the metablog

Thoughts, news and musings from metajournal.

The problem with Electronic Medical Records

Doctors spending too much time using computers and electronic medical records

It is not so much that all Electronic Medical Records are terrible, but rather that it is so close to true that the occasional net-positive EMR roll-out does not move the needle much on its own. The greater challenge is that the reasons why the EMR experience is so poor also make it unlikely that EMRs will get dramatically better in the short-term.

The root of the EMR problem, fundamental to their very nature, ensures that EMRs will get worse before they get better.

I'm yet to be impressed by a hospital-wide monolithic EMR – one that is intuitive to use, enhances safety and reduces clinician workload rather than adding to it. An EMR that offloads administrative burden from healthcare providers, and enhances authentic interactions with patients. Where are the truly efficient EMRs that are true improvements to the paper-based systems they replace?

“Show me an [EMR that] only triples my work and I will kiss [their] feet.” – House of God1

Many EMRs are frustrating and inefficient, though tolerable in a necessary-evil kind of way. Clinicians put up with the many small EMR-inflicted aggravations because of the promises made for improved safety, efficiency and lowered costs. Yet the modern EMRs of today have largely failed to live up to even these low-bar aspirations.2

Read on about failed EMR promises...


  1. Shamelessly stolen and adapted from Samuel Shem's (Stephen Bergman) classic House of God

  2. I use ‘EMR’ (Electronic Medical Record) in the strictest sense here, meaning a system for managing medical records in a hospital or group of hospitals. In North America ‘EMR’ is sometimes used interchangeably with ‘EHR’ (Electronic Health Record) which is more accurately a population-wide record of health, such as Australia’s imperilled My Health Record. In this example the EHR is an aggregator of health summaries, not a hospital medical record. At a medical-practice level, it is more accurate to talk about ‘practice management software’ than EMRs. 

Ketamine, Checklists and Social Media

Metajournal on Ketamine, Checklists and Social Media with ice-cream

As I read articles this week, three very different papers created a nexus of interest and push-back against mildly dogmatic thinking in the critical care specialities. Two challenge existing anaesthesia dogma, while the third highlights the potential for missteps when incorporating new media into our practice and education.

Although critical care specialties like anaesthesia and emergency medicine are often seen from the outside as embracing change and being unafraid of dipping our collective toes into the rivers of progress, there are still many strongly held views that persist even in the face of contrary evidence.

Ketamine and persistent pain

Chumbley, Thompson, Swatman and Urch report in the European Journal of Pain the results of their double-blind, randomised, placebo-controlled trial of a 96-hour perioperative ketamine infusion to reduce persistent post-surgical pain after thoracotomy. Notably they found that this significant-duration ketamine infusion did not reduce post-thoracotomy chronic pain.

This paper is the first quality RCT to follow thoracotomy patients for a year after surgery in the setting of perioperative ketamine. It adds to existing evidence suggesting a lack of effect of ketamine for mitigating persistent surgical pain – even though this has been a popular opinion (hope?) among anaesthetists and pain specialists in the past. The results of the ROCKet trial will provide us with more confidence in answering this question.1

Read on for anaesthesia checklists and FOAMed mistakes...


  1. A collection of related articles can be found here: Does ketamine reduce persistent post-surgical pain? 

Are there any truly universal anaesthesia rules?

It’s not uncommon to hear anaesthesiologists drop verbal markers of universal truths into their clinical utterances: always, every, never. Often it's the most banal practices ("always attach the cannula tegaderm so") that generate our greatest passions.

However there are few, if any, universalisms in anaesthesia. Almost every rule has caveats and exceptions, reflecting the shades-of-grey reality of patient needs and human physiology.

When clinicians decree something is always or never so, they are often confusing truth with convention. Sometimes confusing an absolute with what is instead dogma. A minority reveal the rigidity of their thinking, impeding rather than enhancing the performance of their practice.

