June 19, 2021

Happy Juneteenth. (A holiday long deserved and which better not be taken over by white culture with mattress sales or beer busts). Mine is starting at 4:30 AM as it’s my call weekend and a resident at the nursing home that I cover as part of my call duties decided this was the right time to act up in such a way that the nurses needed to wake me up. Call is a necessary part of the job and my duties aren’t especially onerous (about three weeknights a month and a weekend every other) but I learned long ago that my brain/sleep physiology is such that if I’m woken up in the middle of the night, I rarely am able to get myself back to sleep again and I’ll be faced with a number of hours of wakeful tiredness before I have to get up and face whatever the next day has to bring.

This is my first call night without a beeper. UAB has finally fully joined the digital/cell phone age and replaced beepers with an app on our smartphones that serves a similar function. Having had a beeper on my belt for professional purposes for something over thirty years, it feels a bit odd to be without one. I was a bit worried that the phone wouldn’t wake me up (I’m well conditioned to that obnoxious beep but can sleep through nearly anything else – internship in the pre-limitations on residency work hours will do that to you) but the ring tone they’ve chosen is piercing enough to work just fine. So here I am, in the pre-dawn hours, listening to the birds outside my bedroom window greeting the imminent arrival of the miracle of another day and batting away Anastasia who is trying to help me type.

The persistence of the beeper is only part of the health care system’s continued reliance on 80s/90s technology in a world where other industries have fully embraced the digital era. For instance, we are the only industry that still runs on the fax machine as an essential mode of communication. (I still have a landline not because I use it or because anyone ever actually calls me on it but because it’s necessary at times for me to fax documents larger than the fax app on my smartphone can handle). Some of this is due to the medico-legal system. Most of the laws that govern the handling of medical information were written forty or fifty years ago and haven’t been updated to take modern technology into account. Things change piecemeal bit by bit. The electronic transfer of prescriptions for controlled substances, which used to only be valid via hardcopy with an original signature, became a reality a couple of years ago making everyone’s lives easier. The home care and hospice industries, however, still run on fax and I get about 150 pages a week, each of which needs to be signed and dated and sorted into the appropriate piles to fax back. Everything in the medical system requires the signature of a licensed physician somewhere on some piece of paper in order for things to move forward. (Electronic signatures now work within certain parts of electronic health records). If we were all to break our wrists on the same weekend, the entire US healthcare system would grind to a halt.

Some of the lack of progress comes from the inherent conservatism of the profession and its practitioners. You don’t really learn to be a physician in medical school. You learn a lot of random facts and you learn how to train your mind to sort through those facts and parse them properly to understand what’s going on. All the things you really need to know are actually learned on the job by observing your colleagues and peers and modeling what they do. This makes the profession very dependent on ‘we do it that way because we’ve always done it that way’ thinking and highly resistant to change that does not naturally enter the work flow through physician practice. If you ever want to see physicians, especially clinicians, get their collective backs up, try imposing mandates on what they do from outside – especially when they come from areas where they are designed by individuals who are not themselves practicing clinicians.

Then there’s the silos and fractures in the system regarding information. Every other country with an advanced health system has a single way of collecting data and recording patient information no matter where in the system you may go. This allows charts to be shared electronically between any physician or nurse, any hospital, or any ancillary service and everyone is working off a single data stream. (We have that in this country in just one place – the VA system. It’s possible to pull up the same records in any VA hospital or clinic from Fairbanks to Miami). Everywhere else in the US works off jealously guarded proprietary information systems which do not interface with each other. I can see everything that happens in the UAB system in a patient’s electronic chart but if they see a provider or obtain a service outside of UAB, even if it’s across the street, forget it. (Unless somebody sends a fax.) Patients and their families really don’t understand this issue and think that records miraculously move from place to place. A huge amount of my time is spent trying to reconstruct what happened in another emergency room or repeating a test I really didn’t have to repeat because I had no way of accessing the results. Even in the same institution, the data systems often don’t interface properly so that the billing system and the clinical system, for instance, don’t talk to each other which requires everything to be entered twice. This is why you’re constantly filling out forms at the doctor asking for the same information over and over and over again.

We could have a single data system for health care in this country. It’s been proposed countless times. It tends to be shot down for the same reasons that the rest of our infrastructure is falling apart. The only entity that’s big enough to marshal the resources to make it work and bring it to every health care provider would be the federal government meaning a large outlay of tax dollars and some sort of federal agency to run it. For forty years now, the more conservative of our political parties has run on a platform that government is the problem, not the solution and wanted all such issues handled through private enterprise. The result is many small private solutions, developed piecemeal to the detriment of the system and the health of the great American public. It’s not a problem I have a solution to as long as that philosophy remains entrenched.

Back to the beeper. They have changed some over the years. When I started in medicine, they were analog short wave radio receivers. In the hospital, you called a number and spoke into the phone and your voice would emerge from the belt line of one of your colleagues. Given the age of medical residents and the punchiness of constant sleep deprivation, this usually led to a lot of practical jokes which we would find hilarious. One female resident of my acquaintance announced that her beeper must be like a penis. It hung at the front of her pants and would call attention to itself at inopportune moments in an obnoxious manner. No one disagreed. By the early 90s, beepers went fully digital and voices were replaced with short bursts of text. The arrival of the world wide web meant that you could access them from any digital device on your own. Before that, outside of the hospital, you had to call the hospital operator and ask them to access the system for you. The hospital operators knew everything about everyone and you never wanted to get on their bad side for fear they might spill the tea. The ones at UC Davis during my residency years were all very sweet and were good at keeping our private lives private – most of the time…

Digital communication has been a wild ride over my career – from landlines and pay phones to car phones to cell phones to smart phones. You have to wonder what’s next. Implantable devices allowing us to communicate with anyone anywhere without having to actually have an object external to our bodies? Wave your arm over the grocery check out to pay for your items? Download any piece of information directly into your brain? Who knows.

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