Don’t go to Bill Frist’s doctor

Remember Bill Frist?  Heart surgeon?  Former Senate Majority Leader?  Super-genius doctor, such that he could make an authoritative diagnosis about a condition totally outside of his specialty based on videotape of a patient he did not otherwise examine?  (Except whoopsie, maybe not?)  That guy?

Turns out he’s got some questions about ObamaCare.  Humble physician that he is, he relied not upon his own understanding of the law’s impact on doctors.  No, he went to another trusted source — his own doctor.

Want real health reform that is in the interest of you and your family? Don’t make the same mistake that Washington did. In formulating ObamaCare, the politicians listened to lobbyists, policy wonks, academics, health theorists, regulators, and occasionally to each other. But they failed to listen to the people who actually care for patients: Doctors. Granted, the lobbyists for physician groups were at the table, but not the doctor him or herself. Ironic, isn’t it? Especially when it’s the doctor who has the daily responsibility of directly caring for the patient.

I wonder who this “the” doctor is.  Which walking synecdoche would have been a decent stand-in for “the doctor him or herself”?  Stupid me, when the American Medical Association, the National Physicians Alliance, the American Academy of Pediatrics, and the Association of American Medical Colleges all express support for a piece of legislation, I take that as a sign that at least some doctor somewhere has weighed in.  Pity those poor lobbyists for physician groups, who I guess must have all agreed to support the ACA in secret without consulting any of the actual members.  I’ll bet they must have caught hell when word got out.

Go ahead, ask your physician at your next visit what she or he thinks of current Washington-directed reform and its impact on the doctor-patient relationship. What you hear will likely surprise you, because it will likely be markedly  different from what you hear from Washington. The policy theorists are simply too far removed from the reality of front-line patient care. Health reform, whether via the implementation of ObamaCare or the GOP’s “repeal and replace” plan, should no longer ignore the input and counsel of experienced, front-line, practicing doctors.

Here’s my own guess about what your physician will say if you ask him or her about ObamaCare — some variation on “hell if I should know.”  Your doctor probably isn’t a policy wonk, and likely doesn’t have any special insight into the complex behemoth that is the Affordable Care Act.  He might like certain aspects.  She might think it is an unjust infringement on personal liberty.  But your physician’s opinion of the bill is likely informed by his or her preexisting political opinion, rather than particular expertise.

Here is a sampling of what my own internist, who has taken care of thousands of patients over the past 20 years, shared with me:

Frist: We hear the electronic health record (EHR) will solve much of what ails our health sector. 

Doctor: The EHR is not the savior of the medical system. In fact, it is effectively destroying the relational aspect of the art of medicine. Instead of talking with a patient and hearing her “story,” we are being relegated to looking at a computer screen and pointing/clicking during the visit.  I know there are long-term benefits to an EHR,  but most internists who value the art of medicine will tell you it is killing the “story.” And it is expensive. Physicians with EHRs see 15 to 30 percent fewer patients (and work later into the night). And yet with ObamaCare, we will be asked to take care of an additional 30 million patients.  [emphasis gleefully added]

*insert “gales of laughter” sound clip here*

So, I work in an office with an EHR.  However, we get new patients from other practices all the time, many of which come from offices that have yet to adopt an EHR system.  That means I have to review the records before they are scanned into our computers.  Would you like to know the “story” that I  get, without exception, from these reams upon reams of photocopied charts?  (Seriously, I have yet to review hand-written records that deviate from this norm.)  Barely legible scrawled jots.  Nigh unto worthless scribblings.  Maybe internists are a different breed (color me skeptical), but from what I can tell EHRs have been an incredible boon to medical providers who want to know WTF the previous providers have written.  When I get records from a practice that has its own EHR, I can tell what the hell they wrote!  Whatever heartwarming “story” of physician-patient bonding those handwritten notes comprise in their one or two lines of chicken scratch, it may as well be in cuneiform to me.

And I don’t know where Frist’s doctor is getting those figures.  If you are facile with the EHR you use (and some of them suck, it’s true), you can see patients no less efficiently with them.  In fact, on those rare occasions when our computers are down and I have to use paper, it takes me much longer.

If your doctor doesn’t use an EHR, your doctor is doing you no favors.  You should consider finding a different one.

But increased documentation in charts and billing surely improves value to the patient?

