Backwards Fucking Medicine – Garbage Medicine

It’s 2019 and medicine really hasn’t changed my since I last left it. Self-driving cars, apps to order food to your door, and AI to help filter out spam – but medicine is still in the dark ages. Primary Care doctors are forced to practice garbage medicine.

I did my residency training in a low-income clinic and have moonlighted at various different FQHC’s. Now I’m back at a Community Health Center which mostly sees uninsured patients.

This is the first time since 2009 that I have been working outside of Kaiser. 10 years have gone by and shit has gotten worse. So get ready for an onslaught of curse words and observations.

Primary Care Medicine

Nothing’s changed. Primary Care doctors still have a massive panel and see about 24 patients in 8 hours. Imagine that, trying to manage all sorts of complex chronic medical issues in about 10 minutes. And that’s with the constant addition of documentation and bureaucracy which the clinicians have to navigate.

The real time spent with the patient is still only 5 minutes. When in the room you’re looking at your screen and typing things into the EMR. Or you’re spending time looking things up because the patients don’t remember what they had done.

The IRS places the burden of knowledge on the tax payer, except for the very poor. I’m comfortable placing the burden of medical history knowledge on the patient, except for the very sick and the incapable.

Repetitive Tasks

I sit there, trying to navigate the fucking EMR, fishing for the right lipid panel to order. In fact, why are we STILL ordering lipid panels?!

A decade has passed and screening labs aren’t automated. And every single lab that I order creates an endless string of more responsibilities for me. I have to go on a clickathon in my EHR to sign off the lab, result it to the patient, take medication actions on it, and then document everything I did in the EHR.

And, of course, half of the time you get on the phone with the patient they tell you that they weren’t taking their medication. Or it’s the wrong medication. Or that they ate 7 hot dogs right before doing the blood test. Come on.

Sure, many industries are still lacking automation, but we’re talking about medicine with unbelievable profit margins for insurance companies and pharma. The clinicians can’t just get dumped on more; just look at our patient outcomes. It’s not our clinical knowledge that’s lacking, I’m sure of that.

Electronic Health Records

EHR, what’s there to say. My Uber app is smarter than any EHR/EMR out there. They are bloated with information, they are impossible to navigate, and the majority of the information we’re entering in there is to cover our legal ass.

I have a 6-page dossier on a patient who is here for cholesterol medication refill. 99% of what’s on the screen is for compliance, legal, and other bureaucratic reasons. Ironically, her most recent LDL isn’t even in the chart, neither is her diet.

I still have to create telephone encounters, back office messages, click on labs, pick up the phone and talk to the patient, etc. EHR’s are end-stage useless and have become worse.

At this particular clinic I’m using ECW. At Kaiser I used Epic. Before that I used a slew of other garbage software, either web-based or local software.

Patients Waiting

It’s not like Primary Care has changed. It’s not like the science of medicine has changed. And patients definitely haven’t changed. So how the shit have we not figured out how to stop wasting the patient’s time.

Going to your PCP apparently is still a half-day ordeal. My patients have been waiting in the clinic for nearly an hour before I get to them.

Sure, 5 patients will check in all at once. And the one patient who didn’t come on time throws everyone else off because the clinic has no good workflow.

And in these community clinics it seems that there is even less respect for patient’s time. Nurses will chat and socialize while the patient is waiting to get checked in. If asked it’s because they aren’t clocked in or they were busy doing something else.

We as doctors aren’t much better. I’ll spend time doing something unrelated instead of rushing in to see the patient in their room. I won’t spend my time wisely to review each chart before going into the room. And yes, I have my own excuses for that too.

Workflows

There are so many damn workflows. There are binders filled with them in cabinets. Follow these steps for these kinds of events. Order these medications for these kinds of patients.

Workflows can be automated. Wasting the clinician’s time to recall and enact the same damn workflows is an insulting waste of resources.

This goes back to automation but also how muddy medicine has become. I’m the doctor, I’m the expert, I should only be talking to the patient and deciding on their management. Everything else needs to be handled by someone else. Because I’m pretty sure that all of these shit was build around us, the clinician.

Shit on the Walls

I’m looking around me in the clinic and there are posting EVERYWHERE. It’s nuts. It’s a sensory bomb.

