The Good, the Bad, and the Ugly
I have been a Doctor of Medicine for half a century, and I am now in my last month on the job. I have a few observations that I feel I have the right to share “just because”. It has been a wild ride mostly good sometimes terrifying often frustrating. Good does not make headlines, and by nature is often not as interesting as terrifying or frustrating. Also, good can usually not be made better, as they say, “better is the enemy of good.” Among the good has been the joy of seeing pain and suffering eased, a life saved, a new life brought into the world, and tears turned into a smile. The last five years have been especially rewarding as Program Director of a Surgical Residency. Seeing young, enthusiastic men and women learning the art and science of surgery, growing in knowledge and skills has not only been a joy, and a source of pride, but an honor as well. So enough about good. I won’t be able to make it any better, but the bad, now there is something that begs to be made better.
What has been bad? Medicine and surgery are slowly being turned from a profession into a job. A profession is a calling, an inner feeling of responsibility that does not end at 5PM. Although based on special education and training, it goes beyond that. It requires a dedication to do the best you can. It needs the freedom to investigate a problem, and create unique solutions that fit the circumstances. That means the ability to make case by case judgments that cannot be determined by rigid bureaucracy, rule, or instruction. After primary and secondary school, college, medical school, two residencies and a life long quest to remain current and learn new ways to treat diseases I have spent at least 50 % of my life learning. It took 8 years of school to earn my MD degree. I was proud of that.
You would think that in and of itself would put me ahead in the hierarchy of the decision-making process in the care of a sick person. That is, the way it was but no more. The first sign that doctors were losing their prior stature and authority is that the DMV no longer allowed us to put that designation on our driver’s license. Now we are no longer doctors, but “health care providers”. Armies of secretaries, mid-level workers, and yes the administrators of medicine, from insurance companies, HMO’s, hospital administration, state licensing agencies etc. etc. make the rules and call the shots. What medications I may or may not use, how long the patient may remain in the hospital, who I can and cannot ask to help me in the care of sick people, from who I can use as a consultant, to what mesh I can implant into a person to fix a defect is out of my control. A lot has to do with cost and what is affordable by society, but much is arbitrary and yet not challengeable.
This was brought to my attention just the other day when I cared for a homeless person, who managed to fall off his bicycle on the hottest day of the year in Southern California, July 6, 2018, with temperatures reaching 118 degrees Fahrenheit. He sustained third and one area of fourth degree burns on his legs and arms. For a variety of bureaucratic reasons, he was not accepted at a trauma center nor a burn center, the exact reasons were never spoken out loud, but lack of finances were the most influential factor I suspect. I did what I could, and my residents and I took care of him to the best of our abilities. We could not, however, do the impossible, get the skin grafts to take on exposed bone. We needed help and the only doctor in our area that had the skills and knowledge to help him was not on our staff, nor did he have privileges in our hospital. However, the surgeon happened to be just across the street in a level II Trauma Center and had been practicing for 30 years as a distinguished, well-known, reconstructive surgeon. Can you believe that I was told that he was not allowed to come and help me? It would take 3 months from next Wednesday to complete the paperwork to allow him access to our hospital, plus the research required to prove that he has a license to practice, plus searching the National Data Bank to make sure he does not have any adverse legal action, plus proof he has had a mumps vaccination and a recent skin test for tuberculosis!! I was however advised by senior administration that I should just sneak him in through the back door wearing, a trench coat and Groucho Marks nose with horned rimmed glasses (that last addition I must admit I made up) to look at the wounds and see if he could take the man to his hospital. The laws have become so restrictive and cumbersome that we now are actually harming people by applying those rules that are meant to protect the patient. As I mentioned above, a professional is someone that has the ability to make case by case judgements that do not necessarily fit the rules, but solve problems that are presented to us. But no more! The professional is now finally hog tied. It now takes super-human efforts to achieve what used to be the standard of care. That is what is bad and makes me extremely sad!
There are other areas that do more harm than good. The EHR (Electronic Health Record), for example, it was also meant to help. The promise was that it would be more efficient, save time, be more accurate, and be available to all who have a function in the care of the patient. More efficient, and saving time? Hardly! It takes me three times longer to complete the record than it used to. It is filled with so much information that is not useful and clutters the record, making it sometimes impossible to find out what the crucial facts are to render care to that individual. Accuracy is another fallacy. Because all the boxes are required to be checked, the overworked physician and his administrative helpers are tempted to check boxes, the veracity of which are not known to him or her, so not only does the EHR fail to be accurate but it makes physicians liars and in some respects criminals. As much as you make rules to avoid this weakness, they are broken. Rules that are difficult, complicated, or seem superfluous to follow are prone to be ignored. The availability to all has been confounded by competing contradictory rules from another law, HIPPA (the Health Insurance Portability and Accountability Act of 1996) that prevents sharing of health information for privacy reasons.
