I walked into the hospital for my 7-7 overnight shift through the ER, as was my practice. Always good to know what little surprises they have in store for you. My pediatric colleague, whom I was about to relieve, looked upset. She gave me the thumbnail: " Four month old had been there almost three hours, came in looking toxic. Work-up done; blood, urine, spinal fluid all in the lab, fluid bolus on board.The pharmacy would not mix and send the antibiotics, stating the ER's computerized ordering system was not communicating with theirs."

This seemed a simple enough problem to me. " Haven't you just called the pharmacy and asked for the antibiotic?"

 "Yes, but remember this week, the electronic ordering system is in full operation. Administration has told us that only electronic orders are acceptable."

 Ah, yes, our good friend the EHR. Several years before our hospital had converted to electronic notes. As a hospitalist, it wasn't that bad, except on busy nights, because I didn't have that many patients. I sat with each family, looked them in the eye, jotted down a few notes during the history, examined the patient, then entered my note into the system. And the system was decent. Of course for physicians in practice it was harder: seeing 40+ patients daily, face to face patient encounters would morph into Doctor face to computer screen encounters, with a stylus madly checking off boxes so as to not get caught behind. (Where did the patient go?)

 Then came endless meeting after endless meeting of our hospital's enforced transition to electronic doctors orders. They showed us screen snapshots of how the system looked. It looked awful. Every time I asked the question 'why', I was met with an eye roll and told to just accept this wave of the future. The IT people had to train each physician (it didn't cost us a dime for this fabulous educational activity, but our IT friends were no doubt well paid for their expert time).

We entered a months-long period of trial for the ordering system. Took us three times as long to 'write' orders, and with each set of orders came a dozen pager beeps of questions from the nurses, the pharmacy, the respiratory therapists. In the days following each set of orders came the beeps from IT telling us all the little things we did wrong. 

Worst of all.... the mistakes. Not possible, you say, computers don't make mistakes. A patient got Clonidine instead of Klonopin . A mere autocorrect, but not nearly as funny as when my personal yoga parties get turned into toga parties by Evite's system. Entire therapies weren't administered, because in my haste to run to the delivery room for resuscitation, I neglected to click on the correct drop down menu for pulmonary toilet (can we correct that ridiculous term, anyway?) I saw so many more mistakes under our new system than I have ever seen in medicine. It became a joke whenever I raised my hand at departmental meetings, because I was nearly the only one complaining and did so vociferously. We were told many nuances of our very UN-intrinsic system were beyond repair because they were part of the system the hospital purchased. (How come no one ever talks about the billions made by software companies when EHRs became a mandate? That must've been one doozy of a quid pro quo!)

Okay, so the really worst thing was the complacency of my fellow physicians. When did we become such puppets for our masters and the administrators? I understand that hospitals and doctors need administration, but we surely do not need as much as we've got. Who cared if it bankrupted the system?

But I digress.... Let's get back to what really matters: the patient. The moment I heard about a toxic four month old who had waited nearly three hours without crucial antibiotics, I snapped. I was fortified by the months of EHR snafus I had already experienced. I walked to the nearest phone and dialed the pharmacy, asking for the most senior pharmacist. "This is Dr. Mass. Is there any reason that patient x has waited so long for their meds?" .........(party line reply delivered)...." I see. Here is what you are going to do. You are going to mix up the antibiotics and have them delivered to the ER in ten minutes. If you don't I will have the supervising nurse call the hospital CEO and tell him that I am going in to the patient's room to tell the parents that their child is in danger because of hospital policy. I will not have some (un-publishable word deleted) bureaucrat dictate my patient’s care. What? ...Oh, thank you, we will await the antibiotics." Coming clean to let you know how fun and liberating that moment was, as the ER staff stared at me in shock. 

I don't wonder why more physicians don't complain; it takes time. Physicians all need Continuing Medical Education, which takes time. Now add in MOC, state mandated background checks, fights with insurance companies to get patient tests approved, hospital reappointment applications, hospital meeting requirements, blah, blah, blah.... No wonder the patients complain we don't take enough time with them. We have none! Approximately two thirds of physicians are hospital employed, and to buck the system could cost them their jobs. Jobs necessary to pay off their six figure loans, which they will do just in time to pay full price for their kids' five figure college tuition. And if you aren't hospital employed, you are bogged down working long hours keeping your indie practice alive for the sake of the patients you love.

Oh, yes, back to the patient. Isn't that why we all took the Hippocratic Oath? Being a Classics scholar, I consider it truly sacred. The patient comes before all else, even administrators and insurance company execs. But we have created an unsustainably bloated system that the patients can't understand, and the docs have no time and no power to fix. Shame on us physicians for letting it get so bad. The only scenario in which physicians will regain power is the zombie apocalypse, The 'suits' will no longer be useful when the zombies arrive, as they will be unable to deliver babies, remove appendixes, etc. 

And shame on all physicians who remain complacent and allow our current healthcare death spiral. You who sit back and don't inform your patients of what is really happening are creating a bleak future for our country. For God's sake, find your voice, unleash the power of your training, and speak up for your patients and your children, before it is too late. I know it takes time you do not have. But hit fast forward and ask your future self, amidst the rubble of health care's future if you did the right thing to remain silent. We owe thanks to the brave ones who fight. Sympathy for those physicians who are ill, post partum, fighting a lawsuit, or caring for your aging parents… I know you have little extra time.

There is a beautiful passage in Shakespeare's Henry V. Henry's speech before the battle of Agincourt…. "and we few, we band of brothers...gentlemen in England now a-bed shall.... hold their manhoods cheap while any speaks that fought with us upon St Crispin's Day". Naturally it should be updated for the women! 

Our four-month-old patient did well. Blood culture was negative, but what if the patient was frankly septic, and continued to lack antibiotics? Would you want that to be your child? Your grandchild? So the question remains: ‘When will more doctors stand up for their patients and themselves?’