Cowboy Medicine

My grandfather was a cowboy, a salt-of-the-earth man of action, who told heart-warming stories of the old west. One of his favorites involved him getting kicked in the face by a horse and then upsetting my grandmother by blowing cigarette smoke out of the hole in his cheek. He competed in rodeos on bucking broncos, drove cattle across Colorado, and rode the rails as a hobo during the depression. He was a tough old cowpoke, and I thought nothing could stop him.

His cancer proved me wrong.

Learning the Ropes

Charlie Lozar didn’t go softly into that good night, but he did go, and I think part of the reason I became a doctor was to pay homage to him. This was a man who brought newspaper clippings and a story to every office visit, someone who wanted eye contact and honest answers, and who paid for the time it took to listen with the only currency a cowboy values – stories.

So, I shudder inwardly as an “expert” loads yet another program onto my computer, knowing that the extra clicks I’ll be forced to make are stealing seconds of time away from my patients. Individually these moments are meaningless, but cumulatively they consume the time physicians have to listen to non-clinical information. Worse, the problem is growing with doctors spending 40% of their day with computers and 12% with their patients as documented in The Journal of General Internal Medicine. https://www.ncbi.nlm.nih.gov/pubmed/23595927

“Promise me, you’ll always make enough time for your patients,” said my Grandmother, a stout strong-willed woman who made hasenpfeffer with jackrabbits. The practice of medicine is about people, about hands-on-experience, and about service to the community. It is built on a vow to “do no harm” and ends with a commitment to ameliorate suffering. It is not the practice of turning your back on a patient as you log in their data. It is not about making sure every box is checked off so some analyst’s pie chart is statistically significant. It is not about telling a patient they can’t be seen because the computers are off-line. We are aping Joe Friday on Dragnet, “Just the facts, Ma’am. Just the facts,” and our patients don’t like it as published in JAMA. http://archinte.jamanetwork.com/article.aspx?articleid=2473628

To make money as a cowpoke, my Grandfather and his friends trapped skunks for their fur. They kept them alive in a shed until they had enough “critters” to make it worth skinning them. Each night, after sharing stories over the campfire, they drew straws to see who would go feed and water their little zoo. Each man had been sprayed once or twice and had learned how to use a burlap sack as a shield. Over time, the skunks started to get used to the men so that they were almost domesticated. Until one day when a greenhorn the boss hired only a week earlier drew the short straw. Not recognizing the new hand, fifty skunks let loose at once. The smell was so bad my Grandfather freed all the skunks and burned the shed. The moral of this bedtime story: just because something seems to be working doesn’t mean it’s a good idea.

Technology does save lives. It has improved the human condition. It just doesn’t save time. Each click is like a small grain of sand, an insignificant unit of measurement by itself, and yet people die in the desert all the time. In The American Journal of Emergency Medicine, physicians spent 44% of their time logging data instead of doing direct patient care – that’s almost half their day. No wonder the lines are so long. http://www.sciencedirect.com/science/article/pii/S0735675713004051

A glut of drop-down menus, templates, check boxes, and protocols has made us think practicing medicine is as easy as domesticating skunks. We’ve started to think that every disease and person fits into a box, that the tap-tap of a keyboard is more important than the lub-dub of a heartbeat, and that we can use Facetime rather than face-to-face time to treat our patients when they live four blocks away. Maybe I’m just an old-fashion sawbone, but this kind of medicine stinks as bad as that shed.

Technology is to physicians as fire was to the first people: an excellent tool as long as it’s controlled. So, if you’re a medical administrator, please reconsider collecting data that won’t add real value to the office visit. If you’re the government, realize much of what a doctor does is not quantifiable so stop making us count the number of brush strokes it takes to make a painting. If you’re a patient, please understand that we are drowning in granules of sand and some of us don’t even know it. If you’re a physician in the trenches, remember to listen and try not to turn on the computer until you patient is done telling you their story.

Because a good story is the strongest medicine I know.

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