John M. Talmadge, M.D.

A Blog Covering Many Topics

New Video: Why Doctors Hate Electronic Medical Records

Suddenly it's not just the old-timers like me who are speaking out against the negative impact of the "electronic medical record," which is now required by law in hospitals and clinics. Since I am independent, I take my notes on paper in my office. However, I have worked for many years in hospitals, where notes must be entered electronically. This song speaks for me and for many other physicians. I do not use electronic records in my office — for all the reasons described in the video which I have just posted at the bottom of my media page. Extensive discussion of the topic and the video can be found at zdoggmd.

I'm not a fan of hip-hop or rap music, but I love this video. If you're not a health professional you may not understand the jargon, but the lyrics are just simply 100% reflective of the way doctors feel. Here are the lyrics, if you don't have three minutes to view the video and hear the song:

Yeah I’m out that paper, no more chasing med records
Writing so illegible, that I’ll be HIPAA foreva
Bought the new software, and though we use it here
I can’t use it over there, different systems everywhere
I used to chart on paper, all of my verbals recorded
Mix up with the ward clerk, turned “diluted” to “dilaudid”
Switched me to that EMR, meaningless abuse, G
Now catch me at the nurses station mashin’ that F2 key
Notes used to be our story, narrative, but yo
Replaced with copy paste, now a bloated ransom note
Me, I’m at that bedside, focused like a laser beam
On the patient, naw come on, I’m treatin’ the computer screen
8 dozen warnings, click check boxes
Alarm fatigue, vaseline conflicts with doxy??
Nurses they be burned out, we could use some OT
Tell by our wrist guards that we most definitely on
EHR, crappy software some vendor made us,
there’s nothing you can do, stuck with EHR,
best practice pop ups will tire you,
complain and they’ll fire you,
we need a new chart new chart new chart
(you’re welcome, they built you a turd doc!)
Catch me on the phone with IT beggin’ tech support
Shoot, it’s like IT and me be stuck in 1994
Innovation all around, but it ain’t in healthcare
Internet and apps for you, but we get ancient software
Welcome to that EHR, Go Live and it don’t stop
Uncle Sam promoted it, but gone is the interop
CMS, EMS, PMS, holla back
For doctors it ain’t fair, these vendors act like they all kinda wack
8 million stories, out there docs can’t take it,
after this disaster half of y’all won’t make it
How to train your Dragon: “hotmail” isn’t “Hot Male”
If some be saying it’s epic we sayin’ it’s epic fail
Electronic silo, team not talking
Paperless they say, but whole trees we droppin’
Props to case management
Long live the RT
Long live the pharmacist, whole team definitely hates
EHR, just a glorified billing platform,
with some patient stuff tacked on,
give us a new chart, ICD-10’s a disaster,
meet your new robot master,
we need a new chart, new chart, new chart
(this chart wack, welcome to the apocalypse doc)
Tech should bind us, connect, not blind us,
to the reason why we care,
Patient’s face reminds us
Designs like Epocrates, that tap the app agilely
Then magically the team works, let’s bite the Apple, Steve
Caught up in the in-box, now you’re in-sane
Good docs gone mad, the clinic’s filled with them
Nursing, they the heart of everything
Data entry got ‘em hurtin’, life starts when the shift ends
10 years of school, graduated to the OR
Mommy busts a Whipple she deserves a better damn chart
Autocorrect turning Chantix into Champion
Patient needs a sleeper, 30 clicks for a Ambien
EHR, crappy software some vendor made us,
there’s something you CAN do,
give us a new chart,
stand up and make our voices heard,
let doctors be doctors,
we need a new chart new chart new chart
(Stand up, the whole team)

Never Underestimate the Power of a Single Intervention

For many years I have said to my medical students: "Never underestimate the power of a single intervention." Turns out this is true.

A few minutes of counseling in a primary care setting could go a long way toward steering people away from risky drug use -- and possibly full-fledged addiction, a UCLA-led study suggests. (Primary care refers to family physicians and other non-psychiatrists who provide most of our medical care.)

People who participated in the Quit Using Drugs Intervention Trial, or Project QUIT, which was a randomized controlled trial conducted in medical clinics, reduced their risky drug use by one-third when primary care doctors and health coaches provided them with brief interventions during a routine visit and follow-up phone calls.

Risky drug use is defined as the casual, frequent or binge use of illicit drugs such as cocaine, heroin and methamphetamine, or the misuse of prescription medications, without showing physiological or psychological signs of addiction. There are an estimated 68 million such drug users in the United States. These people are at risk not only for becoming addicts, but suffering attendant physical, mental health and social problems.

The study, published today in the peer-reviewed journal Addiction, is the first to demonstrate that a brief intervention led by a primary care physician can significantly reduce risky drug use among patients.

We Don't Plan to Become Addicts or Alcoholics

Most of the patients I (Dr. Talmadge) see in practice did not plan to become addicted to drugs. Casual use introduces powerful chemicals in the brain, and many of us then have our brains hijacked by these chemicals. As described in the HBO special on addictions, the human brain is an extraordinarily complex and fine-tuned communications network containing billions of specialized cells (neurons) that give origin to our thoughts, emotions, perceptions and drives. Often, a drug is taken the first time by choice to feel pleasure or to relieve depression or stress. But this notion of choice is short-lived. Why? Because repeated drug use disrupts well-balanced systems in the human brain in ways that persist, eventually replacing a person's normal needs and desires with a one-track mission to seek and use drugs. At this point, normal desires and motives will have a hard time competing with the desire to take a drug.

