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Unanswered questions about changes in core values of medicine
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Your heart fills with fright
Not filled by the things
that GO BUMP IN THE NIGHT
They walk through the walls
With no time to stall
You call the GHOSTBUSTERS
Well that’s who you call!
Ghostbusters II, 1989, Run-D.M.C., (lyrics by Ray Parker Jr., Joseph Simmons, Darryl McDaniels, Jason Mizell)
The best preparation for tomorrow is to do today’s work superbly well. — William Osler, MD, founding professor at The Johns Hopkins University
Why do we allow the practice of medicine to change in ways that challenge the core values of our profession? The persistent nature of such a maddening question suggests supernatural aberrations. While there is not sufficient evidence upon which to call the Ghostbusters, there is enough of a black cloud that I suggest rainwear.
Three areas of practice that exemplify this dilemma recently became the topic of conversation among colleagues: vaccine administration, electronic health record (EHR), and residency training, the last spurred by a recent New England Journal of Medicine editorial.
Vaccine provisions becoming complicated
I strongly believe in immunizations for my patients and in their pre-eminent importance for individual and public health; provide them at any type of visit; open the office for influenza vaccine season at odd hours; research travel vaccine needs for patients; discuss vaccines and vaccine policy with families whenever they have questions; provide record documentation — and always have despite the cost (time, expense, staffing, storage). So I wonder why recently it is increasingly frustrating to provide these services.
Vaccine provision in private practice is more complicated than ever. Surprisingly, it has less to do with patients or their families and increasingly with imposed medical bureaucratic onuses. In the past, I gave sparse thought to bureaucratic aspects of immunization outside of the occasional influenza pandemic or specific vaccine shortages. Now I need to purchase new refrigerators and freezers and document their temperatures. I need to enter data in state vaccine registries, I need to expand the job of our office vaccine coordinator, I need, I need …
William T. Gerson
Perhaps most annoying is dealing with school systems’ computer software packages that define adequacy of immunization status. I understand that policymakers like systems that rigidly define variables. However, in the past, my ability to look at the individual situation and attest to the adequacy, or inadequacy, of an immunization was allowed. Considering the lack of data, human biology, and the reality of guideline determination done in a conference rooms by individuals who look like me, allowing individual clinical physician input seemed reasonable. No longer is this allowed and the inflexibility makes me feel like I’m in an alternative and unpleasant universe.
Unfortunately, the burden demanded by such compliance is not appreciated by those who do not provide primary care. For all the varied reasons that vaccine efficacy may be inadequate providing the third hepatitis B 6 days early does not seem to me to be public health enemy No. 1. Each case (in this universe) takes at least 2 hours of office and professional time to address, is painful for families and often detrimental to physician-patient/family relationships. The notion that from a public health perspective pursuing those families who have already vaccinated their children might be the wrong population to target is ignored.
EHR and time constraints
Where has the time gone we once had in our offices to read during lunch? How about the time to discuss interesting patients with our partners, or even just some quiet time to re-energize so as to be more available to the next patient? These times vanished as we spend the extra minutes charting in the EHR.
In the hospital, I wonder why it is that when I walk onto the ward I see nurses discussing patient care with consultants at the nursing station but find the residents and students in the conference/working room all with their backs facing the door working on personal computers. Learning opportunities take a back seat to work efficiency.
I suspect the next generation will not have the same difficulties that I have with technologic interfaces. However, I hope the next generation recovers the rewards of face-to-face communication with one’s colleagues and is not enthralled only by the scripted communication of the protocols, algorithms and tools so easily generated by EHRs. I’ll leave the discussion of the intrusion of the EHR into our home lives for another time.
Changes in medical training
I question why we have accepted changes to our training programs without requiring rigorous outcomes data or at the least review. Why didn’t we after the Libby Zion case, and why don’t we now, demand the respect and the ability to deflect public/political near-term needs, as a reasonable expression of our professional status, to be able to put into place well-designed changes to medical education and professional training and not reactive policies that are, in fact, detrimental. Safe and high-quality care must be provided, but despite assumptions of improved care, there continues to be no clear data to show that work hour limits on residents, creation and increased presence of hospitalists, or 24-hour in-house intensive care unit attending presence improve patient outcomes.
The past 2 decades have witnessed a transformative change in American medicine as a consequence of these imprudent initiatives. Private practice physicians, particularly primary care doctors, have and continue to be marginalized from academic medical centers. Resident autonomy has been significantly compromised and many residents may not experience managing events that go bump at night on their own. Experienced generalists and specialists are excluded from general medical wards and replaced by intelligent recent residency graduates who perform efficient medical care. If the data do not find that the care of the patient has been improved and the training of future generations of physicians has been compromised, by what unearthly logic is this progress?
Not yet time to call the Ghostbusters — I hope — but still a good idea to do today’s work superbly well. One never knows when sanity might return.
Goitein L. N Engl J Med. 1996;334:201-202.
William T. Gerson, MD, is Clinical Professor of Pediatrics at the University of Vermont College of Medicine and a member of the Infectious Diseases in Children Editorial Board. He can be reached at 52 Timber Lane, S. Burlington, VT 05403; email: William.Gerson@uvm.edu.
Disclosure: Gerson reports no relevant financial disclosures.