So much writing on so many different posters. Phone numbers, more workflows, announcement, and shitty fucking inspirational messages which were probably hung up by borderline suicidal staff.

Well, not gonna remember this, so let me stick it to this surface.

Toilet Exhaust

Look, we all know that one nurse or doctor who’s gonna go Jihad on that toilet every morning. They are gonna drop the brown bomb and the shitter won’t be accessible for the next hour.

Why don’t these commercial bathrooms have better exhaust? We have state of the art touchless sinks but we still can’t get the feculent smell out of a 5×5 toilet?? Not acceptable.

Interruptions

I’m not sure if anyone else got the memo but interrupting people leads to poor productivity. And since we don’t work in a grocery store, it’s probably good to avoid interruptions in the clinical setting.

And yet some random fuck will come and interrupt you with unimportant shit. Oh, cancel this order. Oh, we need this done. Oh, could fill out this paperwork? Hey, what’s the phone number for…?

Read some self-help books, dude. From the CMO to the clinic manager to the nurse, they all interrupt each other, non-stop.

Shitty Fucking Coffee

It’s not even about the cost of coffee, it’s just the way it’s made. In the same shitty plastic cancer coffee makers. With the same Folger’s dyed grinds. With the same plastic tasting water from the shitty cooler.

I know that coffee has matured in the past 10 years. Why are we behind on this? I should be sipping a cup and forgetting about that horrible diabetic food exam that just assaulted my nostrils.

If you ever build a clinic, invest in a toilet fan and in a good coffee setup.

Clinicians Complaining

Ah, yes, I missed this part. You go to the “doctor’s lounge”, which is just a room with very bad artificial lighting and computer monitors where all the clinicians gather to tap away on their keyboards.

And then you hear the complaints. Something about the pharmacy or a workflow. Or how this or that isn’t working. How they have an add-on patient on their schedule which they can’t get to.

Then the complaints about how one of the cases was really difficult or patient was complex.

Dude, you’re a Primary Care doctor. By definition, you don’t have difficult cases. The trauma surgeon, maybe, or the ER doctor, yea, those guys can complain. You, no, you don’t get to complain about working up a chronic chest pain. Shut the fuck up and go sip on that shitty coffee.

And if you’re an NP or PA, you bottle that shit up. No complaining for you either. Make a mental note of it and then go home and take it out on your partner, maybe discuss it with your therapist.

It sucks that we have this hierarchy in medicine, but we have it. So, as mentioned above, the trauma surgeon and ER doctor can complain. After that, the trauma NP/PA and ER NP/PA. Way down on the list, after everyone cried their hearts out, you, the Primary Care NP/PA, you can say something.

The Hood

Well, the hood will always be the hood. Working in a Community Health Center by definition means that you’re going to greet several security guards before you enter the clinic, and likely be searched.

I’m pretty sure that using the word “hood” is racist or sexist or offensive in some sort of fashion. But you have your big-boy panties on, you’ll get over it. If it makes you feel better about yourself, think of hood as a nickname for neighborhood.

As a doctor working in the hood, you’ll be peaking out of the window to check and see if your car is still there or whether it’s sitting on cinder blocks.

And walking around or driving around the neighborhood looking for food, that’s always pleasant in the hood. The quality of food is what we serve to patients in hospitals and prisons. The last taco I ordered needed CPR from its near-drowning in liquid pig lard.

Obese Nurses

Look, I know how difficult obesity is, it’s not just a calorie problem. But what does it say about our profession when every nurse and 98% of doctors are either overweight or obese?

I mean if we can’t get it right even 10% of the time, how the fuck can we tell patients what to do about their diet.

I shit you not, an obese NP walked into the doctor’s lounge complaining about how an overweight patient wasn’t able to lose weight despite her efforts. I mean if that’s not the pot calling the kettle black…

A rather hefty MA trampled into the break room when I was eating my excessively spicy guacomole salsa and carrots and pesticide laden persimmons and she commented how that kind of food wouldn’t be enough for me. Thank you for your dietary advice, ma’am.

Horrible Progress Notes

The progress notes from hell are found in Primary Care. There won’t be much about the patient in them, that’s for damn sure.

I don’t blame the clinicians for this. We are bred to use the EHR as a legal pad – maybe 5% of what’s in there is clinically useful.

