Bedside Rounds

In this episode, Bedside Rounds will dive into 20th century medical documentation, and how it serves as the most visible lens of the thought processes of the physician. In particular, Dr. Adam Rodman will discuss one of the most influential medical thinkers of the second half of the 20th century, Dr. Larry Weed, his invention of the problem-oriented medical record and the SOAP note, and how his insight – that medical documentation fundamentally influences how we think about our patients – changed the way we think about our patients.

This unique episode of Bedside Rounds includes a live recording of a grand rounds that Dr. Rodman gave at the San Francisco VA and it explores the philosophical and epistemological assumptions that physicians make with a hope of improving medical care. Join Dr. Rodman and guests as they discuss, Problems.

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Bedside Rounds

Bedside Rounds is a medical podcast by Adam Rodman, MD, about fascinating stories in clinical medicine rooted in history. ACP has teamed up with Adam to offer continuing medical education related to his podcasts, available exclusively to ACP members by completing the CME/MOC quiz.

This is Adam Rodman, and you are listening to Bedside Rounds, a bimonthly podcast on the weird, wonderful, and intensely human stories that have shaped modern medicine, brought to you in partnership with the American College of Physicians. This episode is called Problems, and it’s a live recording of a grand rounds I gave at the San Francisco VA last year. If you’ve been to see a doctor lately, you know that we spent a LOT of time with the computer. There’s a decent chance your doctor looked more at their computer screen than you during your last visit. How did this happen? Is there something inherently dehumanizing about technology – the electronic medical record in particular – for both patient and physician? Or are there deeper epistemological questions about the cognitive work of physicians?

In this episode, we’re going to explore 20th century medical documentation, and how it serves as the most visible lens of the thought processes of the physician. In particular, I’m going to discuss one of the most influential medical thinkers of the second half of the 20th century, Larry Weed, his invention of the problem-oriented medical record and the SOAP note, and how his insight – that medical documentation fundamentally influences how we think about our patients – changed the way we think about our patients.

Jack Penner (00:02):

All right. Good afternoon everybody, and welcome to another installment of our joint, San Francisco VA Zuckerberg, San Francisco General Grand Rounds. For those of you who I haven't had a chance to meet yet, my name is Jack Penner. I use he, him pronouns. I'm one of the inpatient chief residents here at the San Francisco VA, and I am very excited to turn it over this afternoon to Dr. Gup Dal to introduce today's grand round speaker. Gupreet, take it away.

Gurpreet Dhaliwal (00:25):

Thanks, Jack. Thanks everyone. Uh, my name's Gupreet Dal. I'm a general internist here at the VA Hospital. It is a tremendous honor to introduce our grand round speaker today, Dr. Adam Rodman. So, Dr. Rodman is a general internist and hospitalist at Beth Israel Deaconess Medical Center, his resume will tell you that he's had a path that's taken him from New Orleans to Portland to Botswana, to Boston, where he is now an instructor of medicine at Harvard Medical School. And I think he is known there locally for holding many medical education roles. I think the most exciting of which he holds are in the digital education space where he is leading multiple initiatives that are trying to transform the way we do medical education using video and podcasts and Twitter, to rethink how we teach in our problem spaces or our education spaces.

Gurpreet Dhaliwal (01:13):

But even though he has that very future orientation, I think what he's best known for is looking at the past. Dr. Rodman is really highly regarded and is a celebrity in the medical space for his podcast called Bedside Rounds, which he started as a resident, has at least 70 plus episodes at last count, and each one of them has probably 30,000 or so listeners per month. It is featured prominently on my, uh, podcast stream. And I think the really interesting thing about the Bedside Rounds podcast is that it looks at everything we do in medicine, and it asks why. He looks at history, philosophy, sociology, and says, how did we get where we are? Um, Dr. Rodman is widely invited at conferences and institutions to speak on these topics. And today he's gonna travel virtually to San Francisco and answer one of the greatest questions in all of internal medicine, which is why do we spend so much time on our long notes <laugh>? So with that, I'll turn it over to Dr. Rodman. Thank you for being here.

Adam Rodman (02:08):

Oh, that was way too gracious, an introduction. I just want everybody to know here that when I was a medical student, uh, Dr. Dal was one of my greatest heroes. So the fact that he is introducing me in grand rounds right now is I can't, I can't believe this is happening. So thank you so much. K. Um, just to say something before I start I want the context for where this Grand Rounds came out of, because I didn't just sit down and say, ask the question. Well, <laugh>, why do we write notes the way we do? I, I've been working on a project and, uh, Dr. Dal knows, is it something I'm, I'm obsessed with, which is this idea of diagnosis, and not just what does it mean to make a diagnosis an individual patient, but what, like, what does the idea of making a diagnosis mean?

Adam Rodman (02:48):

How has that changed over time? And how does that affect the intellectual work that we do on the wards every single day? And this is a project I've been working on for my goodness, like a year and a half and out of this project. And it turns out there's this really interesting story that I'm gonna tell you guys today, uh, that came about in the, let's say, these intellectual ideas in the 1950s through the 1970s that really kind of fundamentally changed the way that we doc. Not only we document that we think about our patients, and I think it's a, it is a, it's recent enough that there are probably people in this room who know some of the people involved we've been talking about, uh, Larry Weed and Alvin Feinstein in particular. Um, but it's distant enough that their impacts have been so impactful that we don't really think about things another way. Uh, so with that, I'm gonna, that that was my, um, that was my promoting my talk that I'm about to give you, which is totally unnecessary, but I am going to start my presentation. Okay.

Adam Rodman (03:48):

All right. So my talk is called Problems, A philosophical and historical exploration of why we spend so much time on Notes, dot, dot, dot, and whether any of it even matters. So I actually want to start with a quote from Bernard Shaw from 1918. I'm not gonna read the entire thing, uh, but the gist of it, he's talking about the intellectual work of doctors in the clinics and hospitals of the near future. We may quite reasonably expect that the doctors will delegate all the preliminary work of diagnosis to machine operators as they now leave the taking of a temperature nurse and with much more confidence in the accuracy of the report, then they could place in the guesses of a member of the Royal College of Physicians. The observation of the symptoms is extremely fallible, depending not only on the personal condition of the doctor who has possibly been dragged to the case by his night bell after an exhausting day.

Adam Rodman (04:34):

I love that that was still a thing in 1918. But upon the replies of the patient to questions which are not always properly understood, and for lack of the necessary verbal skill could not be properly answered if they were understood from such sources of error, machinery is free. And that's 1918 again. So with that, I want to imagine that an alien comes to our medical ward, that San Francisco General here at the bi, at the va, and they look at what we actually do, what we residents, uh, attendings, what we actually spend our time on, the warts. What is it that we're doing with our days? What does it appear to value? And when you look at it from an outside perspective, I think you get a very different look than what we say that we value. So I think everyone has seen this study.