In my institution we have 3 versions of the EHR and none of them can talk to each other, much less to other institutions as a consequence of HIPPA. Again, another well intentioned double-edged sword, that can do and does damage. As the saying goes: “The road to hell is paved with good intentions!” To be sure, with each new (more expensive) iteration, there is improvement, but it is still a long way from fulfilling the promises. The amount of documentation required has increased by a thousand-fold.
My father who practiced medicine from 1930 to 1980, saw the beginning of that explosion. In 1940 when he practiced in a small town in Austria during WWII his records were a one liner: patient name, date, diagnosis, treatment given, the fee, and how many days off work. Now the records are small novels. Most of the information is not necessary and much of it is to protect the author from legal action and to justify the fee. The rule is, “If it isn’t written, it was not done!” (My cynical addition is, even if it is written it may or may not have been done!) The other reason to write a lot is, just as the lawyer’s fees depend on the weight of the document, doctor’s documentation now is starting to look like a legal document with the equivalent charges. Not exaggerating, there is no doubt that more time is spent doctoring the record than the patient. The doctor who is monitored as to what his production is, i.e. how many patients he sees per hour, now walks into the examination room with his iPad Pro and types on it as he interviews the patient. Something is lost by that activity, namely bedside manner and humanity. It gives the impression of inattention, not caring, preoccupation, and mechanized care.
Something that is quite controversial presently in post-graduate medical education is the 80-hour work rule. It too is a double-edged sword that cuts both ways. To be sure a tired doctor is not as good as a spry awake doctor, and that is equally true for doctors in training, residents and even janitors or pilots. An unfortunate case that resulted in the death of the 18-year-old Libby Zion at Cornell University in 1984, and was blamed on overtired residents that cared for her led to this law that residents cannot work more than 80 hours a week. In my training I worked an average of 100 hours a week, and sometimes 120. So, the average surgery resident now has 25% less learning time than my generation. It has led to the fact that 80% of surgery residents now voluntarily add another year or two to their already long five-year residency precisely because they do not feel ready to face the practice of surgery independently. This has changed the profile of the American surgeon, because all these additional years of training are not in general surgery but in subspecialties, such as cardiac, vascular, trauma, chest, cancer etc. The general surgeon is in danger of going extinct! It is clear that some work hour’s regulation needs to be enforced, but the level of strictness is such that if violations are exposed, the training program can be shut down. We who teach must be very vigilant, as the learners try to outwit us, as they often feel the rules cheat them out of an education! Interestingly, verified studies have been done that show the extra time the resident now has for resting is often spent in other actives, such as a second job to provide additional income, family time, or recreation. It is true that in my five years of teaching the rules have relaxed, and become more manageable, but there is still room for tweaking it to make it more acceptable to both trainee and teacher. If a trainee wants to stay, for his/her benefit, to learn or see something which is a once in a life time occurrence we cannot let him. He/she must go home.
The biggest change that has frustrated the practice of medicine in the managing of illness by the third parties, the insurances, HMO’s, Medicare, Medi-Cal (California’s version of Medicaid). Very often it is not a physician who makes the decision as to what can be paid for and what cannot. In dealing with some of these bureaucrats, it appears that many of them don’t even have a high school education. Again, it takes a professional to look at the problem and make a decision, even though it might not necessarily follow the rules. Bureaucrats do not have that latitude. They follow a prescribed algorithm which does not consider special circumstances. I am particularly concerned that when the single payer system comes to us, as it has in the rest of the industrialized world, that the bureaucrats will be even more empowered than they are now. This emphasis on cost of care has stifled innovation and the quest for new knowledge. Why should I, or anybody else go to a conference to learn new techniques, see new instruments, or try a new device? I will likely not be allowed to bring it into my hospital. It is just too expensive, and why can’t I make do with what we have? Nevertheless, I have been fortunate to have lived through and experienced the golden time of medicine and surgery when the doctor was King. The doctor is now a cog in a larger machine and we are in a new era where system-based practice is King.
I left the ugly for last. I am about to change my status from health care provider to health care consumer. I know where the skeletons are buried. That is the ugly part.