Rules are still useful. They are important guardrails, a mental model to keep us on the road of safety unless there is very good reason to cautiously edge onto the gravely shoulder, or even turn down a completely new path. But always with the understanding of the compromise we have intentionally made, reminding us of the cost that may need to be paid.

Universal anaesthesia rules become a problem when we dogmatically extol them without understanding the foundations of why – or use them as a blunt tool to browbeat our colleagues and assistants.

Rules are shortcuts to express the tension between the benefits and risks of different anaesthetic decisions. All difficult airways in specialty exams might require mandatory awake fiberoptic intubation, but in a real world of patient refusals and modern airway toys & techniques, it is a more nuanced decision. In fact, patient refusal might be the closest we get to an absolute rule – but even this is a negotiable area of greys.

As a mental model for normalising risk, rules are an efficient way to communicate our prioritisation of the risk-benefit tension. A tool for education and standard setting, without requiring the immediate overhead of qualifying and rationalising.

First learn the rules. Then master the rules. And only then can you break the rules.

The danger comes when we confuse the mental model – the guardrails – for the reality. Misidentifying a tool to guide perception and practice, as something we mistakenly believe reality can be bent to. When we make this error, reality has a nasty habit of reasserting itself with unsentimental brutality.

I made my mistakes so you don’t have to. Don’t repeat my mistakes. Make your own mistakes. Make better mistakes.

Browse articles by Journal, Year or Issue

As well as suggesting interesting articles online or in your weekly emailed metajournal, you can now also browse articles by journal, year or even just scroll through a single journal issue. Simply click on the journal name or issue date above an abstract to focus your abstract browsing.

So whether you want to see the latest articles from the British Journal of Anaesthesia, the top articles of 2017 from the American Journal of Emergency Medicine, or simply browse through the October issue of Current Opinion in Anesthesiology, metajournal can keep you up to date.

Metajournal.com browse medical abstracts by journal, year or issue

Of course, signed-in users can also search across any of these scopes – say, if you want to see the top remifentanil abstracts from IJOA, or find that elusive C-MAC c-spine article you vaguely remember seeing in a 2017 Am J Emerg Med issue – just hit the Search... button.

The 4th Horseman: Research Fraud & Mountains of Fujii

The fourth and final horseman of the medical research apocalypse is the scourge of medical research fraud. Although certainly not a new problem, the scale and potential impact of research deceit is unlike anything faced previously.

Academic fabrication, falsification, and plagiarism (FFP) make up the breadth of academic fraud – and sadly, anesthesia is the number one specialty by volume. In 2012 our eyes were opened to the sheer scale of the problem as the largest medical research fraud in history was exposed.

Trust, responsibility and the Fujii fraud

Medical research involves a lot of trust. The trust of patients and the public, the trust of publishers and the trust of the research-consuming clinician. Unfortunately we often overlook our responsibility to ensure that our trust is not misused.

"...with increasing amazement, we notice that the results reported by Fuji et al. are incredibly nice ..." wrote Kranke, Apfel and Roewer in their April 2000 letter, politely challenging Yoshitaka Fujii's PONV research.1

And so began the very slow unravelling of the biggest academic fraud in the history of medicine. Despite a meaningless response from Fujii to that first challenging letter, there was no investigation or further questioning from the various anesthesia journals. In fact Anesthesia & Analgesia went on to publish another 11 articles by Fujii over the next decade.2,3

Read more...


  1. Kranke P, Apfel CC, Roewer N, Fujii Y. Reported data on granisetron and postoperative nausea and vomiting by Fujii et al. Are incredibly nice! Anesth Analg. 2000 Apr;90(4):1004-7. 

  2. To their credit A&A were instrumental in ultimately uncovering the fraud and have lead the charge in undoing the damage inflicted by Fujii. Shafer SL. Fujii Statement Of Concern. Anesth Analg. 2012 Mar 7. 

  3. Yentis SM. Lies, damn lies, and statistics. Anaesthesia. 2012 May;67(5):455-6. 

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