• The Present Crises in Confidence With Medicine

    Physicians in the U.S. are going through a trying time. We see a great deal of transition in workstyle, in culture and in our medicine zeitgeist. The corporatization of medicine has generated a tidal wave of frustration.

    We are witnessing a great shift in our culture further distancing us from the classical doctor-patient relationship to that of being part of a business and even more so, of being an employee. We sense that we have become a small cog in a very big machine. Changes in technology have also impacted how we think as well as practice medicine.

    Alfredo A. Sadun, MD, PhD, visits the remains of the ancient Greek temple/hospital of Asclepius 
    (circa 500 BC) in the ancient city of Troezen located in the Northeastern Peloponnese, Greece.

    I have a particular perspective as a neuro-ophthalmologist who mourns our lost habit of analytical thinking. It’s much easier to just order more tests. We are constantly reminded that time is money, and medical organizations, whether HMOs, hospital based or academics, put a premium on throughput. Efficiency comes at many costs, including that doctors should now minimize socializing with the patient.

    Overshadowing all this is the big issue of electronic medical records (EMR). EMRs are advertised as optimizing patient care, providing efficiency, screening medical oversights and mistakes and giving us data for epidemiology.

    Perhaps. But in fact, the cynical reality is that EMRs were designed mainly for one thing: the maximization of billing. We, as physicians feel this cynicism every time we fail to look at our patients due to our preoccupation with the computer screen and the EMR. Our differential diagnosis, once a complicated calculus and an expression of the art of considering the common, the severe and the urgent, is now largely driven by what bills best.

    How did we get here? What lessons can we take from physicians from the past? What about other health care systems in other countries? How can we best cope? And perhaps as important, can we take some refuge in humor?

    These and similar questions have been addressed by recently published books that converge on these topics, but could not be more different in style, content and tone.

    This is Going to Hurt: The Secret Diary of a Junior Doctor
    By Adam Kay (2019)

    This is an international bestseller that describes the life of Adam Kay as he was training and working in the United Kingdom as a house staff officer. The book is hilarious. We learn about the trials of young doctors in training though, in this case, it’s through the lens of socialized medicine in the U.K.: the National Health Service, or NHS. It is largely about how big modern medicine and health care delivery systems are and how small a doctor can feel. Much of this is the same in the U.S.

    The book is a journal. His diary entries were sometimes very short, but very comical too. Shocking, brutal and often sad, but almost always funny. You follow his life along through his clinical training. Despite the side-splitting humor, you can feel his slow descent into burnout. Fortunately, just when you think that his writing is too bitter, his humor saves it all, for a time. Consider this quote from Kay when he was asked what is it like to go to medical school and then clinical training.

    “So I told them the truth: the hours are terrible, the pay is terrible, the conditions are terrible; you’re underappreciated, unsupported, disrespected and frequently physically endangered. But there’s no better job in the world.”

    Kay’s book provides insights into how the U.K.’s NHS works in showing us what the life of a junior doctor there is like. It describes a life not dissimilar to that of what interns, residents and fellows in the U.S. go through. In the U.K., training is probably even tougher. After all, our U.S.-based Accreditation Council for Graduate Medical Education (ACGME) has made a number of changes following the famous Libby Zion legal case, whereby a civil lawsuit was made against a New York hospital blaming a patient’s death on overworked residents.

    In the interest of full disclosure, I was privileged and honored to work for the ACGME as the chair of the Resident Review Committee (RRC) for several years. Our ACGME has addressed the stresses and work hours of interns and residents. As physicians know, the ACGME has limited work hours (to about 60 hours/week) and limited continuous work without sleep for U.S. residents in training. In the U.K., the NHS has not yet done as much for junior doctors. Which brings us to one of the main reasons Kay wrote the book.

    It was in response to the attitude of Jeremey Hunt, who was, at the time, the Health Secretary for the U.K. Hunt claimed that physicians in the NHS were “greedy” and did not have the right to complain about their terrible work conditions and hours (many were working 90 hours/week). Kay uses the book as a form of rebuttal. (More will be said about Kay’s important points after these book reviews.)

    The specific stories of Kay as a house officer in ob/gyn lends the book credulity and the sense that it’s only a little exaggerated. Kay’s book, for me, has a sad conclusion as he ends his medical career and moves on to become a comedian, TV writer and producer. At least he kept some of his skillset.

    The Rhetoric of Medicine: Lessons on Professionalism from Ancient Greece
    By Nigel Nicholson and Nathan R. Selden (2020)

    Before reflecting on this book’s content, it’s important to understand something about the two authors. They are scholars.

    Nicholson is a classics professor and an expert in ancient Greece. Selden is a neurosurgeon and past president of the Congress of Neurological Surgeons. Their partnership in this enterprise is, in itself, remarkable.

    What these two attempt to do is address the zeitgeist of medicine from ancient times by telling us stories from antiquity. They use the term rhetoric to use this process in consideration of the social and ethical issues experienced by ancient Greek physicians and patients. Hence, we can compare and contrast these issues to those confronting modern physicians and patients. Particularly interesting is the common perspective of needing to support physician wellness, then as now.