Hardly. We are now working with 17,000 diagnosis/billing codes — absolutely ridiculous. There are nine codes for abdominal pain (right upper, left upper, right lower, left lower — you get the idea). And the government has recently increased the number of codes from 17,000 to 155,000.   The bottom line — 300 codes would probably cover everything. It could be printed in a four-page leaflet, not three large volumes. It is unnecessarily complicated and it does absolutely nothing to improve patient care.

Curse you, “government”!  You and your regulations!

What Frist’s internist is griping about are the ICD-9 and ICD-10 diagnosis codes.  I will happily concede that they are byzantine in their complexity, and I would be delighted if they were simplified.  What that tricksy doctor doesn’t mention is that the ICD codes are published by the World Health Organization, and as far as I can tell have nothing whatsoever to do with ObamaCare.  (Someone please correct me if I’m wrong.)  Insofar as the Obama administration has had anything to do with ICD-1o code implementation, it has actually pushed back the deadline for the switch to allow healthcare providers more time to adapt.  Turns out “the government” is a complex entity, much of it having nothing to do with the Affordable Care Act at all!  If Frist’s doctor doesn’t understand that, then maybe we shouldn’t pay much attention to Frist’s doctor’s opinion.

This post is already approaching “too long” territory, so I’m going to refrain from going through the remainder of the article paragraph by paragraph.  It goes on to imply that EHRs increase fraud (citation needed), rail against regulations and paperwork that have nothing whatsoever to do with ObamaCare (eg. admit notes to nursing homes, order forms for devices, etc, all of which have been around for ages), and to denigrate nurse practitioners (who I think are great).  Suffice it to say that I found the whole piece totally unconvincing, and hardly a rousing endorsement for the policy expertise of physicians as a group.

Frist concludes:

So for the next round of reform, let’s make sure we don’t ignore the insights of real-life doctors. Let’s make sure this time around they are at the table.

Great!  Let’s just make sure the doctors we invite know what they hell they’re talking about before they show up at the table.


Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. Well, I like ICD-9 codes. they make it so we can do a study without needing to sort through large blocks of free text. Yeah, sometimes you search on ten ICD-9 codes… this isn’t a problem. Maybe it presents a problem if you aren’t using them for billing, or other computerized processes, but in that case, why aren’t the physicians reading the full text??

    It sounds like Frist’s doctor has been hired for his technological incompetence. Not that I’m saying EHR’s are god’s gift to doctors… but, seriously!

  2. I’ve reviewed my share of medical records, too. This description of their typical contents…

    Barely legible scrawled jots. Nigh unto worthless scribblings. … one or two lines of chicken scratch, it may as well be in cuneiform to me.

    …is spot on. A line in “Dx” that reads “Pt joplin 140/3 x/s HEENT y (with the “y” in a circle) Gx 6″ is not particularly helpful to anyone. I’m not a doctor, but 140/3 seems like a decidedly bizarre blood pressure, which was what I thought “joplin” was trying to mean; I know what “HEENT” stands for, but a reported value of “yes” does not make a whole lot of sense.

    But really, what I wanted to point out is — what kind of “stories” do medical records tell? Aside from diagnostics, reports of tests, diagnoses, and treatment plans, the legible medical reports that I’ve seen in my career tend to discuss issues of liability and causation of the condition being treated. Why? Because the reports are, ultimately, commissioned by lawyers, and the doctors who write them want to keep the business coming their way.

    Given that the economic pressures on most doctors is such that the doctor interacts with the patient for literally minutes at a time, it ought to be surprising to one who credulously buys into the purported value of medical records telling the patient’s story, or at least a newcomer to the game, that so much time is spent on “red-car-hit-the-blue-car” kinds of discussions without also getting into issues of “my-mom-had-heart-disease” or “I-dropped-out-of-college-because” kinds of “stories” as well.

    Now, the last time I checked, the identity of the person bearing legal responsibility for the patient’s injury is irrelevant to the physician’s craft and even the way the patient got injured is not typically all that important to it, either. Blunt force trauma to the head is blunt force trauma to the head whether it’s administered by a steering wheel or a truncheon (granted, the severity may differ based on the implement used to deliver the insult).

    Correct me if I’m wrong, but “I-dropped-out-of-college-because” discussions are irrelevant to the science of healing in all but a few exceptional kinds of cases, so that sort of thing doesn’t make it in to medical records. So too with any actual social bonding that goes on. Medical history can make it in, as the doctor considers relevant. But the only “stories” I’ve ever seen have been attempts to assist the lawyer who steered the patient to the doctor win her case. A convenient enough business arrangement, but not one that I think Dr. Frist’s doctor was really talking about.

