These are the good ole days that we’ve been livin’
No more lookin’ back all is forgiven
Ain’t gonna live my life through no picture frame
These are the good ole days
In medicine, the pressure to shorten visits is being exacerbated by demands to devote more time to non-patient care activities. For example, a study of emergency room practice published last year showed that, on average, physicians are now spending twice as much time entering data into the hospital information system as they spend on direct patient care, recording no fewer than 4,000 mouse clicks per shift.
In Sunday’s Pittsburgh Post-Gazette, Dr. Herbert L. Fred is having a downright temper tantrum:
Today, health care in America is a mess. The medical profession has lost much of its nobility, the practice of medicine has lost much of its joy and a disaster is brewing in medical education. Delivery of service is fragmented and impersonal, costs are high, and physicians and patients alike are deeply dissatisfied.
Because of bureaucratic rule, physicians have little or no autonomy and face numerous obstacles to good patient care: federally mandated regulations, constraints from insurance companies, “for-profit-but-not-for-patient” hospital administrators, endless paperwork and the ever-present threat of lawsuits.
Things were not always this way.
Ah, the good old days:
In 1950, the year I entered medical school, and for a couple of decades thereafter, doctors worked as long and as hard as it took to meet their patients’ needs. They listened intently to their patients, examined them thoughtfully and ordered only the simplest of tests, if any. Medical costs were affordable, lawsuits were rare, patients and their doctors were happy, and medical trainees were well prepared to render high-quality patient care.
Then, in the early to mid-1970s, advanced medical technology became available and revolutionized the way doctors taught and practiced medicine. Suddenly, we had tools that not only established diagnoses with unprecedented speed and accuracy, but also greatly improved the treatment of disease.
Dr. Fred goes on to rail against physicians who order CT scans “while largely ignoring patient medical histories and physical examinations” and sometimes even without seeing their patients before they order them. He complains that the modern shift from patient-focused care to “the laboratory and imaging suite” have caused physicians to lose the qualities of their noble profession: “Pride, accountability, devotion to duty and hard work.” The greatest injustice, according to the good doctor and professor of internal medicine at the University of Texas Medical School, is the revelation that perhaps a sleep-deprived medical resident in training might hinder effective patient care:
In the belief that sleep deprivation and physical fatigue in physicians lead to harmful medical errors, the Accreditation Council for Graduate Medical Education acted to protect patient safety by mandating strict work-hour limits across all training programs, regardless of specialty. That mandate launched a new period of medical education in which the focus now rests on the physical comfort of the doctors in training, rather than on the patients they serve.
No, sir. He said it himself: the mandate is for the protection of patient safety. The comfort of interns and residents — past and present — has never been given consideration. In fact, for the several years of specialty training after medical school, residents (and fellows in specialties) are paid barely enough money by their training programs to cover their living expenses!
Dr. Fred paints a grim picture indeed — a picture that is distorted by his memory of days gone by. Yes, the healthcare system is a mess — and we can, all of us, shoulder some of the blame for the high costs and impersonal nature of healthcare. But I’m here to tell current and future patients, as well as young and future doctors, that things are really not that bad! I continue to be impressed with the intelligence and motivation of high school students who come to shadow me in the office over summer vacations, hoping to get accepted to the best colleges for them; with the college students who spend time with me looking to earn some valuable, real-world clinical experiences on their quests for medical school admission; and with the many pediatric residents I’ve gotten to know over the years — some of whom work right beside us in our offices as part of their clinical continuity experiences. Young college students — after doing exceptional academic, extracurricular, and community work — continue to scrape and claw their ways through grueling premedical curricula and arduous standardized testing in the hopes of finding a spot in medical school. Medical students embark on a course of lifetime learning in the hopes of finding the specialty that speaks to them — not for the “nobility” of the profession, nor for the sake of personal profit, but for the simple reasons of helping and healing others. Why else would students of medicine acquire so much debt in pursuing their callings, knowing it might take years/decades to pay it off?
For the most part, men and women who become doctors today are extraordinary people, have done extraordinary things in their lives, and have an extraordinarily positive vision of the future. They are much more adaptable to the clinical and economic changes in medicine than many physicians of my generation (ie. the ones doing most of the complaining) — changes that have been a part of this profession since the first person to take the Hippocratic Oath.
Today, there is joy and satisfaction in the practice of medicine. It’s all about the attitude that’s brought to the table. (And it helps to choose a field like pediatrics!) Dr. Fred should have no reservations about the current crop of young physicians to see us all through this mess. In fact, patients are in better hands than ever before:
But cleaning up this mess will take exceptionally strong professional leadership supported by widespread and unrelenting public demand. It will require doctors to use modern technology to substantiate (not to formulate) their diagnoses, to resist ordering these technologic marvels when cheaper, simpler and safer tests can provide the same information, and to actually think before prescribing a slew of expensive medications in an effort to alleviate every conceivable ill.
We doctors should also remember that doing nothing sometimes amounts to doing a lot; that many patients get well despite what we do, not because of what we do; and that medicine is a calling, not a business.
Most important, we must put the welfare of our patients first — always.
Maybe there are some doctors who would disagree with that. Maybe Dr. Fred has known and taught some of them, which may be why he is so negative.
Maybe I’m lucky that I haven’t, and I’m not.