Doctors, not Tradesmen

How can the drive towards standardization in healthcare delivery avoid reducing a profession to a trade?

I spent yesterday afternoon at the University Hospital as a patient undergoing a preoperative evaluation for elective orthopedic surgery next week. A fit and healthy 51-year old, my risks should be low, yet like any other patient, I worry a bit. I appreciated the systematic manner that the ~ 30-year old internist used in his discussion, examination, and laboratory evaluations.

I anticipate the same when I see the surgeon in a few days, and then undergo anesthesia and the procedure. A checklist can be comforting, the presence of failsafe measures and backup contingencies reassuring.

Every physician applauds advances that reduce errors knowing it better protects our patients and spares us the costs of our fallibility. The growth in standardization whether it be computerized reminders, checklists or algorithms should allow us to reach more patients at lower cost and with improved outcomes.

In the trade-off stakes, the good vastly outweighs the bad. Nobody as close to a surgical procedure as I am would want it any other way. Yet it would be just as foolish to not at least examine the other side of the coin.

Where is the flair if something unexpected happens?
How meaningful can day after day in a preoperative clinic or seeing postoperative patients be, let alone month after month?
How do we avoid reducing our profession to a trade?

I’m confident our patients are safer than they were almost 30 years ago when I first emerged from the pupa of medical school. I also have the strong sense that one reason medicine appeals less as a profession is our greater need to mechanically conform. This is about much more than the soft-spoken (including by me) loss of autonomy or resistance to being regulated.

Doctors are generally intelligent, thoughtful (in the thinking sense) and creative men and women. They worry about being asked to work by rote, by rule. As they try to see each patient as an individual, in turn, they wish the same for themselves. This is not yet a balanced equation.

A doctor without flair in their field is a worry. Proceeding by the book inevitably means some patients will be short-changed. Surgical or perhaps ER and ICU work will show this best of all, yet in every field, mine of neurology, for instance, there can be a chasm between the competent and rote-driven clinician and the gifted clinician.

As a patient, I seek something beyond competency. As an educator, I sought to instill good instincts in addition to mere knowledge. Our board examinations are about measures of competency only – “is he safe?” was the question posed when I examined in the Neurology boards. Surely we want more than that?

In another context, I wrote a piece recently “Does a Medical Career Dumb You Down?”, addressing how the demands of a career in medicine result in atrophy of much that made each of us interesting and pluripotential young men and women.

In a like manner, we also need to examine whether the more mechanical styles of medical practice and lowered levels of physician satisfaction means we are sacrificing on the quality of the recruits to our profession.

With all the evidence pointing to a need to increase medical school sizes in this country, how do we sustain the quality of student?
How are specialties like my own, an intellectually demanding one, going to address the undeniable reality that a significant number of residents in the discipline just don’t have the raw material to practice neurology in other than a rote/mechanical way.

However worthy the availability of preoperative clinics and hospitalist services that I partook of yesterday, and will encounter next week as an inpatient are, is this a career goal for a physician or just a service with a revolving door of young post-residency physicians marking time before moving on to the next real step of their professional lives.

I offer no concrete suggestions to my question posed at the beginning of this entry. I pose the caution that one addition to the flux the medical profession is experiencing is the risk of becoming ever more of a trade. It’s a caution we need guard against.