How We Got Here.
How medical education and practice paradigms have formed the conditions which ushered in a pandemic response strategy that will destroy the credibility of medicine and public health.
I remember applying to medical school, and how daunting the task of securing admission seemed at the time. Hour after hour spent scavenging through special interest forums, like the StudentDoctorNetwork, to figure out how to eek out an advantage during the application cycle. My peers with similar ambitions would bask in the uncertainty and anxiety on breaks we'd take from studying for whatever exam was just around the corner. At the time, our lives revolved around this ambition - whether awake or asleep.
The first rude awakening occurred in Week 1 of medical school, which traditionally begins with an introduction to anatomy.
“I really like surgery, but the lifestyle of both General Surgery residents [trainees] and attendings [staff surgeons] is horrible. So, maybe I'll go into Orthopedic Surgery. They also make way more money.”
"I figure Anesthesia is a great way to still spend time in the OR [operating room], make a lot of money, and have a good work-life balance."
"I wanna go into Dermatology."
And, so on...
What began as a "I find fulfillment in helping those in my community improve their health," very rapidly morphed into a conversation about maximizing $$ per hour spent either taking care of patients, performing diagnostics, or the ungodly amount of hours we spend doing administrative tasks or ‘paper’ work, as it is traditionally called, but what is now performed increasingly on a computer.
Sure, maybe I was naive. I still am...it would seem.
Then came the onslaught of "Professionalism" based dictates, which were to determine if and how we would speak up as trainees and future physicians. It's almost as if it was a certainty that we would encounter problems which would not sit well with us. We were being primed with whether or not we could speak up, and how we would go about doing so, with minimal fallout to the institution. Oddly (I'm sure to the readers' surprise), these rules only applied to the top of the hierarchy and administration when it was convenient.
As we progressed through medical school and started attending clinical rotations in hospitals and clinics, more rudeness awakened us from our initial dream state. One of the most memorable slogans that both senior trainees and faculty would repeat like broken records was:
"How does that change management?"
This opens up a can of worms…
The above is often asked of the student to assert that his or her line of thinking about a clinical problem is actually irrelevant, if indeed management does not change as a result. There are problems with this. First, it discourages students who are in the infancy of their training to ask questions which are unorthodox from the perspective of established management algorithms (more on these later). Secondly, it is frequently wielded as a cudgel to prevent students from diverting discussion away from the clinicians intended course of management. Whether or not the student's line of questioning has merit, can be irrelevant. For the clinicians who humor us in this respect, thank you.
Now, from the perspective of a trainee or licensed physician, "how does that change management" is an important question. The problem here lies in the differences as to WHY it is an important question.
The following is my opinion as to why its use is often premature, or even inappropriate…
Let us pretend for a moment, that you, the reader, and I are coworkers. Our expertise is similar and we collaborate in the care of our patients. A new patient walks in the door of our clinic and illustrates her chief complaint. The initial phase of a medical encounter is primarily concerned with information seeking. We ask the patient what brought them to our attention, and then we take a history. Medical, surgical, social, psychological, etc. After that, we perform a physical exam and maybe even order relevant diagnostic tests. Once that is all said and done, we begin to formulate a differential diagnosis. Then, in the context of all that we have learned, we rank order the most likely diagnoses and plan accordingly. As you may have deduced while reading this diatribe, that the question “how does that change management?” is only relevant at the penultimate stage, before execution - during planning. At all preceding stages, a productive response to a novel question or suggestion would sound something like: “how could that be?”
Does that patient indeed have systolic heart failure? Why do we think he may? Are our data and assumptions consistent with this assertion? If so, what alternatives do the data and assumptions suggest?
“How does that change management” has great utility at the stage in which you are allocating resources, but should have no baring on your formulation of the problem.
As above, this is a great question to ask when considering the next steps to take in the care of a patient. The amount of waste in the US healthcare industry can probably fill a crater as large as….
But seriously, we waste drugs and procedural devices, imaging and lab-work, and money on all of the above. So, considering "how does that change management" becomes crucial for effective resource allocation. Thus, when the mantra is used judiciously, not only does it save the healthcare enterprise from inefficiently allocating limited resources, but it also protects the patient.
For example, being the thoughtful and judicious physician that I am (eyebrows), I have decided against a screening colonoscopy for my 85 year-old and relatively frail patient. By doing so, I have allowed a vacant colonoscopy to be used towards the care of a person who may benefit from early detection. Secondly, I've saved the patient a co-pay for the colonoscopy, which can be a substantial. Third, I may have saved the patient's life. How?
