An Epic Struggle for the Soul of Medicine

Martin SamuelsThis week I attended an all day “training” session in a new medical record system.  I thought it was interesting that the experience was called “training,” which prompted me to remind myself of a few useful definitions.

Education, from the Latin root meaning a drawing forth, implies not so much the communication of knowledge as the discipline of the intellect; an intra-cerebral process aimed in large part at creating principles upon which new knowledge may be elaborated.  Instruction is that part of education that furnishes the mind with knowledge.  Teaching is often applied to practice as in “teaching a dog to do tricks.”

Training is an element of education in which the chief characteristic is exercise or practice for the purpose of imparting facility, as in “training for the marathon.” Breeding relates to manners and outward conduct as in “standing when elders enter a room is a sign of good breeding.” Regimentation is the prescription of a particular way of life or thinking usually involving the imposition of discipline. The term, arising from military regiment, is related to the medical usage of regimen, as in “the patient keeps his prescription medications in separate compartments of a plastic container in order to accurately adhere to his regimen.”  Propaganda is the systematic propagation of a doctrine, cause or information reflecting the views and interests of those advocating such a doctrine or cause, as in “ACCME is propagating the view that elaborate re-certification maneuvers will improve the lives of patients.”

A cheerful instructor started the session by asking each of us to introduce ourselves and reveal a “secret guilty pleasure.”  Mine is to create elaborate cocktails.  If only I had had one of my famous Marty’s Beerjitos with me the whole experience could have been much more pleasant.  In addition to the instructor, there were several “super-users” in the room to facilitate the process.  It was immediately obvious to me that the super-users hovered behind my chair. These friendly young people had correctly identified me a “super-loser.”  Had I been litigious I would have reported the experience to our ombudsperson as blatant ageism.

But, alas, they were correct.  I was hopeless.  Besides, I don’t believe in ombudspeople.  I believe one should speak for oneself.

The experience transported me back to the Northwood Elementary School when my parents decided to enroll me in clarinet lessons.  They rented a metal clarinet.  The teacher, Mrs. Strickland, traveled among the elementary schools in the district, spending a half day in each, introducing kids to music.  The emotional memory remains vivid.  I just couldn’t make a sound with the thing; not even a squeak!  I also didn’t know where to put my hands and, of course, could not read the music.  It was a horrifying experience.  Now, at the age of 69 I was back in the same situation; infantilized in a windowless room with 16 computers, behind each of which was a doctor who should have been seeing patients.  There were only two differences between then and now.  One, I now have many more things that I should be doing than I did then.  Two, at least the end product of what I was doing then was inherently meritorious; namely making music. Now I was playing a video game, and what was even more horrifying was that some of the people around me were actually enjoying it.

I know all the rationales for an electronic medical record, such as bringing our supposedly chaotic medical system into line, reducing medication errors and improving communication; all meritorious goals.  There is nothing inherently good or evil about an electronic record.  After all it is just a computer program; basically a machine.  The fact is that a machine has no soul.  It has no feelings and no commitment to the practice of medicine.  To allow the machine to dictate the rules reminds one of HAL from Stanley Kubrick’s film, 2001: The Space Odyssey.   “Just what do you think you’re doing, Dave.”

The electronic medical record does not adhere to any natural laws, such as the laws of biology.  The rules are arbitrary.  They are created by people.  Playing with the machine is nothing more than a video game.  In fact, at the end of my day in “training” I was told to go home a use the “playground”; a simulated electronic medical record that would help me to become more facile at following the unnatural rules of what is really a billing machine.   But this is not play for me.  It is tedium which distracts me from the job for which I am educated; namely reducing suffering in human beings.  I only have a finite number of days when I can utilize my skills.  One day in the windowless room is one fewer that I have left.  If we are not very careful, we might even convince society that the electronic medical record, and what it represents, is an end in itself; more important than taking care of the sick, training our successors and finding cures for human disease.  Or, is it already too late?  Has the door already closed behind us?

“Do you read me, HAL?”

Affirmative, Dave.

Open the pod bay doors, HAL.

I’m afraid I can’t do that Dave.  This mission is too important to allow you to jeopardize it”

Over and Out!

Martin Samuels is a professor of neurology at Brigham and Women’s Hospital.


