Saturday, September 23, 2017



      When I was in my medical training, I used to write big notes and my Attending  physicians used to say that no one has time to read the long notes . I still do the long notes and there is a thought process in the notes , But now days , since the President Obama made it mandatory to have electronic medical records , I see longer and longer notes . That does not mean it has any information or the detailed thought process . Since these notes have been computer generated , there is lot material that was in older notes and even in the first note .So to find the REAL new information or the change in the patient , by reading these notes is very difficult. No one has time to read 8 page note . But the government has made it mandatory to have certain things included or documented ' , so we don't have choice . So there are these phrases that make no sense like smoking cessation -in house  and this is in patients who have never smoked .
       But I am not doing this  blog to complaints on EMR . But to tell you  the real difficulty when we have a patient who does not follow the medical advice . Or I want to NOT do something as I feel it is medically not  needed . Say I see someone who has clear cut cold  and patient wants antibiotics . There are several studies that have shown that the physicians are prescribing antibiotics much more often than it is needed -as in case of viral infection. I will have to write many more lines to justify why I am not giving the antibiotics. So many a times most will end up giving in and give a prescription for antibiotic rather than argue with patient and write few more lines to justify his or her decision. This brings me to today's story .

      I saw this patient in my office for abnormal chest x- ray and the CT scan . She was 71 years old and had quit smoking about 10 years ago . she had gone on vacation and was at height of 5000 feet . She got short of breath and so she cut short the vacation and then got down to lower level , She felt better and so she stayed there . She came back to the town and then saw the PCP . The PCP did chest x- ray as she still had some cough. She had no fever and had no chest pain , Her shortness of the breath was better , but not normal. The chest x- ray was abnormal and so she got the antibiotics and the she had a CT scan done . The CT scan showed a mass and a consolidation  or pneumonia . so she was sent to me .
         She came with her husband . She looked ok and did not appear to be short of breath . She sounded clear on her lung examination and her oxygen saturation was good . I knew by looking at her CT scan that she had cancer , that most likely was blocking the secretions and so she had the pneumonia . I knew that she needed the PET SCAN and the biopsy to get to the diagnosis of the cancer . But she and her husband were not convinced . She wanted to wait for some time to do any further testing . She felt that her problem was due to high altitude and it was better . So I agreed to wait for 'short' time of 2 weeks . I told them that if it was not cancer , it should get better in 2 -3 weeks . So we agreed  for 3 weeks . Mind you I had to write few more lines to 'document ' as to why I was not doing the scan and the biopsy sooner .
         So we did the PET SCAN and I was surprised . The spot on the lung was hot and most likely cancerous , but there were 'other spots ' in the lung and in the bones . so I called her and scheduled her to see radiation doctor and the radiologist for the biopsy . I did do bronchoscopy and she had the some changes that were consistent with cancer , but my biopsy came back suspicious , but not conclusive . so I called radiologist to do the additional biopsy . I had to again document this . she refused the Biopsy and she also refused the appointment with the radiation doctor . I was worried that bone spread to spine and the hip would cause the fracture and major problem .

       Again I had to document . I also called her PCP and again I had to document . So I was doing all this chart charting -may be 10 times and not going anywhere . So I called her to come to my office with her husband and the daughters .

      This is a very nice patient . But some how she was not getting what I was telling her . We did finally got the diagnosis of the cancer and got her to appropriate doctors for the treatments . She always hugs me and shakes my hand and thanks me for taking care of her. But that does not eliminate the need for the DOCCUMENTAION . If she would have done  things that I wanted her to do and done them sooner , I would have much documentation than what I did .

But I guise that is the modern day medicine --more documentation than patient care !!!