    • I took Dr. Frist’s doctor’s musings about “story” to be the kind of self-aggrandizing rhapsodizing I associate with pompous twits, with little bearing on how any doctor I’ve known actually views the medical record. I do make a point of being “narrative” in my notes about the reasons for a patient’s visit, because I consider it a good way of conveying relevant information to potential future readers. (Also, I type fast.) But the blah blah blah about “story” being an integral part of the physician-patient relationship is so much hooey.

      • Actually, Frist’s musing struck me as exactly the sort of interaction you might have with your personal physician.

        If you were very, very, very rich and had a personal physician. I understand the Senate Health plan is fabulous, complete with an on-site doctor, so even if Frist doesn’t have the very, very pleasant and deeply personal interactions most Senators can afford (you know, if you have the money to have doctors willing to do house calls and show up and generally be exactly like the doctors in the Days of Yore) he’s got the next best thing.

        But that’s not the American experience anymore, is it?

        I think Frist is making the most common mistake of the rich and powerful — he believes everyone’s life is like his.

        He’s got a private doctor that’ll do house calls. Doesn’t everyone?

    • “I dropped out of college because” isn’t what we’re talking about.

      “I’m mentally retarded” or “I got hit in the head and might still have shrapnel somewhere” are actual stories (aka irrelevant crap) that need to be redflagged.

      Person with history of Major Depressive Episodes is enough to get a person dropped out of private health insurance most places… I’d figure the docs would like to know that too (if only to guide potential treatment of HD and other related-to-depression disorders).

      Most of what I’ve read on EHRs tends to be “This is what we just did, in response to xyz”… or “this is how well the last thing worked, why we’re trying something else.”

      It doesn’t feel lawyerly to me… (though OBVIOUSLY it can be used by the lawyers!)

  3. It seems like having a symptom more specific than “abdominal pain” might be helpful for, you know, diagnosis. I haven’t taken any classes on human anatomy but aren’t there a bunch of different things in the abdomen? In different places? I’m not a doctor, but it seems like the difference between “upper right” abdominal pain and “lower left” abdominal pain might be clinically relevant.

    • It’s certainly relevant with regard to diagnosis and treatment, that’s for sure. Location makes a huge difference in determining such things. Frist’s doctor’s point is that it’s hardly necessary for accurate and efficient billing, and I can see what he’s trying to say.

      Pinning it to the Affordable Care Act is just silly.

      • The question is “But increased documentation in charts and billing surely improves value to the patient?”. Billing, perhaps not, but isn’t that kind of detail (captured legibly, if possible) exactly what you what in the chart?

        • Absolutely you’d want that detail recorded in the chart, preferably in a manner that allows someone else who might read it to know what the hell you’ve written

          • I beg your pardon. Would you like to clarify your response such that I can see how I might have communicated an answer more suited to your expectations?

          • Oh, God, no, not your answer. Frist’s doctor’s answer.

            Q. But increased documentation in charts and billing surely improves value to the patient?

            A. Hardly [much blather about diagnostic codes]

            As I suspected (and you confirmed), the increased documentation in charts is of immense value. The intricacies of the billing process are a different subject entirely.

            I’m sorry for being unclear. I hope you know that even if I disagreed with you, I wouldn’t be that rude.

          • Thank you so much for clarifying. I was, I’ll admit, very confused, mainly because you are so assiduously good-humored I couldn’t understand what I’d said to provoke such a vociferous response.

            Yes, you’re right. Frist’s doctor is totally incoherent, there and everywhere in this totally addled piece.

          • MikeS-

            My wife works in this very field. As part of the ACA, providers need to meet certain incremental “meaningful use” benchmarks to keep their federal funding (at least this is how it works for hospitals… I’m not sure about individuals or doctors groups). There are some obvious bumps in the road as they go through adoption, but when she explains to me all the ways this improves services to patients, it’s amazing that this hasn’t been going on for decades. No offense to Russ, but doctors and nurses might be the two groups more resistant to change than teachers. Furthermore, as a patient who has worked with a handful of doctors that are at the cutting edge of adoption, I can say that the benefits are immediate and noticeable. Even things as seemingly simple as printed prescriptions can have a profund difference if they can avoid patients receiving the wrong medicine.

            The biggest jumps will be when the various vendors of the hardware and software become compatible. The goal as I understand it is such that you could get hit by a truck anywhere in the country and within minutes of receiving you, the providers will know your entire medical history. We’re not there yet, and it will take some time especially as the vendors vie for market space. But that’s the goal.

