Refuse to be a Box Checker in 21st Century Medicine

I’ve had several different careers over my lifetime and one of them was in healthcare. After I worked five years as a NICU nurse, I functioned as a nationally Certified Pediatric Nurse Practitioner for about six years. I practiced in the states of Maryland and New York. The advanced degree also allowed me to teach nursing and I did that too at Johns Hopkins University in Baltimore and Niagara University in Niagara Falls, New York. It was satisfying to combine clinical practice with teaching at the college level.

In my first role as a CPNP, at Hopkins, I learned some very important guidelines for clinical practice. The most important thing I learned was to not practice cookbook medicine. This means that each client needs to be considered individually. Standards of practice play a large part but cannot replace critical thinking about diagnosis or treatment plans. They serve as a guide, not an exact recipe or unrelenting steps to follow without exception. In other words, providers should not automatically “follow” the “book.” Ever since learning that way of practicing, it’s been hard to consider any other. It just made sense to me.

This has become hard in the 21st century where physicians and extended providers such as nurse practitioners and physician’s assistants are held to standards generated by their institutions and programmed into the computers which are now used to chart patient needs and outcomes. God forbid a box is unchecked when the computer or institution deems it should be checked. God forbid the provider needs to actually think about whether what they are recommending makes sense for the patient and their care. This creates more issues when the providers are “dinged” by their institutions if a client’s plan deviates from what is suggested by the pop-up boxes on the electronic medical record. “Dinging” could lead to reprimands by the administration or more.

This happened to me recently. I had a history of mild-cough variant asthma. Since I had my three children and gotten older, I’ve not had a problem with asthma in at least ten years. I’ve never been hospitalized for it, nor have I been on any medications to treat asthma for an extended period of time. Yet, despite this, my provider wanted me to have pulmonary function tests (PFTs) and a pneumococcal vaccine. Really? I am not at high risk. But, the computer thinks I am. It’s because my diagnosis of asthma was put on my chart many years ago. I’m guessing the EMR searches for keywords and/or diagnoses and guides the provider into what tests or other preventive measures are needed.

I have bucked the system, telling my provider I didn’t want nor need the PFTs or vaccine. The computer indicated that it was “time” for my PFTs. When I asked my provider why she wanted me to have them, she said, “Well, you have asthma and we do them every three years for people with that diagnosis.” Really? I never had them. And, if I’m not recalling correctly, I KNOW that I haven’t had them since moving to Wisconsin 23 years ago.

And, as far as the vaccine. I will have it when I am of age. I’m not high risk (despite what the computer is telling the doctor) and elected to wait. I’m only 58. There’s plenty of time for me to have a pneumococcal vaccine.

I like my provider, and I like many extended providers, too. However, I wish they would still practice critical thinking instead of placating the computer (and institution) by checking the box.