If recent popular posts on the big physician blogs are any indication, some US physicians are beginning to crack.
Three of the most read recent posts on KevinMD are on the topics of physician burnout, knowing when to quit medicine and—frighteningly– on the conditions that lead physicians to suicide. Along with my now quotidian experiences interacting with unhappy doctors, I’m suspicious that we may be reaching the end of physician professional practice as we know it.
My sense is that external demands, adjacent innovations and a flood of new medical knowledge are pushing our existing “physician production model” to its limits and it’s reflected in the anxiety many doctors are feeling.

I regularly think back to perhaps the most important talk I’ve ever heard addressing the current dysfunction in US healthcare. It was delivered by Dr. Brent James, from Intermountain Health who attributed the huge ongoing problems in healthcare to (only) three main drivers. These are:

  • A dysfunctional payment system that encourages utilization
  • The painful evolution of medicine from a craft business to an industry
  • Clinical uncertainty driven, partly, by the rapid growth in medical knowledge

I’ve blogged a lot about the first point, payment reform.

But, it would be a mistake to underestimate the real challenges stemming from the second two drivers: 1) the evolution from the “craft practice” of medicine into a highly reliable and standardized system of care and 2) the crushing flood of medical knowledge that can overwhelm physicians.

These are synergistic problems: external forces pushing for medicine to be more evidence-based, driven by rapid evolution of IT, genomics and scientific innovation.

It’s actually worse than incremental medical innovation:  I’d argue that the pace of innovation in adjacent industries such as IT, big data and the EMR has led to unprecedented demands on medicine for change.

The pressure caused by adjacent innovation is known as the Hummingbird Effect and is described by Steven Johnson in his recent book, How We Got To Now.  The Hummingbird Effect is when innovation in one field triggers a previously unrecognized demand for innovation in another.  For example, Johnson writes that the development of the Gutenberg printing press led to new demand for spectacles as people suddenly recognized that they were, indeed, myopic.  Before the press nobody needed glasses to read.

My suspicion is that the recent flood of information in medical science (decoding the genome, trials, EMR data mining…) have created a hummingbird moment.  There is an expectation that somehow doctors will know what to do with all of this information.  But the existing chassis simply can’t handle it.


Which isn’t to say that the physician chassis has’t changed before to meet the demands of ever-increasing information.

Before 1850 the US had only generalist physicians, but as medical information was introduced physicians increasingly segmented themselves on the basis of organ systems.  We now have hundreds of specialty areas, with more ABMS approved specialist roles being introduced annually.

The downside to having 130+ ABMS recognized specialties is an ever more complex system with all of its associated issues of discontinuities in care.  Everyone who has an elderly parent carrying around Ziplock bags filled with medications prescribed by dozens of physicians knows what I’m referring to.

A more recent attempt to segment care has been on the basis of acuity. Witness the rise of urgent care centers and the integration of advanced practitioners and non-physician into care delivery “teams” to (often) see lower acuity patients.  Modern Healthcare recently wrote about this attempt to decompress physicans by having them see fewer, but higher acuity patients. It’s admittedly a work in progress, as we try to figure out what “team-based” care is about.

We’re now at a point where the flow of data is too much even for acuity and organ segmented systems of care.  Physicians must feel like Lucy, in the famous I Love Lucy scene at the chocolate factory.


What could the future hold?  What should doctors look like and do to lead systems of care and ever-changing and expanding medical knowledge?

I’ve sometimes wondered whether our practice of producing doctors who manage diagnosis and treatment for a narrow sliver of conditions is the right approach.

I could see another word where we produce two distinct types of doctor: diagnosticians and therapists.

My time working as an attending in the emergency department taught me that  the skills needed to be a good diagnostician are often the opposite of those needed to be a pragmatic and evidence-based therapist.  The art of diagnosis is hard to reconcile with the very disciplined approach that standardized treatment requires.

Despite the range of computerized pattern matching algorithms out there, like Isabel, it’s hard to beat human intuition. The real art of diagnosis, I think, is interfacing with the patient and being ruthless about discarding the noise, while coaxing out pertinent details. Medicine can’t get away from essential heuristic decision making, which is critical to distilling complexity into a manageable bundle.

On the flip side, I’m increasingly convinced that there is real role for disciplined, standardized algorithms of care once patients are diagnosed– and that this sometimes dogmatic approach is the antithesis of the intuitive art of diagnosis.  The best treatments depends on rigorous, conscientious review of the evidence and a process for minimizing needless variation without a good reason.

I sometimes joke that this therapist physician begins to look a lot like a librarian-doctor.  Which may be what our technical advances in genomics and research have pushed us towards.  The therapist physician someone who deals in data: querying the existing knowledge base, while uploading results and outcomes so that treatment decisions are based on near real-time information.

A world of intuitive diagnosticians and librarian-therapists probably sounds downright dystopian to many physician colleagues.  But, one way or another, we’re going to need to get a handle on this new world of systems and information.  The way we’re doing it today is making doctors, and patients, miserable.

 

Photo: Gabriel Andrés Trujillo Escobedo via Flikr, cc License.