The first patients are in the rooms,” the nurse tells me. So it begins. We have no EMR access yet; it’s down and staff are trying to fix it. My first patients are Mr K and his wife. His college-age daughter, Ms D, translates. When she sees my student, Ms D’s face falls. “We are hurried. The student will be slow.”
“This will take some time,” I smile. “This is your dad’s first visit and your parents deserve some time in the clinic. If you’re in a rush, having the student will help us go faster. Our system is down, so we can go more quickly by working together.” She nods ok.
The student takes the history and I hand-write the orders and prescriptions and type a Word document of the visit; we double-team the visit with both Mr and Mrs K. I check the EMR often and desperately hope for it to start working again. Mr K hasn’t seen a health provider since leaving his country, whereas Mrs K has seen a colleague, though I only recall the trends from memory. The EMR being down means that past visits are locked up like tombs.
Both patients have complicated medical issues and we lack any specifics. I feel helpless, like I’m driving blindly along a dark, foreign road without headlights or map. I remind myself that I have skills, especially communication and investigative skills, the family physician’s bread and butter. I lean on my training, thoroughly examine the patients, and think critically through each concern.
The nurse knocks on the door, “We have Mrs K’s labs.” What sweet, blissful relief! I’m so grateful for this tiny bit of vital, faxed data from the lab company. I dance internally, glorying in the diagnosis of H. Pylori. I can treat that! It aligns with the clinical picture! Woohooo!
We educate her on how to take the medications, as the regimen is a bit challenging and adherence is vital to eradication. For Mr K, I order appropriate labs. Well, I try to; I write the words on paper, but the patient leaves without the usual appointment or lab slip. It’s infuriating to be unable to practice my craft appropriately. Did I help or hurt today? His visit is definitely negatively impacted by the dormant EMR. I schedule follow-up for both, or try to…we can’t even schedule with the system down. Two hours later, the visits complete, I feel like I’ve been through a hurricane, unsettled, off-balance. The EMR is still down; perhaps we are in the eye of the storm? I recenter myself to this abnormal normal. I square-breathe and am mindful of my intent and where I am and who I am. I trained in the county safety-net hospital in Miami, often without information, and should be able to do so today!
I debrief with the student. I reset our day, no longer expecting past documentation on anyone, though nursing is able to access labs. We plan to write paper notes, prescriptions, and referrals.
At first, writing the note feels awkward. I can’t write in my lap, where my laptop resides usually and there is no desk in the rooms as the clinic wasn’t built for writing a paper note. But in moments, something beautiful happens. Hand-writing the note feels grounding, like returning to a welcoming, loving home after a long absence. I write so much more quickly than I can type. Everything in the note has a place. I concretely see the whole visit at once on this one page as opposed to clicking and typing through the disjointed EMR to eventually assemble the text of a note virtually in my thoughts. I feel so comfortable—the computer is no longer the third party in the room, a necessary tool, but also an actual physical barrier between the patient and myself. It’s just me and my patient. I feel my day complete its U-turn. I’m actually enjoying myself. The student discovers she also likes writing by hand! And with the prescription pads that are dug up (also seemingly from a tomb), the student is able to hand-write scripts just as I did in medical school. Unexpectedly, the EMR being down means that the student has a wonderful learning opportunity. Without the EMR, I’m able to be a better educator.
Further, without the EMR, I’m efficient, practicing as I was trained, connecting with patients with ease, writing as I go. What a different professional life I’ve been living from the clinical life in which I trained and imagined. Hadn’t I attended medical school, dissected a cadaver, trained extensively in clinical skills, and apprenticed to be a doctor? Yet I enter data. I tolerate the EMR because I have to, but now I discover a forgotten freedom in writing, instead of clicking a diagnosis, then clicking a lab, then linking them, then clicking sign and then ok, I’m writing “anemia-CBC” in one smooth step! I feel connected to the patients and I love this feeling. I glory in being just a doctor, again—talking to, educating, being present with, and bearing witness to the patients I work with and for. I feel like I am rediscovering my love of medicine and just for today, I’m so grateful for the EMR going down.
Epilogue: The EMR was down for several joyous days. When the EMR awoke, I had to enter all of my labs, returning to my role of entry clerk… but I’ll never forget the day the EMR went down. It was like Dorothy in Kansas—a brief colorful respite from the doldrums of reality. I realized that I am not providing better care with the EMR, just different care via an electronic medium. When I worked with paper charts, I had all the information at my fingertips, a cogent narrative, with all in its place. My care nowadays is likely less excellent in that my cognitive mapping is unable to optimally function in the disjointed landscape of the EMR tabs. I have reaccepted the dysfunction of the EMR, but I have affirmed, too, that I love patient care uninterrupted by clicks, accompanied instead by the smooth flow of ink on paper.