Thursday, October 6, 2016
What has become of these marvelous doctors?
One of the topics that I write most about on this blog is the interaction of health care information technology with frontline clinical medicine, which I believe to be among the most critical issues facing the practice of medicine at the moment. With statistics now suggesting that doctors (and nurses) are spending an absolute minimal amount of their day engaging in direct patient care—some research suggesting as little as 10% for new doctors, with the majority of the rest staring at a screen—health care really finds itself at a crossroads. Do we stay true to our ideals as physicians, keeping medicine essentially a social and personable profession? Or do we reduce doctors to “type and click bots”, spending the vast bulk of their day performing data entry tasks, furiously clicking and checking off boxes instead of spending time with their patients and thinking problems carefully through?
Unfortunately, health care information technology in its current state has done more damage to the doctor-patient relationship than any other 1 single thing over the last decade. Ask any doctor who's been around for any length of time (especially in a generalist specialty), and they will tell you straight up that IT represents 1 of their biggest daily frustrations. It's not that physicians are anti-technology (I certainly am not, and love all my gadgets as much as the next person). It's just that the current crop of IT solutions are not reconciled and fully optimized with frontline clinical workflow. There are so many improvements that need to be made, so that we can tip the balance back towards our patients, while making the most of the amazing technology now at our fingertips.
An experience I had recently in the hospital drummed home this message for me more than ever. I found myself sitting next to two older physicians. They are both great doctors, who I've known for some time, and both very much remind me of the old-school professors who taught me so much back in medical school. They are completely dedicated to their patients, extremely knowledgeable, and are usually the last doctors to leave the hospital in the evening. There had been a small change in the computer system (“small” meaning not a new electronic medical record, but a tweak of the existing one), and I saw these 2 older physicians really struggling to navigate the system. It wasn't the most thought-out design (very few are, and I've worked with nearly all major electronic medical records), and these doctors needed a lot of help to work their way through it.
I and some other colleagues tried helping them, and after some time, they were able to figure things out. Frustrated, head in hands, they then bemoaned the current state of medicine, and how issues like this were driving them toward retirement. I knew that these doctors were very old-school (old-school physicians are undoubtedly the best!), and they remarked how they hardly spent any time with their patients anymore. They were excellent doctors, and I knew their patients loved them.
As I sat next to them watching them staring at the screen and struggling, I felt a mixture of emotions. At first perhaps sympathy (but then, most younger doctors also don't like spending so much time staring at the screen either). Then I felt disappointment. Disappointment that doctors like them, who believe in solid bedside medicine, physical examination, and face-to-face communication skills—are being replaced by “type and click bot” doctors. What will become of those great teachers of medicine who I learned so much from? Those doctors who would spend most of their day interacting with patients on rounds, and only a few minutes at a time writing notes and giving their orders. Finally, I began to feel a little fury inside me. Fury that these two amazing doctors were frustrated, staring anxiously at their screen and spending their valuable time ticking boxes and clicking their mouse, instead of sitting by the bedside and practicing the trade they are so good at. For every excess minute they spent on the computer, a patient, usually elderly, was deprived of time with their trusted doctor.
As we stand at this crossroads in health care, let's not lose sight of the unbelievable work that doctors from this generation have done and how loved they are by their patients. We can't let the art of good and thorough bedside medicine go with them as they retire from clinical practice. Art is a good word actually. Despite all the technological advancements around us, medicine is still very much an art. In some ways, yes, a performance. The world of administrators and technologists need to understand this, and work with frontline clinicians to keep humanity and personal relationships at the core of medicine. Nobody who goes to medical school anticipates spending 80-90% plus of their day sitting in front of a screen. No doctor, nurse, or most importantly, patient, wants that. So what exactly are we doing here? When the old-school generation of doctors leaves, I fear for what's left and who our role models will be.
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
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David Katz, MD
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Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
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Other blogs of note:
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
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The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.