To the Editor:

[Re: “Do You Need a Medical Scribe?” March, page 3]

I agree with the reasons outlined by Dr. Greene as to why the electronic health record (EHR) has taken away from the patient–physician relationship. I have refused to work on a computer while with a patient unless I need to show them a film or in some other way interact with both the patient and EHR. The bond and trust we must build with patients and their families to treat complex diseases and perform surgery can only be gained by looking the patient and their families in the eye as you speak to them. Therefore, by necessity I complete most of my charting at night and on weekends. It is simply a fact of life in “modern” medicine. There is no question that this detracts from my family life and quality time. These are the choices we all make. I have read about medical scribes for a while. It is clear that EHRs are no more efficient, faster, safer or even generate less paper than the old charting methods. Having said that, I embrace the access it gives us, the documentation, drawing, graphing and other information capabilities of the EHR.

What Dr. Greene does not address is who should pay for a medical scribe and how they should be paid for. You cannot bill for them. Whether in a small practice or as part of a larger medical conglomerate, in most cases, the cost will come out of your pocket. You can argue the scribe may increase your efficiency enough to cover the added costs, but this remains to be seen. It is clear that this is the result of another unfunded mandate of medicine. Unlike other industries, we cannot pass this cost of doing business to any of our payers.

For now, I will continue to look my patients in the eye and leave the paper work (computer work) for later.

Michael S Bouton, MD, MA, FACS
Fargo N.D.

To the Editor:

In the Surgery Department of Naval Hospital in Lemoore Station, Calif., we have been using surgical scribes for nearly two years. Initially, the concept seemed only to displace work from the surgeon to a corpsman. However, it has been well received for many reasons. Rather than only taking vital signs and checking patients into the clinic, the corpsman have become fully engaged in patient care, which has empowered them and promoted esprit de corps. Surgical providers quickly realized we were mentoring our corpsman with each patient encounter as they were able to better comprehend patient presentations, pathology and treatment decisions. This further fostered their interest in health care, and many are on track to become nurses and doctors, some with specific interest in surgery.

The initial reason we started using scribes was because of the numerous EMR [electronic medical record] systems (yes, we have several and all are different) limiting the amount of time per patient and subsequently the number of patients seen per day. The singular downside was the initial time it took to train the corpsman up (not long because of their prior training and experience in corps school and in theater, respectively), and, of course, the surgeons’ desire to maintain the EMR albatross around our necks. No, that’s not true. I made that last part up.

Eric E. Liedtke, MD
Department Head, General Surgery
Naval Hospital
Lemoore Station, CA

Smoking Cessation Before Surgery

To the Editor:

[Re: “Withhold Surgical Treatment for Smoking?,” March 2014, page 4]

Withholding elective surgical treatment is sometimes not only necessary but is in the patient’s best interest. Consider, as an example, a patient who has vascular claudication, does not exercise and is a practicing tobacco addict. This patient does not need elective surgery, although the indication, “lifestyle-limiting claudication” may be acceptable. If we, as physicians, commit to educating our patients about the effects of tobacco and the necessity of progressive ambulation, instead of rushing the patient off to the cath lab/operating room, the results may be surprising. The key phrase is “elective operation.” We are not talking about the patient with resting ischemia who will almost certainly lose a limb if not revascularized; those patients need treatment urgently if not emergently.

Natural history: 93% of patients with claudication will never need intervention if they are able to stop smoking. If intervention is offered “electively” and the patient does not stop smoking, the effects of the intervention will be short-lived and the failure rate high. If the patient stops smoking for good, guess what? It is a win–win situation for the patient and the medical system as a whole. Most patients who engage in a progressive ambulation program, stop smoking and generally change their habits and lifestyle away from cigarette centric, will never need intervention. These patients are able to progressively attain the ability to walk two to three miles without painful claudication, as their bodies, including the arterial tree, undergo internal modification (collateralization of flow, better oxygen capacity, etc.). By successfully converting these patients to nonsmoking people with healthy attitudes, we not only treat the patient long-term without the risk for complications related to intervention, but we also save our health care system millions of dollars annually in unnecessary treatments.

I agree with Dr. Teitel, that we should never “… punish and harm individual patients by withholding surgical care …”, but I think that he takes the patient who smokes out of context and misplaces ideas of politics with doing the right thing for the patient. Dr. Greene in no way suggested that we flush these patients down the drain because we don’t like smokers; he merely said what has been said before, that not everyone requires surgery immediately. The patient with claudication is better served by withholding “elective surgery.” It is greed that causes the physician to treat claudicants with surgery before attempting conservative measures. Recurrent ischemia, forces further intervention, producing a cycle of ischemia, treatment, failure, ischemia. This cycle is not good for the patient.

Primum non nocere.

Rick D. Pittman, MD
Salem, Ore.

Surgeons and Substance Abuse

To the Editor:

[Re: “Laparoscopic Techniques for Hernia Repair: A History of Ups and Downs,” March 2014, page 6]

Although the historical component of this article was interesting, I am disappointed with the inclusion of a quote from Dr. Ponsky equating the excitement of the emergence of laparoscopy with cocaine use. This analogy is not amusing and trivializes the profoundly negative effects of substance abuse on our patients and society. Furthermore, with alcohol and substance abuse within our own ranks as surgeons, associating cocaine with innovative techniques and ideas is not appropriate in your general surgical newspaper. Please consider examining your article review process.

Robert Noll, MD, FACS
Sacramento, Calif.

Financial Disclosures

To the Editor:

I read with interest the “On the Spot With Colleen Hutchinson” column featuring surgical robotics in the March 2104 issue (page 18). Question: where are the author disclosures? Given the controversial and divisive nature of this evolving topic, and the fact that industry (and one dominant surgical robotics company in particular) is keenly interested in the outcome, a statement of relevant financial relationships for each author needs to be on the first page of the article. Disclosing author conflicts of interest provides the reader with necessary context to the authors’ statements.

Mark A. Carlson, MD
Omaha, Neb.

Editor’s Reply:

Thank you to Dr. Carlson for pointing out this oversight. Here are the participant disclosures for the article “Surgical Robotics: On the Spot With Colleen Hutchinson”:

Yuman Fong, MD: None reported.

Daniel Jones, MD: None reported.

Omar Kudsi, MD: Proctor for Intuitive Surgical

Martin Makary, MD: None reported.

Frank Rosato, MD: None reported.

Noel Williams, MD: None reported.