            The only downside I see are potential privacy issues. I’m sure there exist folks who’d rather they have little to no data collected on them and whatever is be saved only on paper files in a locked filing cabinet somewhere. By mandating these programs, you presumably eliminate that option. As far as I understand it, the data isn’t collected by the government, only the providers and vendors.

            My wife could explain it better, but she’s afraid she’ll catch a bad case of nerd if she ventures over here, so I’ll do the best I can. Hope this helps.

          • Even things as seemingly simple as printed prescriptions can have a profund difference if they can avoid patients receiving the wrong medicine.

            Yes, that seems clear 🙂

          • Kaz,
            We got clinical connect working here! Multiple hospitals passing around EHRs…

      • But the ICD codes are used for more than just billing, right? Even if everyone involved in direct patient care reads the whole chart (on which a more detailed description of the abdominal pain is presumably recorded), the codes are used for statistical tracking and analysis.

        • Indeed. I can understand how the additional detail might be burdensome for medical providers (myself included), but there is some utility in it.

        • ICD codes are used by epidemiologists for use in studies of disease incidence, etc.

          Of course, that also assumes that the correct ICD code has been used (which isn’t always the case) – so sometimes there’s a bit of “WTF” going on there, too.

  4. Just FYI Dr. Saunders:
    “The International version of ICD should not be confused with national Clinical Modifications of ICD that include frequently much more detail, and sometimes have separate sections for procedures. For instance, the US ICD-10 CM has some 68,000 codes. The US also has ICD-10 PCS a procedure code system not used by other countries that contains 76,000 codes.”

    • Thanks for the further detail. I figured the OP was already a little too much inside baseball, and so elided things like the procedure codes and other minutiae. But you’re obviously correct that the US codes are not exactly the same as the WHO versions.

      None of it has anything to do with ObamaCare, however, so far as I can tell with diligent searching.

      • Examples of WHO codes :

        #14263: multiple birth with no major complications
        #16547: unknown etiology
        #42361: amnesia

        i.e. The Kids are Alright, I Can’t Explain, and Who Are You

      • “…a little too much inside baseball…”

        I thought you said you don’t know anything about sports?

  5. EHR! That’s what Zazzy does! Informatics! I know things! YAY!

  6. Great post. So discouraging to see Dr. Frist and so many others obfuscating and waily wailying about ACA… Which I view as not perfect but at least a first step toward needed changes.

    Having said that, I imagine the “story” that the good doctor’s doctor is bemoaning the loss of has more to do with the individual physician’s ability to type and click menus on a computer screen and actually listen and make eye contact with a patient at the same time. Not actually an easy thing to do, and the shortening of office visit times at the same time as EMRs are being introduced may have left some providers grumping into their computer screens rather than connecting with patients. A false dichotomy…. Not the only option available, but one that I have observed among my providers on occasion. More frequently I marvel at the various adaptations folks have come up with. For example my PCP turns the computer screen so we can both see it meaning that when she takes a break to type I see what she’s entering and it almost feels like a third person in the conversation.

    • I certainly appreciate the stare-at-the-screen-and-click non-interaction interaction a healthcare provider entering information can have with patients. My office doesn’t have computers in the rooms, so we make notes on paper and then write our notes in the EHR when we’re back at our desks. It seems a good approach, if I may say so myself.

      • I can say that I, for one, appreciate the nationalized health care I receive out here in Denmark. I have a regular MD for checkups, etc. (for myself and the whole family), and I can get a referral to anything else I need, usually with a short (1-2 week) wait.

        I will admit that some wait times (for example, free fitted hearing aids) can be longer – I have a friend that’s been waiting for 6 months. Of course, she could opt to pay for a private (ie: non-state supported) doctor to have it done within 2 weeks, there IS that option. There’s that option for pretty much everything – private hospitals and private insurance exists out here, as well.

        We have a supplemental policy for us that we pay for, just for insurance. No pun intended.

        But yes, all medical information is electronic; all prescriptions are printed on a special paper (or electronically sent to your pharmacy of choice). It definitely helps to cut down on the “Is that “X” or “Y” drug? I can’t read it?”

        It’s also helpful for the elderly, who may have their regular physician who’s prescribing one set of drugs for high blood pressure or diabetes, and their heart specialist, or another specialized physician who is prescribing another drug – they can see what the patient is taking (as can the pharmacist). So there’s fewer ‘oopsie – shouldn’t have prescribed both those drugs together’ episodes.

        Bare mine 0,50 øres værdi

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