Medicine has lost sight of the big picture

We must bear in mind the difference between thoroughness and efficiency. Thoroughness gathers all the facts, but efficiency distinguishes the two-cent pieces of non-essential data from the twenty-dollar gold pieces of fundamental fact.
- Dr. William Mayo

The practice of medicine involves a lot of details, but details without the big picture are meaningless at best and distracting at worst.

The expression, “the devil is in the details” implies that the details can trip you up, whereas the original, older, idiom “God is in the details” conveys the importance, even beauty or virtue, of paying attention to the details when trying to do good work.

I think medicine has lost sight of the big picture when it comes to its thoroughness and its pursuit of efficiency. And I don’t see much beauty or virtue in today’s medical charts.

This was going on before electronic medical records, but quantum leaped with the switch from transcribed dictation to click boxes and copy-and-paste functionalities.

The root of this problem lies with the evaluation and management (E&M) coding that literally gives points for how many questions a doctor asks about a symptom — onset, character, duration, severity and so on. Points are also given for documenting which symptoms a patient doesn’t have. In earlier times, we used the phrase “pertinent negatives” for items a reasonable physician would want to know in order to work through the possible differential diagnoses for a particular symptom.

With the reimbursement system we now have, the number of questions and physical exam items, regardless of whether they are relevant or just filler material, drives physicians’ income and practices’ bottom line.

It was often possible when reading an old-fashioned, dictated, narrative to relatively quickly sort through the irrelevant items, particularly if the style and grammar were used to provide emphasis. For example, when dictating, you had the option of grouping all the negatives together and of keeping the positives separate and emphasized. With an EMR, the items in structured data entry fields tend to come in a predetermined order, making it much harder for the reader to find the relevant items.

The forest of details in today’s medical record serves purposes other than the efficient documentation for doctors to remember their own inquiry and thought processes. It also isn’t primarily designed for doctors to communicate to each other what they have observed and how they propose to treat it.

Today, under the new government edicts, medical records have to contain hoards of details doctors never thought were relevant, but politicians and insurance actuaries do and future generations of researchers might. Plaintiffs’ lawyers and medical boards might need them, and patients need to be able to read them, so we can no longer create notes that efficiently document our findings, conclusions and plans. It is as if the conductor’s sheet music at the symphony could no longer have musical notes, G-clefs and technical terms like “mezzo forte,” in case a non-musician wanted to follow along with the orchestra.

It is a bizarre situation: Imagine the ministry of culture requiring that all poetry contain certain elements about the beauty of America and the threat of global warming. Similar things have happened in countries that shall not be named here.

This is where the religious analogy really plays out: Which higher power decides the relative importance of what details in medical records?

“A Country Doctor” is a family physician who blogs at A Country Doctor Writes:.

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  • azmd

    All of this, at a time when our “efficiency” is seen as an increasingly critical attribute, because people don’t want to pay for our time…

    • Acountrydoctorwrites

      Agree with your comments about where things seem to be headed, although the “efficiency” Dr. Mayo was talking about was not hamster wheel efficiency but rather doing only what produces value and not frittering away our effort or our time.

  • QQQ

    “Today, under the new government edicts, medical records have to contain
    hoards of details doctors never thought were relevant, but politicians
    and insurance actuaries do and future generations of researchers might.
    Plaintiffs’ lawyers and medical boards might need them, and patients
    need to be able to read them,”

    The truth today is that healthcare in America is broken.While I do not
    agree with those who say healthcare should be a “right as an American”. I
    truly believe there are millions of people who are caught in the middle
    because the cost of medical insurance is too high for them to afford,
    but they make too much money to qualify for Medicaid. This huge gap is
    the central issue and both the Democrats and Republicans by not by
    working together on healthcare in good faith, handed American Citizens
    another( for-profit),( making some corporation rich) bag of #$%$ that we
    all must swallow.

    There are 378 millionaires in Congress both
    Republican and Democrat and they are out of touch with what is truly
    happening to the middle class.The growth of the US economy is driven by
    the middle class and not by the rich as the Republicans would like you
    to believe.On the other side pf the isle, the Democrats are constantly
    looking at ways to provide more benefits to the poor because they are a
    good % of their voting base. This November you should as a voter know
    what your representatives in Washington stands for and what they are
    doing in your name.There are truly too many,(too old) (career
    minded),(focused on their next election)( War motivated)( lobbyist
    pleasing)( power driven) and (out of touch millionaires) in Congress who
    push their personal agendas down our throats, knowing that they can
    have special interests groups spend millions to create false attack ads
    against any person who may wish to actually do something for you ( A
    Taxpaying American who wants their voices heard above the roar of

  • SteveCaley

    I would protest more, but I am sure that we understand that healthcare will die without intervention; and we will let it die.
    As Jared Diamond said “When they cut down the last tree on Easter Island, what was going on in their minds?” because someone did it, and it was done with a will. They may have been fools, but no worse fools than us.
    If we drive ourselves into cultural penury and extinction, no Magic Lamp will appear to save us.
    “Efficiency” is an assumption that a system is inefficient, and that with greater grit and willpower, we can change it. This appears in warfare, a confidence that is sustained until the shock of reality is realized.

  • disqus_McUkQK6a8K

    well done But try and organize doctors to write to the senate finance committee that controls CMS or speak loudly and often publicly Blogging here will make no change

  • Steven Reznick

    On the money! Unless a colleague dictates or types in an impression in their electronic health record notes it is difficult in format to determine if the patient looks like Shaquelle O Neal or Beyoncé?

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