2015 is gone, thank God.


I am content to see the year 2015 gone. I can remember as a college student thinking that 1960 would never come. That was a good year. I didn’t graduate from USC as planned but I did get married and I did get accepted to medical school.

Some of the story is here in my short biography. More of it is here in my “stream of consciousness.” The next installment is here as I describe Basic Training.

When I got back from Basic Training in December 1959, I had my first date with Irene Lynch. A year later to the day, we were married and a week later, I got a letter from SC Medical School telling I had been accepted to the class beginning in September 1961. So, 1960 was a pretty good year.

In 2015 I spent what I think will be my last year teaching medical students at what is now named “Keck School of Medicine of USC” and is where I attended from 1962 to 1966. I went back to teaching there in 1998 in a program called Introduction to Clinical Medicine, which seems to be disappearing into the “Family Medicine” Department which is a shame.

I now have a book of memoirs called “War Stories: 50 years in Medicine” and which is a Kindle book only so far. Much of my medical school experience is included along with stories from my years as a surgeon. It started to be “40 years a surgeon” but I decided to include the rest and changed to 50. In June 2016, it will 50 years since I graduated from Medical School and that seemed a appropriate.

I enjoyed my time with students and I am quitting only because of frustrations with the Electronic Medical Record, about which I used to be enthusiastic, and with changes in the County Hospital which used to be a wonderful teaching institution. The Electronic Medical Record, now more often called The Electronic Health Record, probably because much of it is not about medicine, is a big problem.

The EHR, as it is called, has acquired a bad reputation.

A percolating problem is beginning to boil over: doctors and nurses really don’t like their new electronic health records systems. And, as EHR implementations increase ahead of government deadlines for incentive dollars, dissatisfaction among clinicians is growing.

The problem might be that EHR implementation is treated as a purely technological issue when in reality it is a workforce issue. Several years before federal incentives began for healthcare providers to adopt EHRs, leading healthcare informatics organizations strongly recommended that workforce training and readiness must be a top priority in the national transformation from paper to electronic health records.

While the benefits of EHRs to patient care have been established, persistent user issues may be impacting the technology’s effectiveness. Many surveys and studies show that user satisfaction with EHRs is headed in the wrong direction. An American College of Physicians survey, released this spring at the HIMSS13 conference, showed that overall EHR user satisfaction fell 12 percent from 2010 to 2012, while those who said they were “very dissatisfied” rose by 12 percent.

Could it possibly be the clunky and counterintuitive systems that have been foisted off on the profession by bureaucrats ? Well, maybe that’s it.

As the healthcare industry moves to EHRs, the medical record has essentially been reduced to a tool for billing, compliance, and litigation that also has a sustained negative impact on doctors’ productivity, according to Steven J. Stack, MD, chair of the American Medical Association’s board of trustees.

“Documenting a full clinical encounter in an EHR is pure torment,” Stack said during the CMS Listening Session: Billing and Coding with Electronic Health Records on Friday.

EHRs are also driving the industry toward charts that look remarkably similar because they’re based on templates created by the technology vendors — that includes often using the same words. And that threatens to make doctors appear to be committing fraud by the practice of record cloning, or cutting and pasting from one record to another, when they are not, in fact, acting fraudulently. Alongside the federal mandate to implement an EHR under threat of a monetary fine, that creates what Stack called “an appalling Catch-22 for physicians.”

What is worse for teaching students, is that access to the record is clumsy and cumbersome and the students and instructors cannot compare write-ups to see what good ones look like and how to improve. The EHR seems focused like a laser on billing and “peer review” issues that have little or nothing to do with taking care of sick people. Doctors are retiring from practice rather than spend days typing data into a template created by some low bidder.

The changes in the County Hospital are another factor that has driven me away from teaching. The big hospital that took ten years, 1918 to 1928, to build and which served for 3500 patients at a time for 70 years, was closed in 2008 and all patient care moved to a new 600 bed hospital built with federal money due to alleged safety issues after the 1993 earthquake.

The original hospital opened in 1923 and on November 8, 2008, transfer of all inpatients from Women’s and Children’s Hospital and the historic white 800-bed hospital on the hill to a new, $1 billion, state-of-the-art 600-bed replacement hospital just south of it was completed, and the new hospital was fully opened for service. It is located on the north side of Marengo Street, east of State Street. Designed by a joint venture of HOK and LBL Associated Architects, the new hospital consists of three linked buildings: a clinic tower, a diagnostic and treatment tower, and an inpatient tower. It was built because the old building did not meet new earthquake and fire codes that are part of the California Hospital Seismic Safety Law enacted in the aftermath of the 1994 Northridge earthquake.

This, of course, is nonsense. County politicians saw an opportunity for federal money to build a new hospital and, instead of keeping the old building in service and updating its systems with an auxiliary building containing new operating rooms and technical services, they closed the old building and built a mess of a facility with no organization of patients that corresponds to basic nursing and medical care principles.

The old hospital was four times the size and the services were organized in logical fashion to facilitate nursing care and education. The old hospital had wards organized by diagnosis. Diabetic care was centered on a Diabetes Service run by a clinician who, for decades, was Helen Martin who was the only full time clinician to remain at the hospital during World War II and who ran Diabetes for half a century. I was working on a history of the hospital and the Surgery Department about ten years ago and met with her several times in the assisted living home she occupied in Pasadena. She was nearly 100 and as alert and focused as she had been when I was a student.

Despite her parents’ fears that the profession would be too physically demanding for her, Martin graduated from the USC School of Medicine in 1934 and became one of the nation’s most respected women in medicine — as a physician, researcher and teacher.

During World War II, Martin became the dominant force of the USC clinical teaching program: After virtually the entire faculty — members of the Army Reserve’s 73rd Evacuation Hospital unit — were shipped to the India-Burma theater, she was the only remaining full-time faculty member.

“For about 3 1/2 years, she held that whole department together. How she did it I don’t know, but she did,” said Dr. Robert Tranquada, a former colleague who became the Los Angeles County Hospital’s medical director in 1969 and later dean of the USC School of Medicine.

But that was only one of her accomplishments, Tranquada said.

“Another was her basic research in diabetes, which early on was to look at the influence of electrolytes in the care of diabetic coma and serious problems of diabetes.”

Martin wrote numerous papers on the functions of insulin and electrolyte disturbances in diabetes and was an international expert in the role of magnesium in diabetes.

Those were the people who made USC Medical School the great place it was for education when I was a student. Bob Tranquada was another fine teacher.

The new County Hospital is disorganized and useless for teaching students. I wonder how the nursing staff manages where patients are scattered about with no system of specialization in nursing care. Surgery patients are mixed with medical patients and pediatrics is lost. I tried to take my students to the “Adolescent Ward” once and found no patient under 50. The nursing care on medical and surgical cases is quite different and orthopedics is different again. The University Hospital is better organized but there are just not enough patients for the size of class of students these days. More and more education is using actors and actresses to simulate diseases. Some of that is good, for testing in one example, but students need to see sick people.

Anyway, I spend a few days a month examining applicants to the military at the MEPS in Los Angeles and this satisfies my desire for a little clinical contact. We find some interesting pathology among young adults so it is not boring repetition and I like talking to the kids.

I still keep edging toward Tucson where I would rather be living but family pulls the other way. I hope 2016 will be better. I have a few health issues to settle and that will take place in the next month or two.

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One Response to “2015 is gone, thank God.”

  1. norcal says:

    You have a very interesting history, Mike. I majored in history, so I enjoy many of your posts. I am beginning to see why it was more enjoyable to be a doctor decades ago than now.

    As for how 2016 will turn out, ask me on November 8th. :)