Modern Medicine

Modern Medicine

By

Leonard Zwelling

https://www.nejm.org/doi/full/10.1056/NEJMp2003149
https://www.nejm.org/doi/full/10.1056/NEJMp1915891
https://www.nejm.org/doi/full/10.1056/NEJMoa1900669?query=featured_home

         The June 25, 2020 issue of The New England Journal of Medicine could be retitled, “what’s really going on in medicine.”

         These three articles, two are editorials, the last an actual research study, upend much of what we thought (or thought we thought or I thought we thought) is driving modern medicine.

         The first one is by Pamela Hartzband and Jerome Groopman. It is about physician burnout, a topic being written about now more than ever in the time of Covid-19 and the stresses endured by so many healthcare professionals.

         Hartzband and Groopman discuss the link behind motivation and workplace satisfaction among doctors (and other professionals). It seems that doctors are driven more by intrinsic factors (innate satisfaction and personal interest) than by extrinsic ones (money). It also seems that the management of modern healthcare systems tends to drive the productivity of their systems via extrinsic factors and minimize the contribution to job satisfaction of intrinsic factors. The electronic medical record may be the prime villain here as it demands the blunting of the dependence of job satisfaction on the three tenets of intrinsic satisfaction-autonomy, competence and relatedness. The EHR calls the tune and demands of your time. It substitutes its algorithms for your competence and is far more demanding of your attention that ought to be used to relate to your patients. It is the loss of job satisfaction dependency on intrinsic factors that leads to physician burnout. Returning to a world of intrinsic job satisfaction (and an EHR that is not just a billing machine) would go a long way toward reducing burnout.

         In the second editorial, a first-year medical student at Harvard, LaShyra Nolen makes a great case for the damage done by a male and white centric medical system harming the delivery of good medical care. She notes how Lyme Disease presents with a characteristic skin lesion in white people often missed in patients with darker skin. This missed cue leads to the presentation of Lyme Disease in those with darker skin that is more advanced than the presentation in white people.

         Ms. Nolen also noted that her CPR instruction was only aided by the use of male mannequins—none with breasts and none pregnant and how this too leaves the ultimate delivery of healthcare at the mercy of model systems that do not represent the entirety of humanity or even the entirety of potential patients.

         Finally, Landrigan et al. report that lengthened call schedules did not result in more frequent errors among pediatric residents.

         In essence, the dependence on the electronic medical record, the use of business management techniques to incentivize doctors, the insensitivity of medical education to issues of race and gender, and the hypothesis that less sleep causes errors may all be incorrect.

         Hell, I could have told you that for free in 1975 after my residency. There is no substitute for person-to-person contact in the healing arts. Money does not drive most docs. Women are not men and black people have different manifestations of diseases than white people for a host of reasons. And you better learn to deliver care well over a 24-hour interval because sooner or later you are going to have to do it.

         Now that many of the drivers of modern medicine have been demonstrated to be bad ideas, perhaps we should consider dumping these innovations and returning to the old fashioned way of doing things. One patient, one doc, one chart and a clear understanding that patients come in all shapes, sizes, colors and genders and a good medical education embraces these differences and does not try to blunt or ignore them. And, I’m sorry, just because it’s five o’ clock you cannot go home. Modern medical schools need to get over themselves and produce not only better doctors, but tougher ones and ones whose satisfaction rests on the intrinsic factors of autonomy, competence and relatedness.

         If you want to minimize burnout, discrimination and errors, get back to basics.

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