Thoughts on Gawande’s “The Upgrade”

In the end, we are dependent upon the creatures we have made. Goethe

The Upgrade (Full New Yorker Text)
Why Doctor’s Hate Computers
by Atul Gawande
The New Yorker, November 12, 2018

Gawande’s thesis is that the electronic medical record (EMR) has contributed greatly to the epidemic of physician burnout in the United States.

A 2016 study found that physicians spend about two hours doing computer work for every hour spent face to face with a patient. The result has been epidemic levels of burnout among clinicians. Something has gone terribly wrong.

The software created for the EMR has spawned this massive monster of incomprehensibility. So much of what physicians have document now is pointless. Basically, it justifies coding, billing and reimbursement – not benefit to suffering humanity.

Christina Maslach studied the phenomenon of occupational burnout. She defines burnout “as a psychological syndrome emerging as a prolonged response to chronic interpersonal stressors on the job. The three key dimensions of this response are an overwhelming exhaustion, feelings of cynicism and detachment from the job, and a sense of ineffectiveness and lack of accomplishment. The significance of this three‐dimensional model is that it clearly places the individual stress experience within a social context and involves the person’s conception of both self and others.”1

The rate of burnout seems to vary by specialty. A Mayo Clinic study discovered that one of the strongest predictors of burnout was how much time an individual physician spent tied up doing computer documentation.2

Greg Meyer is the chief clinical officer at Partners HealthCare. He says we think the EMR as a system is for us (as physicians), but it’s not. It’s for the patient. [Clearly, it seems that he is an apologist for the EMR.]

It’s perfectly possible to envision a system that makes care even better for those who receive it and even more miserable for those who provide it. In the past, man has been first; in the future, the system must be first. The computer by virtue of its brittle and rigid nature seems to require that it comes first.

The systems theorist, David Woods, notes, human beings are designed to handle surprises. We are resilient; we evolve to handle the shifting varieties of a world where events routinely fall outside the boundaries of expectations. As a result, it’s the people inside the organizations, not the machines, who must improvise in the face of unanticipated events.

Gawande discusses the evolution of the medical scribe. This phenomenon, as a fix, admittedly is a little ridiculous. We replaced paper with computers because paper was inefficient, so we’re now hiring more humans to do the paperwork that computers were supposed to do away with. The error rate of scribes is between 24 and 50% in the recording key data. Therefore, the physician has to review everything a scribe does and this takes time.

The Massachusetts General Hospital (MGH) has been trying out a virtual scribe service in which India-based doctors do the documentation after reviewing digitally recorded patient visits in Boston. [To me, this sounds crazy. If a physician at the MGH digitally records information that is transcribed by a physician in India how does this really help improve patient care? This is serving the business of medicine, and not the patient as a person. In addition, this takes time away from Indian patients; time these Indian physicians could devote to caring people in India. So, it is immoral, too.]

The story of modern medicine is the story of our human struggle with complexity. Technology will, without question, continually increase our ability to make diagnoses, to peer more deeply inside the body and the brain, to offer more treatments. It will help us document it all – but not necessarily to make sense of it all. Technology inevitably produces more noise and more uncertainties.

[Comment: To me, the EMR is part of a much bigger problem with how medicine is currently practiced. Over the past four or five decades medicine has become more and more a business.

Osler, famously wrote: The practice of medicine is an art, not a trade: a calling not a business; a calling in which your heart will be exercised equally with your head. Today, the fiduciary relationship between doctor and patient has become a mercantile proposition. The treating physician is an integral part in the Medical-Industrial-Academic complex. PhRMA and device makers throw money at practitioners and have co-opted many academic physicians. As government has backed away from funding some research, PhRMA has been all too happy to step in. Our continuing medical education (CME) is often taught by key opinion leaders (KOLs) who push expensive new meds while older, safer and cheaper ones are often just as good.

The EMR was sold to practitioners and organizations as a documentation tool that inflates the billing codes we use after patient encounters. As beneficiaries if this largess we have accepted the inconvenience as long as the money keeps rolling in. Now, like the man who killed his parents, we are throwing ourselves on the mercy of the court because we are orphans. We are content to be employees of organizations being paid better than if we worked for ourselves but the unintended consequence is increased burnout.

In the early 1990s, I read a poem in the medical journal, The Pharos. I can’t find it any longer, but I remember it:

He lost something in the gain.
His face changed in a way I can’t explain.
I look outside and watch the rain.

I’d modify it a bit:

She lost something in the gain.
Her face changed in a way I can’t explain.
I look within and feel the pain.

References:

  1. Maslach C, Leiter MP. World Psychiatry. 2016 Jun;15(2):103-11. Understanding the burnout experience: recent research and its implications for psychiatry.
  2. Shanafelt TD et. al. Mayo Clin Proc. 2016 Jul;91(7):836-48. Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction.

 

 

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