How Does the Brain Become Addicted?

As described in the HBO documentary, typically it happens like this:

-A person takes a drug of abuse, be it marijuana or cocaine or even alcohol, activating the same brain circuits as do behaviors linked to survival, such as eating, bonding and sex. The drug causes a surge in levels of a brain chemical called dopamine, which results in feelings of pleasure. The brain remembers this pleasure and wants it repeated.

-Just as food is linked to survival in day-to-day living, drugs begin to take on the same significance for the addict. The need to obtain and take drugs becomes more important than any other need, including truly vital behaviors like eating. The addict no longer seeks the drug for pleasure, but for relieving distress.

-Eventually, the drive to seek and use the drug is all that matters, despite devastating consequences.

-Finally, control and choice and everything that once held value in a person's life, such as family, job and community, are lost to the disease of addiction.

What brain changes are responsible for such a dramatic shift?

Research on addiction is helping us find out just how drugs change the way the brain works. These changes include the following:

Reduced dopamine activity. We depend on our brain's ability to release dopamine in order to experience pleasure and to motivate our responses to the natural rewards of everyday life, such as the sight or smell of food. Drugs produce very large and rapid dopamine surges and the brain responds by reducing normal dopamine activity. Eventually, the disrupted dopamine system renders the addict incapable of feeling any pleasure even from the drugs they seek to feed their addiction.

Altered brain regions that control decisionmaking and judgment. Drugs of abuse affect the regions of the brain that help us control our desires and emotions. The resulting lack of control leads addicted people to compulsively pursue drugs, even when the drugs have lost their power to reward.

Image of brain activity dopamine

The disease of addiction can develop in people despite their best intentions or strength of character. Drug addiction is insidious because it affects the very brain areas that people need to "think straight," apply good judgment and make good decisions for their lives. No one wants to grow up to be a drug addict, after all.

The addiction study cited above has some limitations. The results are based on participants' self-reporting, so the study may suffer from reporting bias. However, researchers found that based on urine testing, under-reporting of drug use was low. Additional limitations: not everyone in the clinic waiting rooms agreed to participate, which could impact the study's generalizability; there was some attrition during the study, though the 75 percent participation rate at follow-up compares to other studies of low income patients and drug use; and the three month follow up was relatively short.

There is a need for larger trials to gauge the QUIT program's effectiveness, but based on these findings the project appears to have the potential to fill an important gap in care for patients who use drugs, particularly in low-income communities, Gelberg said.

Read the entire report and article by clicking here.

Adderall Time in Texas

We are six weeks into the academic year, and the requests for Adderall ("mixed amphetamine salts") are on the rise. As someone with considerable expertise and experience with ADD/ADHD, I know that stimulants can be very helpful for people who actually have attention deficit disorder. I worry, though, that a high percentage of people taking Adderall or other stimulants are simply looking for a "smart drug" or an energy boost. I also worry about diversion of these drugs, because medications in this class have considerable street value.
Here at the office, where I answer my own phone (and do my best to return all calls myself) I receive 4-5 calls weekly from individuals looking for a doctor who will prescribe Adderall or its long-acting cousin, Vyvanse (Lisdexamfetamine). Curious as it seems, many callers say that they are new to Dallas and need a new doctor to prescribe the medication. I say this is curious for two reasons. First, let's say that a doctor outside of Texas has a patient who is moving to Texas. One thing that prescribing doctor should do is help his or her patient to refer the individual to a reliable doctor in the new city; and apparently, many doctors from other states don't do this. Second, people taking stimulants don't usually have serious withdrawal problems, but coming off stimulants like Adderall can pose problems, because the person's brain has to adjust rapidly to the absence of the drug. The person who depends on Adderall will probably feel lethargic and "flat" when they don't have the medication on board. Students often panic, fearing they won't be able to study or put in the long hours required for academic performance.

As with other potentially risky medications (like Xanax, hydrocodone, oxycodone, etc.), the prescribing physician assumes certain risks and responsibilities in writing the prescription. I worry about this. Many patients tell me that they have only seen the doctor 3-4 times a year, and some say that they don't even see a doctor, because a mid-level practitioner (usually a nurse practitioner) writes the prescriptions under the "supervision" of a medical doctor. The typical "med check" or brief visit to renew a prescription lasts less than 20 minutes. This is not necessarily bad or wrong, but we certainly have to wonder whether the responsible doctor really knows very much about the patient. The Texas Medical Association has noted that authorities are cracking down on "pill mill" physicians in pain management clinics, and it's very likely that doctors prescribing other Schedule II ("dangerous") drugs will face similar scrutiny.
My expert opinion is that medications are very helpful in the treatment of attention deficit disorder. My further opinion is that many people, particularly students and younger adults, are using these medications inappropriately. This is one reason that I answer my own phone. I hate it when someone shows up expecting me to write controlled substances without any discussion. Yes, these are good medications that really help many people. And no, I won't write a Schedule II medication unless there's compelling clinical evidence that justifies the prescription.

Update 10/17/15: I have been reading commentaries by Larry Diller, M.D., a developmental pediatrician who has written extensively about stimulants. He has strong and generally well-informed opinions about the use and misuse of medications like Adderall, Vyvanse, Ritalin, and Concerta. His website and his opinions can be found here.