32 replies »

  1. But you need to be the pilot because you’re best placed to be so. Ignoring the mountain is also not the answer. If you read my first post you’ll see I’m no fan of where we’re going and certainly not government IT or insurance driven decisions. But leaving the plane without a pilot is not the answer. I was simply asking you (in a round about way I admit) to try and be the pilot not the passenger. Easier said than done I get it, but nothing important ever got done by people abdicating responsibility to people without the right skills. Are we struggling yes, should we blame others. No. At least not when we don’t stand to the plate. I think if we were to ever meet we’re closer in our beliefs that the medium of blog comments allow us to express effectively!

    • I have had control yanked from me but I still get to be responsible.

      With deference to BobbyGVegas, healthcare is being crashed by those ill-equipted to manage the roll they have extirpated.

      It is relevant and quite analagous. It is always in bad taste to crash a plane on purpose

  2. ” just that there will be a new set of tools in place to help you”

    Well, at present, the so called set of EHR tools are impediments.

    • This is my whole point. Bad start does not mean bad idea (i had to go through this with the web 20 years ago). If you think digitalization isn’t going to happen you are deluded, if you think its not going to help you’re deluded, if you think there won’t be problems, you’re deluded. We need skeptics to push the indusry to be the best it can be but not “no change is good’ auto responders. Be part of the future by engaging, not part of the problem by deluding yourself that this is all bad because some of it is. Define the future not pretend it won’t exist because you don’t want it to be so. Take 5 mins to REALLY think about your perspective and then act accordingly. If you still think that technology won’t happen, that data doesn’t matter, that Dr’s never make mistakes, that the future could be better then fine. But don’t do it because it makes “me feel uncomfortable” or “its not working now”. Be brave or be silent.

      • Your definition of engaging sounds a lot like “sit down and shut up”..

        Dr’s do make mistakes. The first one is trusting the tech.

        “Be brave or be silent?” Really. I expected better. When you and people like you are flying us into a mountain, I am getting to the cockpit to stop you.

    • Really. I expect better. This is not debate its old fashioned dogma. Please be better than this for all our sake.

    • You’re a bloody DR. A leader in our communities and yet your best response is “in the way” Really! I’ll leave others to judge whether your judgement is one to be trusted/follow.

      • They are in the way if they double the time it takes to do something in healthcare.

        Newsflash…I already know the answer. Why do I have to tell you? Not for the patient’s benefit. I am held hostage to your big idea if I wish to be paid. I have long said I take care of patients for free and charge a lot for dealing with the system.

        You need me. I do not need you. But if I do I will know exactly where to find you.

        • Wow. You really said “you need me. I do not need you” Says it all.

          We all need each other. Always. The ONLY thing I really do know is that I alone don’t have the answers and that believing anyone does is the biggest mistake any of us can make. Saying no technology, saying no to any change, saying no to what people want is not the answer. What is the right balance. Who knows? I’m personally on a journey to try and work this out and no answer is off limits. On previous experience we’ll all be a bit right and a bit wrong. Duh!

  3. I have to disagree with the diagnosis. The patient (Healthcare) is certainly showing symptoms of ITitis but the underlying problem and opportunity may be different.

    The government and insurers are playing in this field for the wrong reason. So called efficiency and planning (money) and not for patient health. They are also terrible at implementing IT systems (name one world class IT project delivered by any large western government that has been on spec, time and budget. Thought not).

    Before I give some thoughts firstly let me agree with you that removing the personal intervention of Dr’s and other healthcare professionals should NEVER happen. However..

    Technology is a tool, not a decision maker. It allows us, when done well to make smarter decisions because we have more information on hand. The revolution in healthcare that s just starting to happen is astounding and will change everything over the next 20-30 years and its driven by data. So much data that it can only be sensibly used if technology systems are deployed to aggregate and deliver it to pint of care in a useful, easy to assimilate way that HELPS not hinders Dr’s. Is that what we have form government/insurance systems now. Now.

    Who will build these systems. In my view some combination of Google, Facebook, IBM (Add long list of others) and, and this is crucial, extremely well funded silicon valley startups that have a need to make this stuff work (i.e. good).

    The complexity of gene driven therapies, predictive diagnosis, wearable health indicators, environmental exposure data etc means technology has to be involved and it will save literally millions of lives. To discount it in some revisionist schoolboy way does you and your profession no good.