Adam Rodman (05:20):

It's from Lena Mao's group. Um, she's in New York. This was, I believe, at Columbia in 2010. And this is, this is at this point, 12 years ago, looking at how residents actually spend their time. And again, everybody knows this. Residents spend over half their day sitting on a computer reading or writing notes. Uh, in comparison, they spend less than 10% of their time with the patient. And I believe they spend more time walking around or waiting for the elevator than they actually spend with their patients. Um, this has been very well described. Uh, Abraham Verges wrote this again in 2008. At this point, this article is 14 years old, talking about how we interact primarily with the patient from, from a computer's crew with a, if anybody's into post-structuralist philosophy, you can think of this as a lar and simul Lara, right? The patient is a simul Lara for the real thing we care about in the computer, which he called the eye patient.

Adam Rodman (06:12):

Eye patients are handily discussed in the bunker, while the real patients keep the beds warm and ensure that the folders bearing their names stay alive on the computer. Uh, so this alien anthropologist might determine, well, these strange, uh, relatively hairless primates, they spend a lot of time on the computer. So it must be really important. This is actually a study from, again, from Lena Makinos group, uh, earlier study that looked at a time tracking of how we spent our time documenting. And you would imagine that if documentation were so important, we would try to do it in an uninterrupted fashion. And you can just look at all the different colors in here, like no one, and you can just ask anybody who writes notes. Nobody is able to sit down and write a note. We are interrupted from 15 different domains at a single time.

Adam Rodman (06:58):

You know, another thing that you might say is, especially if you look at these informaticians we're gonna talk about soon, maybe what we're doing on the computer is really valuable. Maybe we are reading studies, maybe we are looking at decision to support tools that are trying to help us take better care of our patients. Um, maybe we're communicating with primary care doctors. But when you actually, again, look at what we spend most of the time on the computer, it is either writing notes or reading notes that other people have spent their time reading. And one of the, uh, fascinating things, this is from David Bates group, uh, at the Brigham here in Boston, is that this really does appear to be mostly an American phenomenon. Uh, this is looking at the length. These are, these are clinic progress notes, and this is from epi Epic implementations around the world.

Adam Rodman (07:44):

Um, and these are in countries that have health systems similar, similarly complex to RJ Canada, UK, Australia, Netherlands, Denmark, UA, and Singapore. And you can see like, um, American notes are four, five times longer than notes in other countries. Uh, so this brings to a question that I want to, you know, have you guys think about why do we write notes anyway? Uh, we're not in a small group, so I won't actually ask you, and I'll just kind of go through the list. Reason number one, one of the oldest reasons that we write notes is to make a record for yourself, for, you know, for what's happened. Also to communicate with other providers, whether that's other medical doctors, whether that's nurses, whether that's, uh, therapists. There is, uh, America is a very litigious country. I don't need to tell this to anybody. And there is a certain degree of in documentation of risk management, what's sometimes called defensive medicine.

Adam Rodman (08:35):

Uh, there's also value-based care. There are things that c m s that medical payers expect us to do for value. We document those things in our notes. I think everybody's aware of billing. Um, there are <laugh>. The messy reality of American healthcare is that billing makes up a large, not a large part, but it makes up a large part of some of the, the verbiage that we use in our notes. Increasingly, 21st Century cares acts, and even before that, open notes, it's to communicate with patients, right? Our notes are now not only documents for communicating with other physicians or other providers, but with patients at a, at a whole. And then what I'm most interested in, one of the reasons that I spend time documenting, right? If I spend a long time writing a note, because I'm using the note as a document to organize our thought, my own thoughts, right?

Adam Rodman (09:18):

To think about the patient, to put my thoughts on paper, to build a mental model of how I'm going to take care of this complex patient. And I'm a I, I'm a hospitalist. I also work in clinic. So I, I do this in both scenarios to try to organize my thoughts about how I want to care for this patient. And this is going to be a major theme that I'm going to come back to time and time again. Um, really the point of this talk, because how we document is how we think, right? It is how we organize our thoughts to think about our patients. So, uh, I have to give some context on note writing first. So we're gonna go back and talk about, I don't know, 5,000 years of note writing, really focusing on the late 19th and early 20th centuries. Uh, doctors have been writing notes, basically since writing existed. This actually is the Edwin Smith papyrus. This is the oldest medical documentation that exists. It is written for didactic purposes. Uh, this is effectively a surgical treatise. Uh, it starts at the head and it goes down to the feet. We only have half of it. So it starts at the head and goes down to the roughly waist. And it's effectively cases, right? It talks about a number of different cases, uh, what sort of disease this is, what sort of management there is from all of this.

Adam Rodman (10:32):

Um, and, uh, the Edwin Smith Pyrus is very famous for having the first description of cancer that's ever in the literature. Um, uh, I'll give you a better example of how documentation served a largely didactic purpose. This is from epidemics two on the epidemics. Hopefully some of you have read it. It is a fascinating book. So, Hippocrates, uh, is a historical person. He did exist, uh, most of the writings that are attributed to him, he did not write, he did not write epidemics to her on the epidemics, too. Uh, this is effectively the case notebook of a traveling doctor who was sailing around the A G N C. And I'll actually read this case, so you can get an idea of why people were documenting, why this traveling position was documenting. So this is a woman who had Quincy, um, uh, effectively bacterial epiglottitis who lodged in the house of Ayon.

Adam Rodman (11:25):

Um, her complaint began in the tongue. She couldn't talk. Her tongue was red and parched. She felt chilly and became heated. Then she had a rigor and acute fever. There was reddish and hard swelling on both sides of the neck and chest. And finally, her extremities were cold and livid. Uh, she, um, effectively she couldn't swallow anymore. Finally, her both her stool and urine dropped off. Then on the fifth day she died of Quincy. So this is an example of what an ancient note would look like. This is from roughly 500 BCE e. And the purpose of the physician writing all of this down is to teach other doctors, right? It's to communicate with other doctors about this type of patient. Um, and effectively the lesson that this person is trying to give is that if you see somebody with such bad Quincy, and they have these prognostic factors, especially from becoming cool and dropping off of their discharges, that's a really bad sign.

Adam Rodman (12:17):

Uh, to give you a more modern example. So, and, and this you, if you don't know a lot about, um, ancient medicine, this is a humoral explanation for disease. This person is really interested in the fact that their discharges are gone. It's a sign of imbalanced humors. Uh, this is another example. This is from the 18th century, from Mors to Cebu on the seats of disease. So one of the most famous medical books of all time. Um, and this is from a period where medicine is starting to realize that disease is in, um, lives in certain organs, right? There is not these mysterious humors, but disease is actually in a place in the human body. And Morney was actually practicing physician. He was an anatomist, but he, he collected, he, he took care of patients, and he collected all of these cases from his patients.

