of the security the physician offered those friends when they were in medical need. Some of the physicians, notably those in the surgical service, were quick to point out that they deliberately made every effort not to build intimate friendships with other physicians.” (page 121)
Of course the “attitude of the hospital’s administrative leaders were totally non-conducive to friendship formation.” complained physicians. (page 122)
So my question today is how is it even possible to create a uniform medical record system with so much animosity and distrust?
Physician Resistance To Innovation—A Paradox
I believe the origin of physician resistance to innovation is threefold: 1) Fear of change (universal among most people), 2) Territoriality and 3) Culture of distrust.
Our anthropologist points out “ . . . the medical record has traditionally been called the doctor’s record, and progress notes were labeled as doctor’s progress notes. If the record is to be considered the patient’s record and notes labeled as progress notes (with team participation), two areas of resistance can already be identified.” (page 261)
Medicine is conceived as “a discipline receptive to change—constantly and carefully evaluating innovations for better ways to help the patient. Paradoxically, any changes on the traditional doctor-patient relationship, on fee-for-service transactions, on review of medical care by non-physicians (or by peers), and on the demystification of medical terminology are fought vigorously.” (page 267)
On the one hand, the media reinforces “the desired self-image of dynamic medical and research progress” while “higher education is notoriously conservative and resistant to change”—especially in medicine. (page 268)
So that’s the backstory to electronic medical records. Now let’s look forward . . .
Why Medical Records?
The original purpose of a medical record was to simply record the patient encounter. The therapeutic relationship that flourished organically over time. Appointments were face-to-face with eye contact (no staring at a computer screen) and real conversation that allowed the doctor to get to know the patient’s philosophy, desires, culture, and address their medical needs in the context of their real life. Physicians back in the day could do that with no staff as a solo docs in a simple one-room neighborhood office—often right inside their homes. The record could be one sentence on one index card. Before hospitals dominated the medical scene, all records were primary-care outpatient-based and involved two people—doctor and patient.
Now the modern medical record has been overrun by so much complexity and competing interests that the doctor and the patient risk losing the very foundation of their sacred and healing relationship. The medical record system is a multi-page/multi-window experience that is often neither intuitive nor ideal for any specialty. Tertiary-care hospital-based record systems amass so much information from so many sources that sometimes what you are looking for can’t be found. So the SOAP note has turned into the APSO note so we can locate the assessment and plan amid all the crap entered by medical staff. Except maybe housekeeping, everyone seems to have the ability to add to this ever-more-complex medical record.
Medical records are now not so much used for the patient encounter but to document things done to the patient in ever-shorter visits with unreasonably lengthy documentation required for billing and coding in case of auditing or lawsuits. Of course, the sheer volume of material required for documentation requires more face-to-screen time with the computer than face-to-face time with the patient—and sadly encourages dishonesty and outright lying in the official record with boxes checked for questions never asked and entire sections cut and pasted over and over again on a bloated record based on distrust.
Doctors distrust patients who may sue them so the medical record expands due to CYA medicine and excess labs, tests (and additional documentation) increasing medical expense. Patients distrust doctors and don’t share what’s really on their minds (how can they in 7-minute visits?). Many patients have written me seeking help because their doctor profiled them in the medical record as a “drug addict” or a “bad mom” or “noncompliant” and they can’t get that phrase off their records. Even if they change doctors they feel labeled and experience discrimination. Let’s not forget these medical records are stored in the cloud and on systems that can crash and be hacked in a moment with all patient records and physician NPIs and social security numbers leaked to the world.
So if the truth of a patients life is no longer captured by a medical record due to distrust and bureaucratic bloat, what next? Meet some doctors who have actually fallen in love with their medical records.