The HPI and the A/P don’t match. I can’t make sense of what medication was ordered or how it was titrated. I have no idea which tests were ordered for what reason.

Then again, what can you say in Primary Care…. “Patient is obese, has poor health education, works 2.5 jobs, cannot afford a visit with nutritionist.”

Or… “Morbidly obese patient appears to be in pain when getting down from his raised truck with custom paint job. As he was throwing away the bag of McDonald’s he exhibited some shoulder pain. Though he is right hand dominant he appears to be operating his brand new iPhone with left hand; query wrist gout?”

Unnecessary Labs

BNP’s, CBC’s, q3 A1C’s, LFT’s, ESR’s … so many damn unnecessary Hail Mary labs. So many things to sign off on and review.

You cannot get a diabetic to stop eating bread and you cannot get a PCP to stop ordering unnecessary labs. No matter how medicine evolves, even if the world were to end tomorrow, there would be an overweight PCP sitting at their EHR ordering complement levels on a patient with dizziness.

I’m definitely part of the problem. The more tired I am, the more shit I have on my mind, the more tests I order. It just feels better ordering the test and dealing with the consequences later.

Hemorrhoids and Pelvics

I thought that the Urgent Care had it bad. But I think Primary Care wins when it comes to doing pelvic exams on BMI’s over 40. Or checking for hemorroids on a dude with a crater of a gluteal cleft.

I don’t have the scapula power to spread those cheeks apart to even get a glimpse at those hemorrhoids. And the nurse couldn’t get enough friction with her gloves to keep gravity from forcing the cheeks back together.

Patient Education

In the waiting room the patients are eating fast food; that’s fine, I get that. Who wouldn’t enjoy a Happy Meal from Mikidees. Also in the waiting room, everyone is on their phones listening to some funny and loud video.

Why loud, well, it’s the hood, you don’t turn your shit down in the hood, you turn it up. But why a funny video, why not something educational? Youtube is free and you can learn all sorts of things about your health and other useless shit, like learning how to program a computer.

It’s 2019, we are knee deep in the middle of the information age. Anyone can learn how to be a software engineer if they wanted to. That is, anyone who can learn to order a Happy Meal, navigate an automobile through the drive-through, or operate a smart phone can learn all of the free information out there on software engineering.

And yet my patients tell me that they had no idea that fiber would help with their constipation. That their cold is obviously fucking viral. That the reason their diabetes is getting worse is because of all the bread. And that their weight isn’t ideal for their height.

In 2019 you shouldn’t need an MD with 11 years of higher education to tell you what health is. Diet and exercise, that’s not news anymore. Sure, I’d love to educate you, but not when you’re suing me. And not when the medical board is investigating me. Kinda busy with those things.

In the exam room, during those 5 minutes, I have enough time to prescribe you a new medication, order a new test, or place a referral. I can also titrate your medications – but only a few of them at a time.

Printers not Working

I mean, let’s get past the fact that I have to still print shit. How is that even possible in 2019?! But beyond that, printers don’t work. Of course not, fuckface, it’s old fucking technology, much like the fax machine and the home telephone – nobody is working on the printer jamming problem.

Let’s see, first, you’ll never select the right network printer. If you somehow manage to remember the 18-digit code for the right printer, it will be out of paper. Or there will be paper but it will be jammed. Paper not jammed? There is an error message on the printer which you’ll have to clear. No error message? Printer is just not feeling like printing today.  ?

Then there is the low-ink thing – that’s when you have to figure out how to open the plastic piece of shit, extract the ink cartridge, shake it like an idiot (and comment to others that you’re shaking it), and hope that it’ll print your unimportant documents.

Next, you’ll hand off those documents to the patient. And what’s on there? Nothing important. Mostly their medications and procedures which they’ll never remember they had done. There are exercises on there as well, but they won’t remember that you gave them the exercises or dietary instructions. Not to mentioned, you printed them off of a google search.

The Death Stares

Just today, I was about to go take a shit in the community toilet. I chose to take the long way around so nobody would know it was me committing the crime and I happen to walk into a death stare.

As a doctor you’re used to these, it’s just that this one seemed accusatory. As in, “bitch, I know what you’re about to do that toilet, you oughta be ashamed!”

