My young patient was dying as a blood clot under the cover of her brain accumulated and began compressing the fragile tissue within her skull. She needed surgery to remove the clot that would save her life. As the team pushed her from CT scanner to the operating room, it was soon realized labs were missing and were needed before opening her cranium.
“There’s no order in the computer!” someone shouted out. As I pushed the patient into the operating room, what was I supposed to do at that critical moment? Drop what I was doing and find a computer to enter the order or continue in trying to save her life? The world of the electronic health record mandates the former, but my oath and duty as a physician command the latter. This struggle reflects the conflict physicians of today and the future will continue to face as the management and administration of health care continues to monopolize the practice of medicine.
Growing up in a family of physicians, I was exposed to hospitals and health care from an early age. I fondly look back at my experiences in various hospitals around Oklahoma, waiting for my father to finish rounding on his patients while comparing the quality of snacks at each local hospital lounge. The few occasions my anesthesiologist mother made me wait in the operating room (OR) break room, while she finished waking a patient, afforded me various interactions with pleasant OR nurses, anesthesiologists, and surgeons. I would rarely hear complaints from my parents about their work, but occasionally concerns with insurance companies or hospital administration arose. Overall, they enjoyed going to work every day and caring for patients.
When I began flirting with medicine as a career choice, my father advised, “If you’re in it for the lifestyle and financial gain, then don’t be a doctor.” When I pressed him, my father presciently admitted that being a doctor in my generation would be vastly different from his experiences, yet even knowing this, that if he were permitted a do-over, he would still be a physician. In spite of our conversations, I couldn’t perceive any specific changes he foreshadowed or perhaps experienced. He and my mother went to work, they came back home, they enjoyed their patients, the enjoyed staff they worked with, and their routines remained seemingly static.
Influenced by my parents as well as my older brothers (now also physicians), I entered medical school with a desire to channel my passions for people and their health. Four years of classroom learning and hospital rotations in medical school culminated with a match into a neurosurgery residency, and I was ready for the next step of my career. I was actually getting to do what I signed up for: going out into the hospital, learning from the best teachers, caring for real patients and helping people get better. Or, at least I thought I was ready.
What they don’t teach in medical schools, unfortunately, is what my father and many older generation physicians like him clairvoyantly foresaw, that medicine is no longer what it was. What we don’t see as medical students and brand new doctors is the seemingly obstructive components of health care today that bog us down and distract us from the basics of doing our jobs. Thus, when the reality of training begins and the young physician begins spending the majority of his or her life in various hospitals across the country, so begins the systematic jading of the young physician.
The influx of new regulations and administrative oversight into the daily practice of physicians range from the petty and mildly annoying to those that significantly alter how doctors provide patient care. Another annoyance might be the “no coffee in patient areas” policy of many hospitals. Rounding at 5 a.m. often requires some caffeine, but these days you can’t even hold a cup of joe outside a patient’s room. No actual studies are sighted for these changes, but hospital regulations mandate that we all follow silly, yet morale killing rules. These minor annoyances, though likely well intentioned, are examples of the lack of evidence-based policies and changes that come from hospital administration to serve as defensive measures from the most extreme occurrences, yet influence how physicians can best focus on our most important duty, the patient in the bed in front of us.
While the coffee could likely be disregarded by many as the small qualms of physicians, the expansion of electronic health records and “quality assurance” policies are at grave risk of undermining the work of the physician, physician morale, and patient care. As a neurosurgery resident in a busy service, I quickly learned that much of my job was checking off boxes and filling in blanks not necessarily to enhance patient care, but to fulfill some hospital requirement or policy. For example, at the local children’s hospital, an adverse event occurred with incorrectly administered MRI contrast. The event had nothing to do with any physician, however, the response from administration was to compel the ordering physician (me) to spend extra time filling out extra paperwork. All the extra time taken to perform these tasks, undoubtedly take time away from physicians wanting to perhaps spend extra time with their patients
Along with EHR, the new trend of “quality assurance” has begun to sweep through hospitals. Recently, I watched a hospital administrator grade our chief resident on the basis of a single interaction with a patient. Forget that the chief resident manages multiple patients’ problems every day and has 6+ years of residency training, but now their evaluation and record as a healer will come from an individual who has never worked in an operating room, never given a patient’s family the worst of news, and has never touched a patient. By the time we are graded like school children after ten years of medical education and training, the jading of the young physician is nearly complete.
Furthermore, the new generation of health care providers spends so much time involved with “indirect care” (i.e., charting, documenting in the EMR), that the actual art of medicine, the humanistic healing hands of physician on patient has been compromised. Nurses and physicians alike find themselves mired in computer work so that the patient loses out on quality interaction.
I’m sure many who read this will point out how necessary many of these policies are in ensuring that doctors provide the best care. However, a lack of flexibility and evidence-based approaches can do more harm than good in many a situation. Yet, we cannot place all the blame on management. Physicians as a group have lost the battle of controlling the delivery of care patients receive as most physicians in many instances feel their job is to solely care for the patient. Doctors, particularly young physicians like myself, should neither go quietly nor cynically and allow such policies to pass without question and continue to jade our experience. The young physician must adapt and take a leadership role in this modern era.
The challenge for physicians in delivering cost effective, efficient, and high quality care lies in not losing sight of the big picture amidst the fray: the sick patient in a hospital bed who hopes his physician will always do the right thing irrespective of all else. Before medicine became a business, the common denominator was and remains the patients. As physicians, we should not allow ourselves to be weighed down by rules and regulations, but rather understand and appropriately challenge them when necessary. Hospital administrators, politicians, and insurance companies aren’t going anywhere anytime soon, so physicians, young and old alike; have to learn to become a part of the process. “The practice of medicine,” as Osler wrote, is “a calling, not a business “ Even if it does mean losing the coffee, smiling more, fluffing patients’ pillows, and listening to the people who sometimes have no idea what taking care of someone really means.
Hakeem Shakir is a neurosurgery resident.
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