Adam Rodman (13:01):

And this is a patient who's 50 years old, who had suffered great fatigues and journeying. And effectively he comes to Mor with HESIs, uh, and ends up having a, he's got dropsy and ends up having a lot of fluid in his lungs. And he dies, uh, a great quantity of blood burst, both from forth, from his lungs. And he was suff suffocated. And what's very interesting is, again, Morgani actually took care of this patient. But if you read Debu, and this is drastically shortened, the, what we would call a history of present illness lasts like three sentences. And then he lasts, uh, takes five pages describing the autopsy. So again, you get a sense Morgani, he's doing this for a communicative or didactic purpose. But what he's really interested in is thinking about this patient and in particular, thinking about how pathologic changes during death related to the guy's symptoms during life.

Adam Rodman (13:50):

Uh, we'll go into the 19th century. So New York Hospital, I'm gonna actually reference New York Hospital a number of times here because New York Hospital has digitized all of their notes from the early 19th century, uh, up until like the 1920s. And then new, well, we'll, we'll go into it in a little bit. And this is from the 1850s of a patient come, or 1840s coming in with Rheumatism. Uh, you can see they're still using Latinate names. And if you read this note, this is the only documentation that existed for this person's hospital day. It is what four lines. It effectively says they came in the date, they were admitted with rheumatism. It talks about the treatments they got. They got some bags, they got some herbal medications, and they were discharged. Much improved. And you can see the date they came in, the date they, they discharged.

Adam Rodman (14:33):

This is effectively a discharge summary. Uh, this note serves a different purpose, right? This is not necessarily didactic in major, but this is, um, what would you, what would I say? What's the word for this? This is like keeping a record. They, they, this note was created to keep a record of what happened to this patient to communicate if they ever come back. Uh, this is now New York Hospital in the very early 20th century. I think the date here says 1900. And this is a young man only, what is he, 26 years old, who's admitted with Bronco pneumonia. Um, and I believe the length of stay says he is admitted in January and March. So he's, he's in the hospital for two months, which, you know, sometimes you hear like, oh, the, you know, the hospital is different. People stay much less time than they did.

Adam Rodman (15:16):

Well, the pneumonia and a healthy 24 year old stayed in the hospital for almost three months in the year 1900. But if you start to look at this, you can actually read something that is remarkably similar to this is the admission note to a modern h and p. You have the persons at the top, you have their history, present illness, you have a physical exam. And there's a plan at the end. What's very interesting is when you start to look at the progress notes, cuz the same patient, a New York hospital has digitized their progress notes. And these are the progress notes for the patient. So you can see there was a chart with, uh, standardized, printed out, um, information here where both the nurse and the doctor would document. And you can see they document the number of stools, the number of urine, and effectively the progress note says what it says, they slept well, right?

Adam Rodman (15:59):

There's very little information here. You can see when the medication is given, uh, cuz the nurses are documenting the m a r right beside when the doctor is talking about how the patient did. So that is the early 20th century. I think we need to talk a little bit about what happened in hospitals in the beginning of the 20th century. Um, the hospital of 1900 wasn't that different than the hospital of let's say, 1800. However, by the time you get into the 1930s and 1940s, hospitals start to look very similar to the hospital of the 21st century. And why is that? Well, you have the integration of new types of imaging modalities, right? The rent genogram was invented in 1896, and by the 1920s was largely co-located in hospitals. They had a radiology department you could take patients to go down to, just like we do today.

Adam Rodman (16:45):

Um, you start to have subspecialists examining patients in hospitals, whether those are medical consultants or therapists or social workers start to have more of a place in the hospital. The hospital as a whole becomes more of a place of healing and care coordination. You start to have more diagnostic tests. Uh, the urinalysis starts to really enter practice the nineties. Um, and then by the 1910s and 1920s clinical, uh, clinical laboratory medicine is really taken off. Uh, poor interns would be expected to collect the bloods and then put them in a, uh, literally a centrifuge to calculate the hematocrit. And, and, you know, by the 1920s, we're having laboratory studies done in a scientific setting. Not quite like what we're doing today, but very similar. And then obviously there's other new types of studies EKGs are invented in the early, well, the late 19th, early 20th century.

Adam Rodman (17:34):

And by the 1920s are becoming increasingly standard in hospitals. Uh, so things change a lot in the early 20th century. You know, those progress notes were one to two lines. Things don't quite look like that by the time we get to the post World War II ERA Act. I wanna take, take a pause and talk about an economic slash historical, uh, idea for a second. And that is path dependence. I don't know how many people have heard this word before. Historians like to talk about path dependence all the time. So I'm gonna very quickly explain what it is in just a, a couple minutes. And path dependence is essentially the idea that, you know, a lot of things that we do that exist in the world don't necessarily exist for a rationalist reason. It is not because a lot of people sat down and thought, oh, this is a, this is a good thing, we should do this.

Adam Rodman (18:19):

But because of historical contingencies, because of decisions that have been made in the past leading up to the present. So the classic example path dependence comes from economics. Like I mentioned, uh, I I'm sure everybody knows this, but virtually every single major city in the world is located on a waterway, on a river or an ocean. Why is that path dependence first entered the literature when looking to answer this question. The answer of course is that in, you know, prior to railroads, uh, most, most trade and communication was done by waterways. Even though that's changed. We have trains, we have automobile mobiles, we have airplanes. The location of those cities and the fact that they serve as incubators for all these surrounding industries was already in place. Those cities are kind of locked into their positions. Um, the classic example actually in history was to explain why trains derail all the time.

Adam Rodman (19:04):

You guys are in San Francisco, you have a public transportation system, uh, bart, right? And then I know you have, uh, street cars as well. We have the M B T A here in Boston. Um, the M B T A derails, I'll just say a fair amount. We have one of our lines down right now. Why do trains derail so much? Well, it turns out that our railroad tracks are actually a little bit, uh, too far apart for ideal fast train travel. So when trains try to go faster, they derail. In fact, if you look at what bullet train means in Japanese, it's chinen is referring to the gauge of the rail because it's a narrower gauge. So why do we have train tracks, uh, too far apart such that our trains derail when they try to go the appropriate speed? And the answer is that, um, the first early trains, locomotives were in coal mining in England, and there were passes that needed a certain size to get through.

Adam Rodman (19:52):

And when railroad railroads, railroads switched from coal mining into passenger service, they hired the same people who had made those railroads to set the new standard for the country of England. Then once the country of England had done that, well, other places want to have rail systems that like, that are integrated, that communicate with other, other systems. So the United States, much of continental Europe used the same gauge. Well, there's colonialism. The British went everywhere. They introduced their same railroad gauge. So you end up having the system with a suboptimal railroad gauge is introduced all across the world, not because anyone sat down and thought this was a good idea, but because of historical contingency. Uh, this happens in medicine all the time. This might be modestly controversial, but why do residents work 80 hours a week? Um, you could make a rationalist argument. Maybe you could say, you know, uh, is really important to follow a sick patient when they first come in to see how they do.

