EMRs and Alternative Facts

As students of medicine, we have always placed an esteemed emphasis on "history taking." A process of listening to the patient while gathering clues to the ailment. William Olser, often described as "Father of Medicine," had this to say on the matter:

"By historical method alone can many problems in medicine be approached profitably." 

It is still a dictum we hold close to our heart and try to impress upon our students and trainees.

Alas, Dr Osler lived in a world without electronic medical records (EMRs). I sometimes find myself pausing in embarrassment while gathering information from the patient alongside the EMR. "How many doses of zoledronate infusions have you received so far?" I would be asking the patient while simultaneously pulling up the medication administration record. They would tell a number that turns out to be completely different than what has actually been given. As we find out a different record of actual medication administration, patient winces, and I blame myself for putting her on the spot by asking the question. I could have just explored the EMR beforehand to gather that data for something that I can hardly rely on patient's memory. And over the years I have learned how unreliable it is to base decisions based on patient recall. On my good days now, I would have performed a thorough exploration of patient's EMR and gathered necessary information before I enter patient's room to talk. Good students of medicine these days put due diligence in gathering exhaustive information from EMR. I am certain Dr Osler would have emphasized this in more eloquent terms were he around.

Still, the importance of listening to patient holds an irreplaceable import. There are no descriptions of patient's emotional states by a clinician's notes that can substitute a voyage of thoughts in a calm absorption of  patient's patter. No algorithm of information can match the patient's descriptions of their priorities and beliefs. You might have the right answers for the disease afflicting the patient. But listening and talking with the patient is where you build the trust. Ultimately, we humans are not automatons making decisions on rational choices. Our patients weigh their trust on us to adopt our recommendations. We might be brilliant in medical sense but if they do not find an emotional plane of trust, they might not adopt our solutions, even if by objective measure it is a wrong choice.

A good doctor in the current environment is one who can be exhaustive at data gathering from the EMRs, capable of listening and connecting to the patient, agile in compiling information needed to manage the issue in the most evidence-based manner, able to synthesize emotional information with objective data, and masterful in conveying the information in literally and emotionally understandable terms to the patient.  

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Recently, we have been introduced an oxymoron term "alternative facts." While the messenger received some serious criticism, unfortunately, there is a populace who share her belief. If we were to heed the back and forth between the protagonists and antagonists of the alternative facts, we might find ourselves confused about the reality itself. If we do not belong to any particular ideological camp, we might throw our hands up in the air and say the world is an illusion anyway! There is no reality!

As I think about this I can not help going back to the EMRs. There I see two discernible aspects of realities in that interaction:
1. Objectively verifiable information (e.g. the information about what date, time zoledronate was administered)
2. Interactions involving feelings/thoughts

The objective information is fixed and incontestable. If the patient has received medication only in this facility and there is no reason to doubt the accuracy of documentation, that information is incontestable. There is no subjectivity.

But in our human interactions not everything is objective and fixed, we rely on feelings and perceptions. We imagine. We dream. Not by threading the plausible and actual but rather freewheeling in the cloud, in the subconscious, beyond our realm of reasons and rationality. Do I like this doctor? Does he sound reliable?

We are entitled to an unbridled freewheeling in the perceptual realm. But if we try to claim that objective reality should also acquiesce to our perceptual world, that's when the problem springs. When we start claiming that our feelings of the number of zoledronate administered should trump the objective documentation of administration, there is a serious problem. There is the world of "alternative facts."

I do not want my doctor to rely on her feelings about the objectively verifiable information to decide on my health. It is also clear that the society should not rely on "alternative facts" to run the governance.   

Martin Luther King Jr (MLK) Day

There were warnings of freezing rain. Although it is a hospital holiday today, I am on call. Black ice-covered driveway greeted my journey to the hospital for rounds. Roads were largely desolate. It was a while before I saw any car. Sky was gloomy and dark. Skidding here and swerving there, I reached the hospital. I rounded with a competent clinical fellow and we were done by the afternoon. I drove back home. As I was attempting ascend up the steep driveway to my garage, the car protested. On the ice, the car veered in wanton. It would slide to the right, glide to the left, drift backwards but not up. 

Defeated, as I waited at the bottom of the driveway for some brilliant idea to materialize, I could not escape the irony of this day. A day commemorating a man who sacrificed his life peacefully striving for racial justice. Today, it feels as if the world is back to square one. The West staggers in an amnesiac stupor, completely oblivious of its treacherous past, as if it is seeking a calamitous jolt. No wonder the day appears weepy. And the town frozen in its wistful tears. 

Over a pile of snow on the sidewalk adjoining the driveway, I made an attempt. One side of the car was on grass now.  Riding the crunchy friction, I made it to the top of the driveway. The vehicle will witness this blubbering night while I seek warmth with my family inside. 

Artha

Dear son Artha, 

Not long ago, your mommy and I were rewarded the knowledge of your conception through a positive urine pregnancy test. It is hard to describe the exact feeling of seeing those lines turn color on the pregnancy test kit. An abstract announcement of life. Precipitous. Somehow, fragility has piggybacked that moment and trails to date. That we have a fragile and precious existence bestowed upon us and told: you are responsible. Anxious about your safety, “one-day-at-a-time,” we have told ourselves since.  

A notion at that moment, you asserted your presence in mommy’s nausea and anorexia. We saw you for the first time as a wormy construct on the ultrasound. On the second ultrasound, your structures became clearer; we could make out your head, heart, hands and feet. We even knew that you are a boy! Very early in a cool spring Maine morning, you decided to make entry into the external world. Mommy writhed in pain for hours while daddy was consigned a role of passive witness (remember, that is one reason why we boys will always remain the inferior sex- we are biologically incapable of that sacrifice). You came screaming. Those were the most genial decibels your parents have experienced in their lives. When I saw you for the first time, somehow, it did not feel like a first encounter. It felt as if I had known you always. Introduction was needless.

It has now been over eight months since your arrival. You sit stably. You smile abundantly. You speak in syllables. You like company. You like outings. 

Well, that is your daddy's attempt to express your development in tangible terms for a process that is much more nuanced. If you asked daddy to sum his experience of witnessing your growth and parenting so far, it would be this: Daddy had thought parenting would mean teaching you things to help grow to a more mature individual. What he has realized is that it is more of a role of servitude. Servitude to an innocence that has certain needs. It is parents who are taught things. Taught by being positioned in extremes- a crying baby amidst sleep deprivation, you can not resolve what is bothering, can you maintain your patience? We constantly try things, learn new things; you keep changing, we try to keep pace. At this stage, we are the learners. Daddy's dear friend says, as you grow there will come a time when you will look up to us to learn things. I trust that. It seems to me that we are in for a journey where we will learn from each other, always.

Forever yours, 

Dad.