Imagine our frail elderly patient goes for a colonoscopy. Being that he is 85, he may have weakened physiologic function simply as a result of senescence (fancy talk for aging). One such faculty may be a diminished capacity to regenerate tissue, another in the form of a weakened immune system. So, this patient goes for his colonoscopy. Unfortunately, during the procedure the endoscopist accidentally perforates a rather tortuous and diverticula-riddeled segment of large bowel. In most cases a perforation like this could easily be treated with some empiric oral antibiotics which would prevent the minor spillage of feces into the peritoneum (the abdominal cavity lining which surrounds our organs) from resulting in a severe infection or abscess. However, being senescent, our patient not only has trouble clearing the spillage and healing the perforation, but this often minor issue has led to full-blown septic shock. His consequent energy-intensive and long-term admission has opened him up to a super-infection with a hospital-associated super-bug. Mortality rates in these situations are very high. Some don't make it.
Thus, by avoiding a colonoscopy I saved resources for both parties, and also saved the patient from the high-risk complications associated with his demographic.
"How does that change management?" comes with some implicit assumptions. First, that there is an established ‘management.’ Where does The Management come from, you say? As evidence-based medicine has taken on wings of its own, so too has the belief that the best way to manage patients is by some sort of consensus-based algorithm. A bunch of experts get together, analyzes swathes of patient data and determine which decisions result in enough overall impact on the study population to warrant publication - this statement, though cynical, touches on another critical problem in academia and medicine. But, this type of behavior happens at multiple layers of medical research - from single-center decision making models, to multi-national randomized control trials determining the efficacy of an intervention. Across time, these statistically significant determinations make their way into management algorithms.
However, almost everyone in clinical practice is aware that each patient is different. As a result, the management of each patient will be unique in some way. Which means that despite the existence of ‘averaged’ management algorithms, there are going to be patients for whom they do not apply, in part or whole.
Unfortunately, the litigious nature of Americans has resulted in strong adherence to these algorithms. Because the question becomes: how should one practice medicine to incur the least amount of ethical, legal, and financial blow-back? In pursuing this objective, we fail to recognize and act on the instinct that some guidance need not apply to certain patients. This is inevitable. There are always exceptions to the rules. But by following all the steps in an existing algorithm, we minimize the likelihood of encountering legal trouble with the solid defense:
Over time, we develop a shift in the teaching and practice of the art of medicine:
Stick to the guidelines.
Obviously, there are philosophical and practical problems with this mentality. That's discussion for another time. The consequences, however, are worse than they seem. Trainees develop a habit (conscious or otherwise) of memorizing the guidelines. Honestly, it's not entirely the trainee's fault. They are asked to memorize this stuff.
"What are the management considerations for systolic heart failure?"
Rounding on wards is often dominated by recitations of these management algorithms. As if that's all there is to consider in the care of a patient. Regardless, this habit develops. Then, board and certification exams focus their questions on how well a physician can regurgitate these algorithms on command. You see where I'm going with this.
Medicine becomes algorithmic. Algorithms can be automated. Automation can be manifested by both humans and computers. Thus, if you are not careful as a budding doctor, you may slowly morph into an automaton. Rendering yourself eminently replaceable. Placing yourself, and your license, under the whim of administrators and bureaucrats.
Where am I going with this?
Over time this approach to medicine continues to evolve, and it has done so in ways which weren't plainly obvious to me in the past. Fortunately and rather frustratingly, the COVID-19 pandemic has both worsened and brought this problem to the forefront. Now, this idea is going to require further dissection in another blog post or maybe a podcast, but I just want to touch on it briefly.
The insistence on and adherence to guidelines, has shifted the authority of medical practice from the licensed physician to centralized organizations which fund, perform, and even publish the Science behind the Management. Pick an organization...like the American Heart Association. The AHA is a collection of leading figures and bodies within the cardiovascular health enterprise. It's Huge. With involvement from independent physicians, labs, hospitals, universities, and more. The AHA is heavily funded, either directly or indirectly, by industry leaders such as Aetna, Eli Lilly, and Boston Scientific. The AHA has its own annual conference, and a whole gamut of medical journals. The AHA publishes guidelines. Thus, the AHA is a central authority which determines how most physicians practice medicine. Any deviation from the AHA can be met with ethical, financial or legal scorn.
Unfortunately, the more financially bloated and centralized an authority, the easier it is to capture. After-all, losing funding can be relatively devastating depending on how large the operation and thin the operating margin. But, since we've centralized authority in medicine, it actually becomes quite a bargain to influence it with financial incentive. Incentivizing a couple of people high in the hierarchy, is logistically (and maybe even financially) more feasible than influencing every practicing physician.
It saddens me that this problem of institutional capture has become so systemic that it sits at the core of all the pain and suffering we've had to endure over the last 18 months. Though many are just waking up to this painful reality, it may be that the worst is yet to come…
Read Part 2:
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