By Atul Gawande
The New Yorker, November 12, 2018
My hospital had, over the years, computerized many records and processes, but the new system would give us one platform for doing almost everything health professionals needed—recording and communicating our medical observations, sending prescriptions to a patient’s pharmacy, ordering tests and scans, viewing results, scheduling surgery, sending insurance bills. With Epic, paper lab-order slips, vital-signs charts, and hospital-ward records would disappear. We’d be greener, faster, better.
But three years later I’ve come to feel that a system that promised to increase my mastery over my work has, instead, increased my work’s mastery over me. I’m not the only one. A 2016 study found that physicians spent about two hours doing computer work for every hour spent face to face with a patient—whatever the brand of medical software. In the examination room, physicians devoted half of their patient time facing the screen to do electronic tasks. And these tasks were spilling over after hours. The University of Wisconsin found that the average workday for its family physicians had grown to eleven and a half hours. The result has been epidemic levels of burnout among clinicians. Forty per cent screen positive for depression, and seven per cent report suicidal thinking—almost double the rate of the general working population.
Something’s gone terribly wrong. Doctors are among the most technology-avid people in society; computerization has simplified tasks in many industries. Yet somehow we’ve reached a point where people in the medical profession actively, viscerally, volubly hate their computers.
Human beings do not only rebel. We also create. We force at least a certain amount of mutation, even when systems resist. Consider that, in recent years, one of the fastest-growing occupations in health care has been medical-scribe work, a field that hardly existed before electronic medical records. Medical scribes are trained assistants who work alongside physicians to take computer-related tasks off their hands. This fix is, admittedly, a little ridiculous. We replaced paper with computers because paper was inefficient. Now computers have become inefficient, so we’re hiring more humans. And it sort of works.
The story of modern medicine is the story of our human struggle with complexity. Technology will, without question, continually increase our ability to make diagnoses, to peer more deeply inside the body and the brain, to offer more treatments. It will help us document it all—but not necessarily to make sense of it all. Technology inevitably produces more noise and new uncertainties.
By Don McCanne, M.D.
Almost no one should be surprised by Atul Gawande’s observations on the physicians’ role in the use of computerized medical records. The trade-offs have been almost unbearable. He discusses the solution of using medical scribes, yet “research has found error rates between twenty-four and fifty per cent in recording key data.”
Although he says that the use of scribes “sort of works,” that really isn’t a satisfactory solution. Does anyone think that Gawande will do much better as he crafts the Bezos/Buffett/Dimon-sponsored solution to the problems with our health care system? At least it seems clear that we should not take a wait-and-see approach before we decide to move forward with Single Payer Medicare for All. We should do that right now.
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