Adam Rodman (20:46):

But that's, I mean, if you look at the historical contingency there, there's a reason, right? Uh, when residency was formalized, everybody worked 80 hours a week. If I worked in a restaurant, I worked 80 hours a week in a factory. I worked 80 hours a week. Weekends didn't exist yet. It was before the labor movement. Uh, the difference is that in residency was formalized and then formally baked into the staffing models of hospitals. And hospitals operate in a pretty narrow margin. So you have a system where, I mean, I don't think there's a great rationalist reason why residents work 80 hours a week. It's, it's very historic contingent. Another example I like, uh, why is dermatology a specialty outside of internal medicine? Um, every other organ internal medicine is a subspecialty. Why is dermatology the skin different? And this goes back to the debates with the a a P, the American Academy of Physicians, which would later become the A C P.

Adam Rodman (21:32):

Uh, when the a a P first got together in the 1890s, they intentionally did not want to be a group, uh, that conferred like specialty training. Um, in the meantime when the A C P finally got together in the 19 pens and made those decisions during the dermatologists that already formed their own group. So there's a, a historically contingent reason for what today is a fundamental, um, change, like a fundamental division in medicine that doesn't really need to be there. Okay? That was a huge sort of rant. Uh, why did I go over this? Because if you had asked me of, of let's say 16 months ago, Adam, why do we write notes the way we do? I would've assumed it was because of path dependence. It was because of these little decisions that were baked in over, over time, which affects so much of the world.

Adam Rodman (22:16):

And it's so much of what a historian does is looking at all these historical contingencies. And what I found, and the reason I'm giving this presentation is that's not true. Um, the way that we document today is out of really two parallel movements, and it was created by a group of, of visionaries, by a group of innovators in the 1950s and sixties. Um, and we're still, we're still dealing with the fallout from all of that today. So that is what I want to talk about next. Okay, so first I want to talk about, I don't know if anybody knows what the C M I is, the Cornell Medical Index. Uh, if anybody's ever been to a doctor themselves, which I assume, uh, everyone here has been to a doctor themselves, you may have been given a review of systems sheet where you check off review of systems, or I'm sure you've been in a clinic where you've received one of these sheets.

Adam Rodman (23:03):

And if you're anything like me, I, I don't look at these sheets. I just talked to my patients. And if you've ever wondered why, this is why. So in the 1940s at Cornell, uh, Dr. Broadman, uh, Keith Broadman developed something called the Cornell Medical Index. It was a paper health questionnaire. Um, it was, I believe five sheets along 125 questions. Took about 15 to 20 minutes to fill out. And it was this entire idea that medical history taking could be reduced to this idea of a database, right? That in order to appropriately collect information about your patients, you would need to have to build a database that would be standardized for every single patient. And the Cornell Medical Index was copied all over the world. It actually lasted at Cornell in until 1990. And at the same time, uh, this is from a Warner Slack, you have people starting to take this idea of the database and trying to build kind of a smart branching database.

Adam Rodman (23:57):

Uh, this is from a paper in the early sixties. It's for allergies where they had branching questions. So they're taking this idea of the Cornell Medical Index, but now having branching questions similar to what a physician might ask. Um, and this is actually an example. It ran on link, which is a old computer from the sixties. Uh, I believe it costs about half a million dollars to buy. And this is the, uh, the cathode ray tube that people would use to input. And it was a quote unquote online computer, meaning that you, instead of putting punch cards in, you would actually use a keyboard to enter information. So this is the idea of the database. At the same time, there is a very, very influential movement that starts right, actually during World War II and really takes off after. And that's the field of cyber nets, uh, cyber nets.

Adam Rodman (24:40):

I, I think that these days, cyber nets, I cuz of these cyber punk, uh, movies and TV shows, everyone has an idea of cybernetics being, I don't know, like cyborgs, uh, modified, modified human beings. But cybernetics as defined in the 1940s and fifties was this idea of a computer, a computer program that could respond to changes in inputs and outputs. And what's very, very interesting is actually this is from Keith Broadman, the same guy who invented the C M I. This idea starts to come around in the 1950s and sixties. Well, if we're collecting this database of information and we know that computers are capable of responding to different inputs to give different outputs, could there not be an ability to develop a computer that thinks like a doctor? And in fact, that is exactly what Keith Broadman did with the C M I. There's this, this is a famous study from, uh, I think this was published in 61 62, but it's from the late fifties where they looked at the Cornell Medical Index.

Adam Rodman (25:34):

They to, they went to an insurance company, they found like 150 people, made them all fill out the C M I. They already knew their medical diagnoses. And they looked to see if symptoms on the c m I could accurately predict their diagnoses. Okay? So that's number one theme that I wanna talk about that's going on in the post World War II fifties and sixties period. The next is this idea of the source oriented medical record. I don't know if anyone has heard this to term. It was in use a lot in the sixties and early seventies. It's largely gone out of, um, favor as it's gone extinct. No one talks about this before, but it's the idea I showed you what those old progress notes look like. Well, medicine had become very, very complicated once we're getting into the, you know, into the post World War II period, or hospital medicine in particular, but increasingly primary care also, and this is from a 1968, uh, paper by Larry Weed, who I'll talk more about in a second.

Adam Rodman (26:26):

And you can read through this, uh, this, these are the progress expectations. So, um, patient received 40 units of regular insulin yesterday, uh, four plus urine sugars. Hey, I'm not gonna read this to you. You can go down and read through this. And I am a reasonably intelligent physician and from le reading through this, I can get an idea of what's going on, but I, I have no idea what's going on with the patient. And there were broad complaints during this period that hospitalized notes or hospital progress notes were virtually unreadable. That unless you knew the entire chart of the patient, uh, that you had rocked the chart to use the 1970s hippie language, stranger in a strange land, you would have no idea what was going on with this patient. Okay, so enter Larry Weed. This is why I wanted to do audio, cuz I'm gonna play some audio clip clips.

Adam Rodman (27:12):

I'll talk to you a little bit about who Larry Weed is. He is one of these, I guess I would call him a second generation informaticist or maybe first generation informaticist. This of the first groups that would call themselves informatics. So like Keith Broadman, Larry Weed was one of these advocates that we could use medic like medical technology. We could use computers to not only, you know, not only document better, but improve medical thinking and hopefully build a computer that could think like, doctor, I want to play you two short clips of his thinking, uh, before I summarize it up myself, because not only I, I want you to not only hear what he has to say, but to hear how charismatic and powerful a speaker that he was. Oh, except I don't know how to use my own computer. Let me just share my entire screen. Okay,

Speaker 4 (28:04):

Four. So I'd say I'd like to know the problems. You say, well, they're at the end of the workup. Find the first workup and you'll find the problems. So I come to here one and I read through this impression cva number two, extreme anxiety neurosis. Is that all the problems? All right, if that's all the problems, we can see how you diagnosed it and what you did for it. And we'll see if that's good, good care for cva. So I'm thumbing through here and it says, blood pressure 180 over a hundred or 98 thk. They're giving the Thorazine for a stroke. Now they're giving that for the anxiety. Maybe I'm not quite sure. Then what's all this? S k i then here le preps times three, you know, for anxiety or a stroke. <laugh>,

Adam Rodman (28:57):

This is at Emory by the way. You can tell they're internists because they're laughing the

Speaker 4 (29:01):

Hip, hip and the pelvis. Now you might say, oh, well, don't get excited. She probably fell outta bed. Did she? I don't know.

