Henry Wadsworth Longfellow
“There’s nothing in this world so sweet as love. And next to love the sweetest thing is hate.”
In the realm of love and hate the thing that bears out this sentiment better than all others is the “computer”. PC, MAC or any other operating system, the computer engenders strong but divergent opinions on almost every day. I am not sure how this affects other professions but for the physician this relationship becomes very apparent. Even on days when he or she is not working the computer is revered or reviled each day, although perhaps not quite as often as on a work day.
The physician has become wedded to the computer for better or worse, a sentiment we share. The patient’s medical record, his history, physical examinations, laboratory and X-ray findings are all recorded. Since the advent of Medicare and insurance physicians have tried to justify their charges by increasing the length of their records. The x-ray once pronounced as being *normal* is now described in detail and in some cases even the abnormality which may be the main reason for the examination is missed. History and physicals are given considerable verbiage and in many cases once something is in the record it is perpetuated even though it may be wrong. In the case of my wife, one physician many years ago stated she had had a hysterectomy, although this was not true it was recorded the same way on many physicals after this.
During a recent visit to a physician I noted that he spent far more time looking at my medical record than on any history or physical examination, I guess he thought that whatever someone before him had done and recorded it must be accurate.
The insurance companies have also had a problem with computer generated medical records. If you ever applied for insurance or a loan there was a small print section that authorized the company access to your medical records. Recently the length of the medical records has made it difficult for the person reviewing the record to understand all of it. A mistaken diagnosis can be perpetuated forever.
The computer records make the interchange of information simple and extremely valuable but not without some problems.
In view of all of the above drivel, I think it is still a good idea to talk to your patient, examine him and add your findings to that invaluable medical computer record.
After all is said and done there is still another computer problem that adds to our frustration and that is the “password*, which can make all things difficult..