What has gotten better and what has gotten worse since you started in medicine
6 doctors respond.
I asked 6 doctors — at different stages of their career — to tell you, dear Reader, what has gotten better and what has gotten worse since they began in medicine. I also took a stab at it. Here are our answers. If you leave your answer in the comments, I will curate and publish the most interesting responses.
Vinay Prasad, MD
Vinay Prasad’s Better and Worse
I started in medicine 19 years ago, and during this time there have been gains and setbacks. Among advances are our drugs – probably the biggest change. Pembrolizumab and Nivolumab came out of nowhere and have dramatically improved cancer outcomes. Ironically, the Nobel Prize also went to ipilimumab, which is the worst of the lot.
The quality of medical students has also improved. They are smarter. Maybe that is the Flynn effect. Finally, you can hear a range of voices and opinions through the democratizing power of social media, though I suppose this is also a setback.
It is only the rest that has gone to shit. Discharge planning is worse than ever. Medical education has been hijacked by woke warriors. Those smarter students now have a dumber curriculum. The hospital is breathing down your neck to discharge patients who still need care. Annual training modules no longer let you click to the end, skipping the bullshit. They are psychologically abusive and remain unhelpful. Doctors are less likely to own their practice. We are employees working for the worst administrators imaginable.
The EMR makes some things nicer, but the 350 ms delay every time you click, gradually grinds your soul. Universities have abandoned academic pursuits and desperately try to prostitute themselves to Pharma, to acquire enough cash to buy up regional practices, and further their monopoly. Every oncologist also “runs trials” and that title takes on greater importance than “actually being a good oncologist.”
It is a small thing, but the quality of the bedsheets has hit a new low. It is coarse and threadbare. The blanket is not warm and the bed has been coated in neoprene so it is uncomfortable. That symbolizes the patient experience. Calling an insurance company or hospital or doctor makes you want to kill yourself instead.
When I started in medicine, there was a rack with scrubs and you could take what you needed. Now they are dispensed from a vending machine that stores only 2 credits per person, and doles them out capriciously, because you are probably a thief. That’s the perfect metaphor for medicine. Some piece of shit administrator made it harder for a doctor or nurse to do their job, demeaning you and wasting your time. They probably hired a consulting firm to give them that advice, and would have saved money, except the machine keeps requiring repairs.
John Mandrola’s Things that have improved; things that have worsened
For the better: The most obvious improvement has been innovation in therapeutics. It is crazy good. I’ve stopped asking cancer doctors whether I should treat a person’s arrhythmia, because the answer is nearly always: we can treat his cancer, please fix the rhythm. Heart failure therapy has allowed patients to live long enough to die of something else. When I started in medicine, patients with myocardial infarction suffered severe heart damage or died; now, they get sent to the cath lab, have a stent, leave the next day with a band-aid on the wrist and play pickleball in two weeks. And. All of this occurred because of profit motive. Milton Friedman would be proud.
Innovation has also transformed medical information. In the old days, to see a simple x-ray, I had to go to the film library, check out a film and bring it to a radiologist. Now, I can review images with the patient in the exam room in two seconds. Then there is the smartphone and internet. Things that once had to be memorized can be found in seconds. New procedures can be learned via YouTube. Plus, we are likely at another inception point with artificial intelligence.
Worse: Profit motive is like wind when you are outside cycling. As a tailwind, profit motive powers innovation. Yet profit motive also serves as a tortuous headwind to the medical profession. Perhaps the ugliest effect of profit motive has been the corporate takeover of healthcare. Policymakers promised that merging health systems would make care more efficient. Nothing could be further from the truth. Administrative bloat born from merging of hospitals has nearly decimated clinical medicine. Employed doctors got nice signing bonuses but soon learned that they served two masters: the patient and the mid-level manager. I struggle to find words to express how demeaning it is to answer to non-medical mid-level managers.
The flip-side of progress is how it has worsened end-of-life care. I tell learners in cardiology that your greatest challenge is not having something to do to patients, but whether you should do it. Almost every day, I have to decide whether to do something to an elderly person with multiple diseases. Nearly all the evidence we use to guide care comes from trials that enrolled younger patients with minimal co-morbidity, but, too often, we forget that older people benefit more from common sense and empathy, than evidence. Perhaps the loss of professionalism has reduced our ability to stop the madness at end-of-life. It’s getting worse too.