Adam Rodman (29:10):

Uh, you, you, you got the idea. Um, uh, uh, I'm gonna play another clip in a second. But just a story. Like a lot of some, some of you may have known Larry Weed. Um, one of our, one of one of my mentors here actually has memories cuz Larry Weed was at the University of Vermont of, um, of Larry Weed coming on the wards and picking up charts from, from bi residents and effectively doing to them what he's doing to this. This is a real patient at Emory. Um, so now, now this is him talking about why, why he's so passionate about this.

Speaker 4 (29:39):

Very unscientific, but it's even worse than the appearance. It's the very essence of the practice of medicine. This is not an idle discussion of little technical bookkeeping details. The practice of medicine is the, is the way you handle data and think with it. And the way you handle it determines the way you think. Once you get over a period of time with multiple variables, the very structure of the data determines the, the quality of the output. And this is what's so hard for medicine to accept. They can't say things like, I know lots of good doctors don't keep good records. They can't be separated that way. Now you might say, well, you could figure out what's wrong with that ear. If you wanted to, you could sit down and read the whole record. Well, with 200 million people and to get quality, I might spend three hours, but even then I couldn't do it. It would be impossible.

Adam Rodman (30:49):

Okay, you get, you, you get the idea. I mean, if anyone hasn't watched this, this is from Emory as 1971. Uh, internal Medicine Grand Rounds highly recommended to watch the entire 53 minute, uh, grand rounds. Uh, Emory actually had a, um, a TV quality camera. So a lot of the grand rounds from that period survive and are in remarkably good shape. Okay? Okay, so what was Larry Weed's solution? And it's something called the problem-Oriented medical record, P O M R sometimes called the Problem-Oriented Health record. And I am going to, I've, uh, I actually brought something for a show and tell I love this. This we had hidden in the stacks of the main Harvard Library. This is his, uh, this was published in 1968. This is his like, thesis on what, what we should do with lots of examples. And I'm going to show you some things from the back.

Adam Rodman (31:44):

So I'm going to summarize this whole, this whole book to give, to say what he advocated. So, uh, Larry Weed believed that data should be collected as routinely and completely as possible. You can see this idea of the database here. A questioning should be standardized with branching questions. And if possible, not done by doctors, by paramedical personnel or even better computers. Physical exams similarly should be standardized and complete. And when he said complete, he meant complete doing many, many different exam procedures. Recognizing that this might be complicated to do for a phy. Uh, he had overworked house officer in the ward. He points out that these can be done by nurses. Nurses can be trained to do some of these exams. A laboratory and diagnostic test similarly should be performed as thoroughly and frequently as possible. Larry Reed was a believer in daily labs, uh, long before that was a thing.

Adam Rodman (32:36):

And the goal of the patient encounter is to build a large analyzable database. It is to build a database of clinical information, um, as much of it objectively coded as possible. Um, when we organize this data, it should be done in a scientific fashion. And everyone knows this. I I think most people don't have a sense of where the SOAP note comes from, but the progress note becomes that method of organizing in a scientific, a scientific fashion. Uh, this data should then be used to generate a list of problems. And the goal now of the medical encounter becomes to clarify and solve as many of these problems as possible. And I'll be very clear, he likes the word problems, not diagnoses. Uh, Larry Weed would argue that there should be no uncertainty. You should discuss things to the best of your medical ability. And one of the examples he gives in his book, he also says it in his grand rounds.

Adam Rodman (33:28):

Let's say that you're not very good at EKGs, but you get an EKG on a patient and it looks funny. There's something off about it, but you don't know exactly right. Exactly what, uh, Larry Weed would say. It's okay to list a problem as funny looking EKG as long as you take this appropriate steps, for example, consulting cardiology or consulting electrophysiologist to better clarify those problems as you go on. Uh, progress notes, he would argue, are now the most important part of the medical record. They're important for building this database, for showing track, uh, for showing the progress of the patients about the hospitalization and for tracking quality. I mean, Larry, we just talking about quality in the late 1960s, long before the QI movement started. Um, the problem is, should be consistent, accurate, and complete. Complete it being the keyword word. Everything that is abnormal should go on the problem list.

Adam Rodman (34:19):

Narrative data as well should be standardized and coded as accurately as possible. Uh, Dr. Weed believed that it should be, um, when possible entered directly into a computer. He even built an emr, one of the first EMRs called Promise. I'm gonna show you what it looked like, cause I have it in here. Um, the, this is the co Well, this is the code. These are the, the branching problems for Promise. Um, I don't know if anyone has ever played around with Promise. It was on punch cards. It doesn't work anymore, but it actually had a touchscreen. Um, again, I, I know a faculty member who worked with Promise and you would touch one or the other. It was apparently very clunky to work with, but you would start entering, uh, and would ask you to choose one or the other, and eventually you would code things as accurately as possible.

Adam Rodman (35:04):

Um, these are, I have these photos in here. These are from BI in the 1990s showing what our, uh, we built an emr, um, oh my goodness, I don't even remember what the name was called at the time. It's called CCC now for the Center for Clinical Computing. But what our early electronic medical record look looked like. And I think everybody knows about what happened next, right? So promise is introduced. Uh, region Streif builds a very popular electronic, well, not very popular. They build an electronic medical record Vista at the VA build electronic medical record to the point that by the nineties, uh, it became pretty accepted that EMRs were a good thing. There is a Maita analysis from 2001 showing that physicians liked EMRs. They found that it helped them take better care of their patients, uh, spent, you know, spent less time documenting, uh, and there was more revenue captured, which is very funny.

Adam Rodman (35:51):

Like if you look at the, the, the literature in the nineties and early, very early two thousands, there's a lot of optimism around electronic medical records. And the Institute of Medicine named it an essential technology for healthcare. Uh, and I'm the pur the purpose of this talk is not to talk about how we got to our current EMR Molas, but I think everybody knows what happened next. So I wanna go back to this idea of how we document is how we think, because one of the things that is incredibly interesting to me is that if you look at the early informatics movement, if you look at broadband, you look at Slack, you look at Larry Weed, they had very, they would agree with me a hundred percent about this, that how we document is how we think. And what is interesting is that they are positing a very specific way that they think that physicians think.