    Understanding what is really happening, being part of the discussion on how to make healthcare in the future a better experience for all is how to make a difference. Just because its less than perfect now does not mean it will be for ever. It certainly doesn’t mean the role of the Dr will be replaced, just that there will be a new set of tools in place to help you.

  4. Yup, go play in the Epic playground.

    What a bunch of bull crap!

    Mass murder promulgaterd by the Congress and HHS.

    These folks ought to be defendants in lawsuits, in addition to the vendors, and hospital “champions”.

    • “Mass murder promulgaterd by the Congress and HHS.”

      Well disgruntled hyperbolic Rn, my wife also works with a year old Epic install.

      Some glitches and some bug fixes but generally working well with much more capability for patient tracking. The docs can even pull up a chart from home if they want to check on a serious case. Good history at the push of a button (or two). The docs were intensely involved with design and implementation.

      • She must be working at Duke.

        I watched the nurse charting on my daughter yesterday after her C-section. Nurse was very divided between care and computing. Computers in the room are a conflict of interest.

        Patient should not stand for computer in room.

        • Not at Duke. Nurses have always had to chart and the chart has always been in the patient room. If a nurse is computing over necessary patient care then the nurse is not doing her/his job. The computer does not demand when to chart, the computer does not know if it is necessary to chart – it just sits there waiting for input.

          My wife says that one thing the computer looses over a paper chart is the narrative, which can make the overall story of the patient easier to understand in the full context.

  5. After 32 years, I have also been forced to use this garbage. I clearly deliver less quality care and see less patients. I do however generate nice little data sets and MU reports.

  6. We should fight it….for our testosterone receptors.
    1. Insist of clinical trials comparing the two systems. Which has the more broad range of diagnoses? Which brings up more accuracy in diagnosis? Which has the larger number of bits of information? Which is the more secure? Which has the better outcomes? Which is the more efficient and productive?
    2. Write articles and books about privacy and security, and the costs and benefits off the two systems. Get the patients to refuse to participate with their data.
    3. Invite hackers to jump in and test us.
    4. Ask patients how they would feel having their records in the cloud?
    5. Show how our energy is being diverted from CME to accommodate this distraction.
    6. Show how this an expensive factor of production and link this to increasing costs of our output.

  7. obviously it is epic and it may not have a soul but it will surely steal your soul and your pateints will be the first recognize it. I have been on epic since 2000 and no doubt a worse doc now then i was before. its goal is to not to monitor the patient or improve patient outcomes, it is to monitor you and control cost outcomes. if anyone tells you different they are lying.

  8. ” If we are not very careful, we might even convince society that the electronic medical record, and what it represents, is an end in itself; more important than taking care of the sick, training our successors and finding cures for human disease. Or, is it already too late? Has the door already closed behind us?”

    Closed and locked, I’d say.

  9. Kaspar has changed places with Peterkin.

    To modify Southey.

    “But what good came of it at last?”
    Quoth old Kaspar.
    “Why that I cannot tell,” said he,
    “But ’twas a famous EMR”

  10. http://www.jointcommission.org/sea_issue_54/

    Pathetic that the JC has taken 7 years after its first Alert on the dangers of HIT to circle back! Nothing has changed over the near decade. Patients, doctors, and nurses remain guinea pigs for the HIT experiments of the vendors and the US Government.

    Sorry Marty, but you are a sucker for sitting there and putting up with these unregulated experiments that have not been vetted by your hospital’s IRB.

    • The sorry state of Health IT is the most dangerous thing being faced by medicine today. The ability to concisely assimilate information about patients is being destroyed. Privacy…forget it. Communication…gone. Good point on the JC. Hand washing does not hold a candle to this massive acute problem. Having 2 patient identifiers will become irrelevant when different patients are only millimeters apart on a touch screen. The industry will remain unregulated and unsafe, because now it’s “too big to fail”. There are people at HHS who should go to jail for such reckless implementation.

  11. Please simply retire now. Handicapping only based on your self-centered attitude and advance years, I’ll wager you’ll reduce far more suffering by doing nothing than you do by actively trying to do anything for anyone.

    That said, Epic is the very devil


    • “Look Dave, I can see you’re really upset about this. I honestly think you ought to sit down calmly, take a stress pill, and think things over”. HAL

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