Friday Reflection 38: Yesterday’s Solutions; Today’s Problems

PR is a 66-year-old man who presented to an emergency room with a week of decreased exercise tolerance. He also reported brief episodes of chest pain. His initial work up was notable only for an elevated d-dimer. He was started on anticoagulation, admitted to the inpatient general medicine team, and scheduled for a CT angiogram of the chest to verify the suspected diagnosis of pulmonary embolism.

The practice of medicine is continuously evolving. The most notable advances are those that beat back the most frightening diseases. Changes that make the practice of medicine easier, more humane, and more efficient get less attention.

I am pretty certain that career satisfaction for doctors is declining. For probably the twelfth time on Sensible Medicine, I’ll reference Lisa Rosenbaum’s essay, Being Well while Doing Well — Distinguishing Necessary from Unnecessary Discomfort in Training which brought some of the current inter-generational angst to the fore. There has been no shortage of thoughtful hypothesizing on the causes of the current state of the workforce: the pandemic, the corporatization of healthcare, the parents of those darn Gen Z-ers.

The Thomas Sowell quote, “On closer scrutiny, it turns out that many of today's problems are a result of yesterday's solutions” has been ringing in my head a lot lately.¹ In my decades in medicine, I have watched the promise of the changes we adopted, changes that seemed necessary, be fulfilled. I have also watched as those changes later caused real problems. To keep this around 1500 words, I’ll limit this to the discussion of two of these: duty hour reform and the electronic medical record.

Duty Hours

A lot of ink has been spilled on the benefits and harms of restricting resident duty hours. There have been observational studies and a handful of actual RCTs looking at how duty hours have affected medical education, patient outcomes, the prevalence of medical errors, housestaff satisfaction, sleep duration…

I am definitely not one to question whether restricting housestaff duty hours was necessary. Most of my undergraduate medical education took place at New York Hospital, where a medical error occasioned the first calls for duty hour reform. I have written about the misery of my schedule during residency.

A week during my internship often looked something like this:

Arrive Monday 7:00 AM – Leave Tuesday 5:00 PM

Arrive Wednesday 7:00 AM – Leave Wednesday 5:00 PM

Arrive Thursday 7:00 AM – Leave Friday 5:00 PM

Saturday off (at least after September 15th when we started to get days off)

Sunday 7:00 AM – Midnight (when I was still at work, but the week had ended).

Duty hour reform was necessary.

Duty hour reforms have led to problems that we face today.

Most medical students feel as though they have been “called on” to enter the field. When I trained, this sense was enhanced by the feeling that I was the primary caretaker of my patients from my earliest days in medical school. During residency I was made to feel like it was up to me and my fellow residents to figure out what was going on with each patient. I was responsible for staying at the bedside of (or at least in the hospital with) my patients until they were stable.

I have no doubt that it is easier to lose the feeling of vocation when your commitment to a patient stops at the end of a predetermined shift; when the care of a patient is assumed by a team that may not even be part of your program; when much of the diagnostic reasoning and many of the treatment decisions are outsourced to an array of consult teams.

That 95-hour work week was not all work. There was a fair amount of downtime. Some of the patients we cared for would not even be in the hospital today. I spent time during these hours bowling, riding around a VA on electric carts, and eating chocolate Ensure pudding.² I also spent a lot of time talking to my co-residents, the inpatient and emergency room nurses, and my attendings – attendings who had worked a similar schedule a few years, or a few decades, earlier. Those attendings were on the service with me for an entire month. There was often a night out together for a beer in the middle of the month and a dinner at the end. You couldn’t help but feel you were being adopted by a family, apprenticed before admission to a guild, pledged to a select society.

It was hard to feel bitter, or abused, or used, when you were surrounded by this kind of community.

Not only am I prone to these navel gazing reflections, I’m also prone to hand-wringing and self-flagellation. Part of what made me write this piece is a feeling that I have been part of the problem, one of a generation of well-meaning physicians whose solutions led to today’s troubles. I was an internal medicine clerkship director who didn’t argue when our attendings lobbied to reduce their stints on the inpatient service from four weeks to two – I was perfectly happy to only work two week shifts. After that change was made, I shortened the students’ rotations to two weeks as well.

EMR

When we whine about the electronic medical record, we forget about how painful – and dangerous -- it was having paper charts: seeing patients in the emergency room with no prior information; spending post call mornings poring over old charts (assuming they’d been found in medical records); constantly placing, and answering, calls from consultants so everyone was “on the same page;” and searching desperately around each floor for a patient’s chart. If we include PACS with the EMR, there was also the waiting at the radiology file room window, while a clerk tried to find an old X-ray.

The EMR can be magic, a wealth of information literally retrieved with fingertips. The ability to “chat” with consultants while the patient is with me at an appointment. The access to medical records from hospitals across town or across the country.

But, as is so often the case, the technology that makes many things easier also causes us to lose something. “MyChart” messages give patients easy access to their doctors for important questions but also overwhelm their doctors with messages about fleeting symptoms or passing 2:00 AM concerns. Electronic communication between doctors undermines collegial relations and educational exchanges, and eliminates nuance from clinical questions. Digital X-rays have turned radiologists — once valued colleagues with whom you would round post call — into mere digital signatures.

PR was admitted to my service at a hospital where I briefly attended. Given his history, physical examination, and lab work, the leading diagnosis – in fact the leading three diagnoses – was pulmonary embolism. His PE protocol CT, however, was negative. We proceeded to evaluate other possibilities. By day three of his hospitalization, we were without a diagnosis. We decided a traditional pulmonary angiogram was necessary – we were still suspicious of PE – so we trudged down to the radiology department to speak to the human being behind the digital signature. When the radiologist reviewed the initial scan, she said, “This CT is negative for PE but only because it is an inadequate study. The scan was done too long after the dye was infused.”

We repeated the CT, which revealed bilateral pulmonary emboli, and recalled the days when the radiologist would have instructed about the inadequacy of the scan during post-call radiology rounds. 

Tomorrow’s Problems

Our current brilliant fixes are, no doubt, creating problems for tomorrow’s doctors. We have an entire cadre of authors warning us about a dystopic future ruled by artificial intelligence while we invite AI into our clinics and hospitals.

We seem to be hoping that AI will bail us out of the fix that the EMR, absurd documentation demands, and overbooked schedules – themselves the result of corporate medicine’s greed  and ill-considered efforts to limit the supply of doctors -- have gotten us into. Already I am watching efforts to have AI answer messages from my patients and document my visits. What could possibly go wrong?

At least this presents the opportunity for an Ozempic metaphor.³ America’s current obesity epidemic is the result of us destroying our food supply over the last 50 years with more inexpensive, hyper-processed, sweetened, fattened, salted food. We have also designed our environments to exclude exercise as a normal part of life. Our reaction to rising rates of obesity, hypertension, and diabetes has not been to repair the food supply -- investing in simple, local produce and taxing the most harmful foods — and to redesign our cities. Instead, it has been to commission designer pharmaceutical products to treat our man made problems. In the same way, after making the practice of medicine nearly impossible, we have chosen to invest in AI tools rather than investing in primary care.

1. If you don’t know much about Sowell, give his Wikipedia page a read. He has had an amazing career – after getting his PhD at The University of Chicago, of course.

2.  At 170 calories per 4 ounce cup, this was a habit I desperately needed to kick.

3. I am hoping that citing Ozempic will increase clicks.