Adam Rodman (36:35):

So I want to now push back a little bit about the problem oriented medical record to talk about some of these assumptions that will say that the early informations made that may or may not be true. So I think problem number one, uh, this is, this is, sorry, the other thing I should say, the problem oriented medical record was widely accepted throughout the seventies to the point that by the early eighties, no one even says problem oriented medical record anymore. Because that was just how we documented, right? Everyone did soap notes. One of the most, um, vocal critics was Alvin Feinstein, who is known as, uh, the father of clinical epidemiologist. He's a practicing physician. I think he was an ID physician, but also an epidemiologist. And he wrote a famous book called Clinical Judgment, uh, that pushed back against a lot of the, the informatics movements and the informatics ideas on, you know, on talking about a how we document and, and how we structured data.

Adam Rodman (37:31):

So some of these, uh, these points in here are his, some of these points are mine. But I, I just want all of you to think about some of these assumptions that are made with the problem oriented medical record. So I'd say problem number one is that our patients are not just collections of problems. And our obsession with filling every single problem can blind us sometimes to the bigger picture. Uh, an example would be, my residents do this very frequently, and a patient who comes into renal failure, they'll diagnose or they'll document a non anion gap. Metabolic acidosis, almost certainly it's because of the renal failure, or a patient who has sepsis still document a leukocytosis. These are both benign examples. But another example might be hyponatremia. A lot of our heart failure or liver patients, liver failure patients will come in with hyponatremia, mild hyponatremia.

Adam Rodman (38:13):

And I think all of us know it's because of their, their volume situation. And, and it's okay to note that. But the fact that we name things as problems drives us to do something about them. Uh, number two is a, um, this idea of completeness is in itself very fraught because the selection of problems is inherently subjective. There is no objective way to select problems. And the ironic thing is, uh, Larry Weed was a generalist at heart, and he actually believed that the problem oriented medical record would drive more people to be generalists, right? It would give us the confidence to take a, a look at the patient as a whole and not, uh, you know, he, he felt that people were driven to specialization because of the uncertainty and the difficulty of dealing with these very complicated patients. I would argue that the way that we describe problems is actually driven by some of our bias towards, uh, hyper specialization.

Adam Rodman (39:04):

And I'll, I'll give a couple examples here. Um, you know, your, your septic patient comes in and they have a tropic 0.01 uht troponin assays from 15 years ago wouldn't have picked that up. Uh, before that, if you were using the CK wouldn't have picked up anything unusual. But I see, and a lot of us put something like chronic myocardial injury or myocardial injury, or God forbid you write it as an n stemmy in there and you may just think, oh, I am being, you know, I am being, uh, complete, right? I'm just putting every single problem. But a lot of that comes because we value the heart, right? The heart cardiology is a sexy field. We value problems with the heart. I have many problems where the patient might say, you know, I haven't been really walking as well. I can't get up and down my stairs as well, or, I'm very constipated.

Adam Rodman (39:46):

And I think we are all much more likely to put things that appear to be, yeah, a they're involved with organs that we're excited about, or b, their laboratory values rather than taking a holistic view at actual patients' problems and things that might matter more for them or for getting them outside of the hospital. Um, one of the reasons that I talk to my residents about this, and one of the reasons that I sometimes don't even do problem oriented charting is I truly believe that chopping people up into lots of little problems rather than looking at the big hole now sometimes, not all the times, it can drive over testing and overtreatment. It drives us to, to, to look at the small things and deal with the small things instead of looking at, for example, the person is dying of cancer. Um, and instead dealing with a bunch of small little problems all at once.

Adam Rodman (40:32):

Now, Larry Weed and the informatics movement did not invent evaluation and management codes. Evaluation and management codes are not their fault. Um, I would, I would argue that the desire to have things as specific as possible is what led to E N M codes in the nineties. And I think we get in trouble here where we use a lot of E n M codes because, you know, we need to make money for our hospital medicine. We, uh, hospitals don't run on a very large margin and there's this desire to maximize revenue, and we end up using these codes that probably are not the best way to think about our patients. And I think acute hypoxic respiratory failure is one of those examples, right? Like in a complicated hypoxic patient who gets intubated in the unit, it may be useful to think about them as that.

Adam Rodman (41:14):

But in a patient who, for example, has pneumonia on top of C O P D, I'm not sure that describing that person the same way would as a, uh, as a complicated ICU u patient is necessarily helpful and toxic metabolic encephalopathy is a, is a classic example, right? I have a lot of my students who think that's an actual medical diagnosis instead of thinking about what's actually going on with the person. Um, another problem, this is an Adam point, is that we, on Larry Weed was very against uncertainty. All of the implementations were against uncertainty. And you can understand why they wanna build a database. Their hope was that computer could analyze all of this. We understand today that there is a certain fundamental uncertainty, either epistemological uncertainty from incomplete information, or there's some noso graphic uncertainty. And I think a classic example is pneumonia, right?

Adam Rodman (41:57):

We label lots of things as pneumonias that are they pneumonias? I, I, I don't know. The question is, do they benefit or not from antibiotics? And our desire to have certainty that the pro, the certainty that the problem-oriented medical record requires, I think is not necessarily helpful or indicative of how medicine is practiced in the year 2022. And this is a classic fine scene, and this is one of the, um, one of the big arguments always against all of this focus on documentation is that the focus by making the progress note, the soap note, the most important thing that we do, the focus becomes on keeping records and not on taking care of a patient. And you can read, I can read beautiful progress notes that emotionally copied forward and have no idea how the patient is doing. No idea if they're satisfied with their care, sometimes not, no idea, even if they're getting better.

Adam Rodman (42:45):

And then finally, they're not focused on diagnosis. Uh, some people argue that, uh, by listing out the problems, it can help with pattern recognition, right? This is what, this is what Broadman thought that you can identify, uh, patterns and get diagnoses from this. It, it turns out with a modern understanding of diagnostic thinking, that it's much more complicated than that, right? The, the medical, the mental work that goes into making a medical diagnosis is much more than say, recognize patterns and different problems. And I think it can be a problem when we focus too much on problem orientation to make the diagnosis rather than other methods. Alright? So I wanted to stick a couple minutes because as somebody who, like I've read, oh God, I've read probably 800 pages by Larry Weed. I've read 200 by Keith Broadman. I've been like living in the minds of these or informaticians for the last year and a half.

Adam Rodman (43:40):

And one of the things that's always struck me is how optimistic they were. If I were in 1967, I would be so excited for the future of electronic medical records. I would just think it was gonna change everything. And it's tough for me in 2022 to look at what medical records are, to look at how much time we spend on them, how much time we feel we need to spend at them, at the expense of spending time with our patients. And it's just, it's so frustrating to see such a idealistic movement end up like that. So one of my questions always, I, I mean it's unfair to always ask this if a historian, but like, is there a way to make things better? And, uh, this is from a wonderful article. My, my friend actually, Mike NOIs, he's a great historian. He's actually a historian who's interested in informatics.