But no, it wasn’t that. It was your run of the mill death stare by a patient who was desperately waiting for their doctor. Debating in their mind if they should just walk out, watch yet another useless YouTube video, or go chew out someone at the front desk.

See, the actual treating provider doesn’t get the death stare, it’s only innocent bystanders. Because you don’t want to piss off the doctor who’s got your life in their hands. But you definitely want the rest of the world to know what a waste of fucking time it is for you to have to wait for your late-ass doctor to show up.

Angry Pharmacists

I don’t understand what pharmacists are so pissed off about. Their problems are yes/no problems. Clinicians have the kind of problems which often have no solution or have 75 options to choose from.

I totally understand that the pharmacist has to call me about the hydrocortisone 2.5% anal cream, no problem there. But why the attitude? Why so distraught?

You can chew me out, you can be passive aggressive on the phone, you can refuse to authorize a medication, but in the end you will have to fill some sort of medication. That patient has to walk away with something, even though it’ll offer nothing more than a placebo effect.

So why don’t we all try to get the fuck along.

Garbage Medicine

What is garbage medicine? Garbage medicine is me babysitting patients and EMR’s and paperwork. It’s me telling a patient that their A1C is high and that it’s probably because of their diet. That they are overweight.

That their sudden onset unilateral blindness since last night doesn’t fall within my scope of practice in this outpatient Primary Care clinic.

Garbage medicine is using nothing from my medical education during an 8-hour prison sentence in clinic. It’s me prescribing metformin to a patient who won’t take it because of the flatulence it causes.

It’s me waiting on the nurse who is being passive aggressive with a patient because they checked in late. And it’s me having to justify to the patient why I won’t order an antibiotic or refill an opioid.

What I do is closer to sales than clinical medicine, it’s retail work – customer service. I’m trying to sell you on my diagnosis and tell you why you weren’t approved for the “better” medication. I’m then kissing your ass enough to not get a bad patient review or an eventual lawsuit or a complaint to the medical board.

Garbage medicine is treating the EMR instead of the patient. It’s having 5 minutes with the patient and 15 minutes with the chart.

And to all of my physician friends who say that I’m just a jaded fuck, and that your patients love you and have much better outcomes because you actually care, let me show you the current stats on obesity, heart disease, and diabetes.

Bureaucracy

A huge problem at this clinic is access, obviously. It’s a community health center and they have a lot more demand than they have providers. We have mostly NP’s here and 1 or 2 MD’s.

So how do you increase access? You can add more providers or you can see more patients per appointment. Or, you can add in telemedicine.

Of course, no, we can’t just add telemedicine. Because CMS won’t pay unless the patient is physically located in the clinic. Which sort of defeats the purpose of telemedicine.

It’s infuriating. I have to bring the patient back in for their medication refill or to review their lab just so that I can get paid for that visit. Otherwise, if I relay that information to them on the phone, it’s money down the drain.

Now, that’s bureaucracy.

The Future of Primary Care Medicine

Despite my sarcasm here, I feel that Primary Care medicine has a lot of potential. And I actually feel that it’s going to eventually take a turn in the right direction.

I’m impressed and humbled by the doctors who have broken free and started their private practices. Instead of tucking tail and running away, like I have, they have decided to stay and fight.

I know it’s cliche to say this but Uber saw how fucked up the Taxi system was and they decided to reinvent paid transportation. Of course, they also break damn near every law, But at least they did something.

It was their decision to sidestep the whole Taxi medallion bullshit that provided the rest of us access to paid transportation. And these Direct Primary Care docs who are giving the middle finger to insurance companies are doing something amazing for their patients.

These doctors don’t deal with pharmacies, don’t minimally with big lab groups, and they don’t have to justify any test. They also recruit the kind of patient who WANTS to pay for better care. Imagine that.

Imagine 60-minute visits with a patient. Imagine spending time with a geriatric patient showing them all of the core exercises they need to do. Or spending time with a patient going over their entire diet in detail. It’s both great an intimidating. No more hiding behind a statin pill to hope for a lower LDL – these docs have to actually know something about lifestyle modifications.

I hope that one day I won’t practice garbage medicine. But for now I look at my education in medicine and I’m scratching my head as to why I learned all of the things I learned.