Twenty-five years have passed since I finished my residency, and a lot has changed. Back then, we hand wrote all our notes, and the only time we looked at a computer screen was to obtain laboratory results. Now, residents spend more time in front of a computer screen than at the bedside.
I contend that electronic health records (EHR) are an obstacle to learning the art and practice of medicine during residency training. A far more insidious and formidable obstacle may be the health care system itself, which now seeks to produce “health care providers” that generate revenue value units (RVUs) and quantify patient “encounters” according to mandated metrics. More and more, we, as physicians, are becoming servants to bureaucratic and technologic “masters” and increasingly serve as cogs in a soul-less machine.
The challenge facing you and each of us that has come before you is to confront and overcome these obstacles … while, of course, giving the devil his due … and to remember the impulses that led each of us to seek a career in medicine.
The essence of residency training includes the development of the essential clinical skills of obtaining a thorough and relevant history without checking off a series of boxes on a computer screen, performing a competent and relevant physical examination, and, in my specialty, neurologic examination, composing a proficient differential diagnosis, arrive at a reasoned assessment and produce a diagnostic and treatment plan based upon sound medical reasoning, not from a cookbook “order set.”
These are your challenges and should be your obligations during residency training:
To master the art of ferreting out a history from a fellow human being in the sick role or what we call a “patient.”
To master what many older physicians consider a disappearing art…that of the physical examination.
To master the art of reasoning through history and examination findings to formulate an appropriate differential diagnosis.
To learn to utilize diagnostic testing judiciously and appropriately rather than using them as a substitute for critical thinking.
To continuously strive to appreciate the humanity of the people you care for, your colleagues, coworkers, and yourself.
Oliver Sacks, a prominent neurologist and author, once said: “In examining disease, we gain wisdom about anatomy and physiology and biology. In examining the person with the disease, we gain wisdom about life.”
I always encourage residents to learn more about the world we live in and the people in it; to read not just medical texts and journals but also the writings of Dr. Sacks, Atul Gawande, Jerome Groopman, Lisa Sanders, and others which appear not only in books but in essays in the dwindling print media or, in the case of Lisa Sanders have been adapted from her New York Times Magazine articles to the Netflix series Diagnosis, which, I suspect, that many of you have seen. These writers provide a window into the very humanity that our system and electronic health records obscure.
During the current pandemic, many of you may have read or reread The Plague by Albert Camus. I have. One of the great literary masterpieces of the 20th Century, it describes the humanity of those afflicted by the disease as well as that of those seeking not only to care for the afflicted but to stem the spread of disease. I suggest that this novel is particularly relevant today.
I hope that your time here is well spent and that you each reach your goals of becoming compassionate and competent physicians. There are real obstacles in your way, but they can be overcome.
We are here to help you as you continue your journeys. I am sure that I speak for everyone here in saying that we are here for you and available to help and support. I am here pretty much every day and happy to chat with any of you regardless of the circumstance.
So, welcome and best wishes over the next few years.
Thomas J. Clark is a neurologist.
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