Adam Cifu’s Better and Worse, and what remained Good
As you would hope, what is better is that we have so much more to offer. The medical advances during my career are miraculous. Because of our cardiovascular prevention efforts, not one of my patients has had an MI in over a decade. I care for the 3 patients with HIV; they are all over 80. I manage their hypertension, diabetes, osteoarthritis, and other “diseases of aging.” I care for people with melanoma, breast cancer, and lung cancer who have lived with their disease for years. I care for two woman who presented in in their 30’s with widely metastatic triple negative breast cancer. They are both cured. Cured!
In addition to the progress, we have acknowledged dozens of reversals and changed our practice.
We no longer starve people with pancreatitis.
We don’t give antibiotics to everyone with diverticulitis.
We don’t operate on everyone with appendicitis.
We don’t fix degenerative meniscal tears.
We don’t try to convince every post-menopausal woman to start estrogen.
We don’t stent everyone with stable angina.
We don’t do “radical mastectomies.”
What has remained good is that visits to a primary care doctor can still be patient life-changing. In this crazy, fast moving world, in which everybody seems to be selling something, the office can still be a place where I get to know a patient and we work together to figure out what is the right thing to do. We work collegially, incorporating my medical knowledge and clinical experience with their goals and values.
What has gotten worse? I continue to believe that the impact of duty hour limitations in residency training has done net harm. The errors that led to duty hour reform were the result of poor supervision. Instead of improving supervision, we limited duty hours. Sure this has made training more humane -- residents no longer fall asleep over charts, doze at every conference, and nap while driving home as I did. But duty hour limits have cut into the volume that is critical to mastering independent practice. It has robbed the sense of responsibility that comes from “owning” a case. Our residents are amazing, and with deliberate practice most still come out OK, but something has been lost and there is no data that shows us that anything important has been gained.
Sarah Stein’s Better and Worse
I have been practicing medicine for about 30 years, including six years of post-medical school training. The digital world has emerged during this time, transforming our lives in ways fundamental to the daily activity of patient care. Sometimes we aren’t even in the same room as our patient, opting to obtain a history in a remote environment, practicing what has been termed “telemedicine” (some might rate this as improvement, others the opposite).
The changes that I celebrate include:
A medical record that is easily searched and accessible and legible, and includes data from care provided at not just the patient’s primary care site (though not all sites of care are yet reliably included).
A medical record that contains clinical images accessible to all providers.
Technology that allows for clinical photos to move seamlessly from the camera to the medical record. This technology has saved me hours of photo management. Gone are the rolls of film that had to be developed, the slides that had to be reviewed and sorted and labelled and stored.
Access to the medical literature from any computer anywhere. Gone are the days of schlepping over to the medical library, scouring Index Medicus for relevant literature, pulling journals off the shelves and photocopying articles. And let’s not forget the selection of referencing software technologies that create reference lists at the click of a button.
The ease of looking up details about obscure or simply forgotten diagnoses, often accomplished between patient visits, or even while sitting with a patient as we puzzle through their concerns together.
Electronic prescriptions. No more calls to the pharmacy, spiraling through phone menus, leaving voice messages, or waiting on interminable hold for the pharmacist.
Biologic and small molecule therapeutics have provided previously unachievable results in the treatment of some of our most refractory diseases.
What is worse today?
The proliferation and easy access for patients to inaccurate medical information.
The constant churn of the EMR that never stops requiring a response to patients, pharmacies, other providers, etc.
The “prior authorization” process that often impedes providing optimal care and sucks the time and energy of providers.
Sarah Stein is a pediatric dermatologist and a Professor of Medicine and Pediatrics at the University of Chicago.
Will Ward’s Better and Worse
In my short tenure, I’ve noticed a rising problem: instead of thinking for themselves, medical professionals increasingly defer judgement to the most accessible expert. This can have unfortunate consequences. Yet, a countervailing trend lends me hope. Platforms like Substack have decentralized access to information, debate, and opportunities to deliver evidence-based care.
During residency, I frequently heard this refrain, “It's great that you look into things, I simply don't have time.” It is not difficult to understand why so many physicians feel this way:
The number of guidelines, quality metrics, and incentives has made the administrative and intellectual burden of medicine untenable
People are burdened by more chronic illnesses, medications, and devices than ever before
The volume of research publication increases every year. Physicians do not know which articles to read or how to read them.
