What we are trying to do is create a system that gets rid of the human factor.
– an internal medicine physician
I heard this statement in a patient safety seminar designed for medical residents. I paused, shuddered even, as a resident who writes poems and reads novels in my free time. To my surprise no else blinked an eye. And why should they? The concept that physicians’ humanity and empathy shape health care may be popular in the press. But it is frequently a side-note to real medicine, where science means getting rid of human error.
The new buzzwords in health care (efficiency, checklists, productivity, pay-for-performance) share a common target of making the hospital run more like a factory. The history of this shift is understandable: after the Institute of Medicine’s To Err is Human report citing over 50,000 preventable deaths per year to medical error. What is missing from this analysis is an examination of the nearly 700,000 deaths yearly due to gaps in screening, immunizations, and access to care. Clearly, designing better systems (with the help of non-human computers) could help in keeping track of increasingly complex patient data.
But a factory model of health care can only go so far. We know that the physician-patient relationship is a powerful motivator for change; we know that primary care saves lives over time; we know that physicians have a unique perspective to advocate for improved social conditions for patients.
Here is the big question: Is it possible to design a health care system that optimizes the human factor? Context matters. The above physician was not maligning the human factors of medicine — he was just selectively forgetting them. He spoke about a project that aimed to increase the use “sedation holidays” in the intensive care unit, resulting in massive changes to the existing electronic medical record (EMR). It is a zero-sum game. For each project devoted to EMR there is a missed opportunity to study human factors of empathy, motivational interviewing, or physician creativity. This is not for lack of an evidence base. As physician Danielle Ofri notes, the rate of severe diabetes complications in patients of doctors with high empathy rating is 40 percent lower than in low-empathy doctors.
I wish I could create a catchy bullet point plan to re-imagine medical training that optimizes human factors. But this would be disingenuous. The increasing shift to a factory model of care is not going away as its roots are deeply embedded into the financial structure of medical training and practice. To re-imagine a medicine that takes seriously the depth of human connection requires one to separate oneself from vocabulary of efficiency, checklists, and productivity. To shift vocabulary is the first step: The next is to change the questions we ask ourselves as clinicians. As individuals and care teams, we might ask the question, “What are the human factors that lead our patients to get better?” And going a step further, “How might we measure this?”
Tom Peteet is an internal medicine resident.