Adam Rodman (44:22):

Um, that was published in J M I A, looking at the history of the E M R and then actually being historically informed to look at ways that we might get things better in the future. And these were their recommendations, right? That if we want, we should reform EMRs to focus less on measurement. And when we do measure things, measure things that matter, a decrease focus on finance and billing, just give up on incentive programs. Um, don't task shift, right? There's a lot of concern that you make something easier for doctors by making it worse for the nurses. Uh, use modern improvement science principles and then really involve everybody. Uh, this is a big concern for R E M R, where changes are often made by people who don't take care of patients, but really involve everybody in the organization to build the best emr.

Adam Rodman (45:02):

These were their recommendations. Um, the one thing I say I, so I work in the outpatient setting as well, is the inpatient setting. And I think everybody knows that c m TMS made changes starting last year that we could now bill on medical decision making and not have to bill on some of these extraneous things in the medical record. The idea being that some of our unnecessary documentation unnecessary and unaccurate comes because of exi exigencies of billing. Um, I will say this has made my outpatient notes easier to write. I think there's a wide expectation that this might happen in the inpatient setting. Will that be enough to make things better? I don't know. I, I wanna end this cause I wanna have time for questions or discussion by just reiterating this point. I hope if I've convinced you of nothing else, that the way we document is actually really, really important because it shapes the way that we think about our patients.

Adam Rodman (45:51):

And at the end of the day, I, everyone here became a doctor, not because they wanna spend time writing notes, but because they wanna, they wanna build relationships with other human beings. They wanna make their lives better. And I, I don't want you to take away from this talk, um, that note writing is not important. I actually think it's really, really important. I just think we need to be thoughtful of, of what we're doing and what we're doing mentally when we document in a certain way. And to understand that <laugh> the malaise that we find ourselves in it, it was created by humans. Um, there's no, there's no magic rule that says we have to document in a a certain way. And I don't have any answers, but I would hope that maybe somebody in this room does. Uh, and we have enough creativity and motivation to go forward from here.

Adam Rodman (46:36):

Um, I have two papers, uh, if anyone is interested in learning more. The first one is by Andrew Le, uh, he is an amazing medical historian. He's gonna be an intern across the street at, um, at the Brigham. And he wrote this amazing essay on Keith Broadman from June, 2019. He got a bunch of his correspondence and looked into what he was thinking when he was writing these papers. And then this is the other paper and J m I a if you want to have a, you know, like a 10 page rundown on the history of EMRs. And, uh, oops. If you want to contact me, that is my contact information. I am always feel free to send me an email or you can tweet, tweet at me at any time. I love to talk to people. And that is it. I'm done.

Jack Penner (47:17):

Fantastic. Thank you so much, Adam. That was an absolute blast to listen to and, and incredibly educational. Um, we have a few minutes for questions here and so I will, I will open it up to the, to the audience to uh, to ask any questions. Feel free to either unmute and share your questions out loud or you can type them in, type them in the chat.

Adam Rodman (47:38):

Yeah, I miss talking in person. It seems like such a novel.

Speaker 5 (47:43):

Hi, I dunno if you can hear me.

Adam Rodman (47:45):

I can,

Speaker 5 (47:47):

Um, sorry I'm walking to clinic. Um, but I'm wondering if you can talk a little bit about the idea of audience for notes. Um, I think audience has shifted from maybe just this like siloed community of doctors and even doctors within your own institution, probably to be more specific to, uh, doctors, colleagues and now patients and their family members and how you kind of whe whether you have a framework for about that.

Adam Rodman (48:13):

So it was so interesting to hear you say that. Um, and I think that's the biggest shift that's happened in our own documentation in, in my lifetime is the, the generalized acceptance that the audience of our notes is going to include the patient, uh, who we're taking care of at that moment. Um, one of the things that I will say is that if you read what, uh, what Larry, we wrote, what some of these early informations wrote, they actually feel that the problem orientation, medical, the problem oriented medical record is good for patients that patients will appreciate. They, they, they, um, they thought open notes was coming like 60 years before it actually happened. Um, I don't have, I mean, I I'm curious to know what you guys think. I don't know how I, I don't think it changes my documentation that much. I don't know if it changes yours. I don't have specific thoughts beyond that. Sorry, that wasn't much of an answer.

Speaker 5 (49:12):

No thanks. I don't, I don't think it changes my documentation too much either. Um, I think if it did change our documentation, that's like some self inquiry that we have to do, um, <laugh>. And then it's also opened up some conversations between me and a patient or me and patient's families and actually, um, helped me give explanations or realized that I wasn't explaining things well in person. So I think it's like, for me been good, even though I think I reacted negatively to the idea of it at first.

Adam Rodman (49:41):

But it's been good for me too. And even when patients, even when there are, you know, the factitious disorder is the classic example, I haven't even seen those negative effects. Um, you use the, I mean, I think it's the, the reason it's challenging is that we've been taught to think that the progress notes are, are so important, right? That's the job of our day. And it feels weird to say, I think fictitious disorder is, is the best example to sort of change your documentation in a way. But at the end of the day, as long as you're taking good care of the patient, I, I think that's the most important thing.

Jack Penner (50:11):

There's a question in the, a question. Oh, sorry, go ahead. Oh, I was just say there's, um, a question in the chat from Marshall asking for physicians on salary with limited, such as Medicare external submission for reimbursement. EE Kaiser is documentation different?

Adam Rodman (50:25):

Um, so I don't know for the Kaiser system, uh, what I will say is that the, in the United States problem oriented medical documentation has taken over in a lot of Western Europe. Also, it has not taken over everywhere in the world. Um, I have some medical, some residents who have done medical school in other countries where they have not adopted, um, problem oriented medical documentation. It very much was an American movement that is not universally accepted all over the world. So in Botswana, we did not do, we, we didn't do problem oriented documentation. Um, I don't know if the Kaiser notes are shorter. Uh, in my experience, I worked at a VA during residency. I think the notes were still just as long. I, I don't know. You, you guys are at the va. Do you think there's a, a significant difference?

Gurpreet Dhaliwal (51:11):

Adam? This is ri I could chime in on that. Cause I do think, yeah, places like Kaiser or perhaps the VA are like an interesting experiment. Um, cuz you could ask yourself what would happen if I didn't cut and paste everything from the emr. And I wrote a short paragraph on how the patient's doing today. And I, I don't know. I mean, there's some, there are quality metrics that are baked into a lot of outpatient VA notes, but I don't know what the consequences are. I guess people always could say, like, from a risk management standpoint, have to record everything that happened. But if you put that one concern aside, which is muted in the, in the federal system, um, I think there's a lot of license, right? Much shorter notes that, that people might appreciate. But, but because of the, like you said, it's, it's more the, the standard note writing is across the country and across all medical education systems. It's hard to adopt it. Um, once you just enter one system.

Adam Rodman (52:01):

I also have billers reviewing my documentation. They're not, so once someone, the billers asked me if somebody's hemato was due to a doac or not due to a doac, and I responded, I could not determine, that's a philosophical question. They weren't happy with me.