    This book occasionally drifts to the pompous and pedantic. That might be expected, as the authors are both academics and intellectuals. They support every argument with evidence, and often do so repetitively. It is good scholarship, but sometimes a bit tedious. Their main goal was to examine how physicians worked and competed in the pre- and early-classical Greek periods of about 550 to 400 BC. This was the period that conceived the Hippocratic Oath. The authors felt that in examining this time and place, we might gain instruction for modern medicine as practiced in the West.  

    Jumping to the meat of their issues, they tell us about how some ancient Greek physicians worked primarily for money and status. Even in ancient Greece, there were physicians who saw medicine as a business and used their advantage for personal gain. These physicians were also accused of selling snake oils, literally and figuratively.

    Against this, many other physicians made the case for professionalism. Ethics, values, and medical codes, were argued over and prescribed to the profession. This led to competition between groups, as well as collaborations that might have been to help restrict trade as much as providing for the maintenance of ethical conduct. Evidence-based medicine had a form of its own, in ancient Greece, and it pitched itself against alternative medical approaches, even then. Related issues included the necessity for teaching and mentoring (and the expectation that students show respect and gratitude to those that supervised their professional development). To what extent did the physician act on his own, or within the context of his profession and the needs of his colleagues?

    This was also a time when Greek culture was obsessed with athletics. Consequently, the physician was regarded as an important resource in helping the athlete with information regarding training, diet and the treatment of injuries. It was interesting to me to see that even then there was competition between physicians and athletic trainers.

    Their rhetorical approach demonstrated that the problems we are confronting in modern American medicine are not so new. I was amazed to read several excerpts from ancient Greek physicians that I regard as lessons. As an example, the ancients taught the value of removing the physician as a participant when writing the medical note by writing in the third and not the first person. Third-person clinical notes lessened the physician’s emotional ownership and was designed to reduce physician burnout. This was recommended 2,500 years ago!

    One interesting and scholarly point of the professors, is that ancient Greek doctors found themselves at a crossroads. They were about to break from their version of superstition-laden ancient medicine to their form of modern medicine. Likewise, we are at a crossroads with the introduction of modern technology and new ways of delivering medicine.

    At the core then, as now, was the question of a physician’s identity. How did a physician meet the demands and needs of his patients, of society, and of his teachers, against personal needs that included money, status, health and the challenges of aging?

    Remarkably, the professors did not address these deep and complex issues on a meta level. Rather, they examined the mundane, everyday practices of medicine. That made the book and the ancient Greek zeitgeist, much more approachable.

    Man’s 4th Best Hospital
    By Samuel Shem (2019)

    For young doctors of my generation, Samuel Shem’s (pen name of Stephen Bergman) “The House of God,” was a watershed event.

    “The House of God” came out during my internship in medicine in 1978. I found myself shaken to the core by this book. I couldn’t put it down, thus spoiling my only vacation as an intern. Though the book was satire, it touched on many truths, and I was frustrated by the same sorts of institutional absurdities. “The House of God” revealed to me some personal rage I didn’t know I had.

    Shem almost did it again. In his new novel, he picks up the story 40 years later with the same characters and the same outrageous satire. This time, the title character Basch and his colleagues are late in their careers as physicians. They are brought back together to work in another medical center — formerly known as MBH (not MGH), which formerly stood for Man’s Best Hospital. But now, national rankings are everything and it has fallen to fourth.

    This is a story, like the first, of institutional evils. Shem points out and condemns corporate greed, bureaucratic idiocy, branding and the newest disaster in medicine, the EMR. While the interns and residents of “The House of God” were powerless, the attendings of “Man’s 4th Best Hospital,” seem less sympathetic. But it’s still funny and we are still outraged by how politics, corporate values and administrative stupidity have both hindered the efficient application of medicine and also undermined compassion and the individual physician’s autonomy.

    By now, you will recognize these themes from the first two books I’ve reviewed. Only Shem takes everything too far. Sometimes it works, and you laugh. Other times, it’s just silly. Shem shows particular sensitivity to the subject of physician health and burnout. When he’s funny, we feel a little relief from our own miseries. But at other times, he’s preaching a return to medical ethics, values, compassion and sensibility that we know is improbable. One of his medical students is a computer whiz who manages to disable the entire EMR system. Not only do the patients get better, and the physicians feel better off, but productivity and even billing improves. Eventually, of course, the EMR system is fixed and everything returns to the abysmal state of serving only one real end: The maximization of profit for the hospital system. You laugh and you cry.

    Taken together these three books explore identical issues but from very different points of view. Like the authors, we fear these changes, we try to avoid burnout, and we mourn the loss of humanity in medicine. We physicians must transition to the new way medicine is practiced in the U.S., and in that crossing find our North Star again. We must learn to cope with EMRs, with the corporatization of medicine and with all the other issues of health care delivery as it is today. All the while, we must keep our old values of prioritizing patient care, compassion and taking pride in our own work and profession.

    So, we struggle to find a new compass for these uncharted waters, pointing us to the central value, which remains the preciousness of life. It is a challenge. For me, humor, as exemplified by these books, is part of the solution.