Many feel the only reasonable option is to defer judgement to guideline writers. The pandemic revealed the consequences of this anti-intellectual tendency. Covid should have brought people together to have challenging conversations, maybe even participate in critical appraisal workshops. Instead, Jay Bhattacharya’s covid symposium was portrayed as heretical.
Too many of us were unfazed by babies getting covid shots, perpetual boosters, vaccine mandates, the delayed release of Paxlovid EPIC-SR data, and the prolonged shuttering of the schools in pursuit of health. Our eagerness to be missionaries of guideline-writers overruled our capacity to debate the evidence.
But. This problematic trend is countered by one that makes me optimistic: access to information is improving. There have never been such abundant opportunities to engage with courageous and critical thinkers.
Substack, for example, is a rising model for distributing information that legacy journals and news outlets are struggling to keep up with. Here, nuance is in demand; black and white thinking is going out of style. Now, anyone can develop critical appraisal skills. It merely requires effort.
It matters less where one goes to medical school or residency. What matters most is one’s curiosity, resourcefulness, and humility: attributes that seem as important as ever.
Decentralized communication on platforms like Substack may reinvigorate jaded physicians. It may also improve delivery of evidence-based medicine.
Will is an internist in Iowa, and a frequent writer for Sensible Medicine.
Timothee Olivier’s Better and Worse
When Vinay Prasad asked me what I saw as the positive and negative changes since the beginning of my medical practice, I chose to focus on just one element in each category.
In workplace relations, particularly in hospital settings, it seems to me that certain violent behaviors, especially verbal ones, are now less tolerated than before. As a medical student, I witnessed surgical clamps being thrown in the operating room, people being verbally humiliated, and abusive behaviors carried out with complete impunity, often by individuals in positions of authority. Today, and this likely reflects a broader societal shift, such behaviors seem rarer, at least in their visible forms.
Conversely, a fundamental aspect of medicine appears to be deteriorating: the ability to synthesize information and maintain a global vision of the patient. I remember my early internships in oncology, where weekend handovers were conveyed in just a few words on a simple piece of paper. Today, that clarity is disappearing. Digitalization, largely driven by billing requirements, has made access to medical information more complex. Logging into a patient’s file no longer guarantees an immediate understanding of the reason for their hospitalization or the key issues in their care. I feel that this is gradually affecting the way medicine is taught, and synthesis is becoming a less and less cultivated skill.
Timothee is an oncologist in Geneva, Switzerland and my co-Editor at the Drug Development Letter
I hope you found this as interesting as I did. There were some recurring themes. Several of us said drugs or therapies were the biggest difference in medicine. A number of us lamented the relentless profiteering or its’ downstream sequela. A few of us discussed cultural changes, both the good and the bad. And a couple of us appreciate the fact that you can now read diverse ideas in medicine. What do you think? Write your better and worse below, and I will compile the most interesting responses for a future column.
-VP, San Francisco
I have two.
1. Mental health care is abominable (and almost entirely drug-dominated) or it is completely non-existent (especially for people who need it most). It is the most shameful embarrassment of modern medicine.
2. For a nation that spends nearly 20% of its GDP on healthcare (largest globally), the return for patients is pathetic. The return to healthcare corporations (mainly ownership and management) is immoral. The operative model is really “disease care” — not healthcare. More sickness means more money. So, where’s the incentive for wellness?
I enjoyed this read immensely. As a PT since 2000 and an owner of my own practice since 2009, I think my experience mirrors a lot of what is written here (translated to PT of course). The admin burden will continue to choke us, declining reimbursement will finish us off. In Massachusetts where I practice we are in the precipice of changing our practice act to include being able to order imaging. That frightens me. As the docs here talk about the potential of over medicalizing a patient, how many times do I hear I need an X-ray or an MRI and in the end, most of the time (more than 95%), it does not change what we do with our patients as PTs. So change can be good (not hand writing 20 notes and 3 evals in a day) and it can be bad (needless waste of healthcare dollars that don't impact the plan of care significantly). One last thing. I love this group of doctors and wish I knew such thoughtful and engaged care providers in my local area. You inspire me to be a better provider and not let the bad parts get me down and cloud my way to doing what I love.