Jack Penner (52:15):

Um, there's a question from Lenny about reviewing the new guidelines about the, about documentation focused on decision making and reasoning.

Adam Rodman (52:23):

Oh yeah, yeah, yeah. So does everybody know this? Does I, I actually, does anyone here work in the outpatient setting so they know the new guidelines? Um, so since, so I, I everybody knows for, for inpatient billing that you need to meet two of the three criteria. So now in the outpatient setting, you only need to meet medical decision making criteria or a time-based criteria to meet the various levels of, um, of outpatient billing. Um, that still requires, I, it is not that difficult, but it requires a certain number of problems documented. But in my, I mean my clinic population is, is quite sick. So it's very easy to meet higher levels of, of medical complexity. Uh, it's made, what it's done is it's made me focus a lot less on, um, the other parts of the node. And I certainly don't copy things in anymore and just focus on the assessment plan

Jack Penner (53:17):

And a comment from, from Erica Price and the chat from a standpoint doing qi and peer review here. I think short paragraphs of how the patient is doing today are incredibly helpful. And I encourage trainees to always include what is different today versus yesterday. And sometimes the billing questions can nudge just to be more concise and clear in notes.

Adam Rodman (53:34):

Uh, uh, Dr Dal and I were talking about this the other day about, uh, like at the end of the day, like what, how do you solve some of these problems that are present in problem oriented documentation? And the answer's not very satisfying. It comes down to, it comes down to exactly what Dr. Price is describing. It's like narrative. It's paragraphs. It's using human language to talk about how your human being patient is doing. Um, it is the exact opposite of what Larry Weed and like Robin would. It's something that's not really codeable by a by a computer, but it's something that we understand on a human level.

Jack Penner (54:11):

Um, if I could ask maybe one final wrap up question. Are there, um, uh, strategies that you share with either colleagues or trainees who work with you in, in either the inpatient or the outpatient setting of like small changes that we could make day-to-day to help improve both the utility of our documentation, but also the ways in which we can use documentation as a way of helping us think?

Adam Rodman (54:32):

Uh, I I, I wish I could throw that back to you. I mean, we also have Dr. Dolly while here. There's so, there's so many great people, uh, to ask. What I'll say, what I'll, what I say to my trainees is that you do not have to list every single problem. You don't have to get in a situation where you're listing every single thing that has happened during a patient's hospital stay. It is okay to focus on the major problems that are going on. And if you can spend your attention on, for example, the fact that they have, I dunno, pseudo mold, pneumonia and a pulmonary embolism and not worry about something that happened resolved 15 days ago that's copied into the note that makes them easier to read. It allows you to spend that cognitive injur energy on the decisions that you're making on a day by day basis. And I like, I actually disagree, <laugh>, I get into this with the implementations. I disagree. I don't think we need to list every single problem. I don't think that should be the goal of what we're doing. We're human being physicians, using our human being mind to understand our patients. And at the end of the day, we should document like we think about our patients and not let assumptions about building a database that a computer can read, drive how we think about our patients. Cuz that's not how we think.

Jack Penner (55:35):

Thank you so much. Well, I know we are, we are at time. Um, one, one final point here in, in the chat about some of the potential downsides of time-based coding about how it starts to encompass time we spend delivering care in, in, in, in inefficient systems, particularly in primary care. We are seeing that quite a bit at the va. Well, I just wanna say Dr. Robin, thank you again for a phenomenal presentation. We are so lucky to have gotten to learn from you and to have gotten to talk with you today. Um, uh, this was such a joy and so educational. Thank you again for coming. Um, um, uh, yes, I hope you have a great, great rest of the afternoon. And

Adam Rodman (56:09):

One, one plug. If anyone is coming to a c p I'm gonna be there. So come, come find me at, uh, in Chicago if you're gonna be

Jack Penner (56:14):

There. Awesome.

Adam Rodman (56:15):

Very excited to meet everybody.

Jack Penner (56:16):

Awesome. Well, uh, traveling from, uh, from San Francisco virtually to Chicago in person. Um, uh, well thank you again Dr. Rodman for being here. Thank you again, Dr. Dolly Wallford Dewing to the introduction today. And we hope everyone has a great rest of the afternoon. We'll see you next time.

Adam Rodman (56:31):

Bye Jack.

Jack Penner (56:32):

See ya.

Adam Rodman (56:33):

Hi everybody.

That’s it for the show! I am trying to do better at turning my grand rounds into podcasts so everyone can listen. I generally prepare one “big lecture” a year that I then iteratively improve throughout the year. This year it’s called “The Two Faced God,” and it’s about how fundamental tensions in the collection of clinical “data” aka the facts of disease have shaped the way we practice medicine and interact with our patients. And yes, I will eventually get that one in tip-top shape also. But I’m also always willing to speak virtually if any students or residents want me – anywhere in the world! Just DM me on Twitter or send me an e-mail.

For once in the history of this show, I have a lot of stuff in the pipeline – so thank you all for bearing with me! There will be a two parter on the evolution of clinical decision support – I promise, it’s actually interesting! And an episode of digitizing diagnosis. And with any luck, later this summer we will be launching on new series on the built environment of healthcare. And of course, a huge thanks to Jack Penner and Gurpreet Dhaliwal from UCSF and the San Francisco VA for the very gracious invitation. It’s an honor knowing both of you!

CME is available for this episode if you’re a member of the American College of Physicians at All of the episodes are online at, or on Apple Podcasts, Spotify, Google Podcasts, or the podcast retrieval method of your choice. The facebook page is at /BedsideRounds. The show’s Twitter account is @BedsideRounds. If you want amazing Bedside Rounds swag designed by Sukriti Banthiya, the official merchandise stores is at I personally am @AdamRodmanMD on Twitter, which still exists!

All of the sources are in the shownotes, and a transcript is available on the website.

And finally, while I am actually a doctor and I don’t just play one on the internet, this podcast is intended to be purely for entertainment and informational purposes, and should not be construed as medical advice. If you have any medical concerns, please see your primary care provider.


Adam Rodman, MD, FACP
Jack Penner, MD
Gupreet Dhaliwal, MD


Jordon Talan, MD
Geeda Maddaleni, MD

Those named above, unless otherwise indicated, have no relevant financial relationships to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.  All relevant relationships have been mitigated.

Release Date:  March 19, 2023

Expiration Date: March 19, 2026

CME Credit

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American College of Physicians and Bedside Rounds.  The American College of Physicians is accredited by the ACCME to provide continuing medical education for physicians.

The American College of Physicians designates this enduring material (podcast) for 1 AMA PRA Category 1 Credit™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABIM Maintenance of Certification (MOC) Points

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1 medical knowledge MOC Point in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program.  Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

How to Claim CME Credit and MOC Points

After listening to the podcast, complete a brief multiple-choice question quiz. To claim CME credit and MOC points you must achieve a minimum passing score of 66%. You may take the quiz multiple times to achieve a passing score.