This week Atul Gawande has published “The Upgrade” in The New Yorker. It is the best article I have read on computers in practice. The title in the online edition is the more appropriate “Why Doctors Hate Their Computers. He uses stories that feel like snapshots from your own experience, whether you are a practitioner or a patient. He explains the nature of our dysfunctional relationship with computers but moves beyond complaining to a better understanding of the technology that has altered our lives, and over which we feel we have little control. If you read the almost 9000 words, you are left with a sense that things could get better.
Gawande begins with a depiction of the mandatory training that all the clinical professionals working at Partners Healthcare had to take in 2015 as Partners transitioned from its clunky homegrown electronic medical record to Epic. He reminded me of how amazed I was to hear that Partners was spending $1.6 billion on Epic. The number had seemed high because our costs for Epic had been in the tens of millions. Partners added all of their lost revenue during the Epic launch to their “cost.” The actual payments for the product, plus the personnel for the installation and training, were a little under a hundred million. At either price what are we buying?
After a humorous description of the training session with a young man who reminded him of Justin Bieber, and a confession that he was never worried that he was up to understanding how to use Epic since he had been into computers since he built his own computer in 1978 when he was in the eighth grade in Ohio, Atul does tell us what Partners was buying for hundreds of millions of dollars in 2015 for its vast system of twelve hospitals:
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.
The intervening three years have been an education for him and now he has some concerns:
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.
If that had been all that Dr. Gawande wanted us to know, he could have published the article in KevinMD.com or some other online medical throwaway. What follows are several stories from practitioners and a patient about why things are the way they are. The first insight that he offers is that Epic software is “revenge of the Ancillaries.” The process that he describes during the Epic installation is exactly the process that we experienced in my organization.
Many of the angriest complaints, however, were due to problems rooted in what Sumit Rana, a senior vice-president at Epic, called “the Revenge of the Ancillaries.” In building a given function—say, an order form for a brain MRI—the design choices were more political than technical: administrative staff and doctors had different views about what should be included. The doctors were used to having all the votes. But Epic had arranged meetings to try to adjudicate these differences. Now the staff had a say (and sometimes the doctors didn’t even show), and they added questions that made their jobs easier but other jobs more time-consuming. Questions that doctors had routinely skipped now stopped them short, with “field required” alerts. A simple request might now involve filling out a detailed form that took away precious minutes of time with patients.
Gawande says that he adjusted to the changes in a few months, but he sensed that the life of a surgeon who spent much of his time in the OR might be different than the life of a physician who saw patients all day in the office so he checked with a respected internist who confirmed his hunch. Her life had been significantly disrupted and she was now taking work home.
Now she routinely spends an hour or more on the computer after her children have gone to bed…[she] used to keep the list [her problem list for a patient] carefully updated—deleting problems that were no longer relevant, adding details about ones that were. But now everyone across the organization can modify the list, and, she said, “it has become utterly useless.” Three people will list the same diagnosis three different ways.
Both of the issues, the revenge of the ancillaries and the ruination of the doctor’s problem list, make the same point. We still prefer to practice alone and in control of our support systems and isolated from other opinions. A common system forces collaboration, like it or not. Gawande points out that this is an issue that is seen in other industries that have shifted to shared computer systems.
Difficulties with computers in the workplace are not unique to medicine… Frederick Brooks, in his classic 1975 book, “The Mythical Man-Month,” called this final state the Tar Pit. There is, he said, a predictable progression from a cool program (built, say, by a few nerds for a few of their nerd friends) to a bigger, less cool program product (to deliver the same function to more people, with different computer systems and different levels of ability) to an even bigger, very uncool program system (for even more people, with many different needs in many kinds of work).
… People initially embraced new programs and new capabilities with joy, then came to depend on them, then found themselves subject to a system that controlled their lives. At that point, they could either submit or rebel.
Electronic medical records certainly seem to have followed the reality that as a system expands to more users it becomes..
…more rule-bound. Changes required committees, negotiations, unsatisfactory split-the-difference solutions.
The “Tar Pit” is a reality in complex computer systems like Epic, and also systems in many other industries and professions.
The Tar Pit has trapped a great many of us: clinicians, scientists, police, salespeople—all of us hunched over our screens, spending more time dealing with constraints on how we do our jobs and less time simply doing them. And the only choice we seem to have is to adapt to this reality or become crushed by it.
At this point Gawande shifts to a discussion of burnout. He presents the work of Berkeley psychologist Christine Maslach and her definition of burnout which is:
“…a combination of three distinct feelings: emotional exhaustion, depersonalization (a cynical, instrumental attitude toward others), and a sense of personal ineffectiveness. The opposite, a feeling of deep engagement in one’s work, came from a sense of energy, personal involvement, and efficacy.”
He concludes that almost anyone who has worked with an electronic medical record is a potential burnout victim:
As I observed more of my colleagues, I began to see the insidious ways that the software changed how people work together. They’d become more disconnected; less likely to see and help one another, and often less able to.
Before we descend into a state of hopelessness Gawande offers insight that he gained from Gregg Meyer, Chief Clinical Officer at Partners HealthCare. Meyer acknowledged all the objections, but then he said, “But we think of this as a system for us and it’s not. It is for the patients…” Atul added, “Today, patients are the fastest-growing user group for electronic medical records.”
Meyers does not stop with the focus on the computer as a new tool that enables patients. He describes how having an enormous amount of data in one system facilitates insights that improves management of everything from the opioid crisis to lowering death rates in Medicare patients. That sounds great to Gawande but he observes:
…it’s perfectly possible to envisage a system that makes care ever better for those who receive it and ever more miserable for those who provide it.
At this point he digresses into a discussion of people versus machine or system going all the way back to Frederick Taylor, the efficiency expert in the era of Henry Ford. His musings lead to describing the advantage that humans have and so far that machines do not:
We’re resilient; we evolved to handle the shifting variety of a world where events routinely fall outside the boundaries of expectation. As a result, it’s the people inside organizations, not the machines, who must improvise in the face of unanticipated events..
…Medicine is a complex adaptive system: it is made up of many interconnected, multilayered parts, and it is meant to evolve with time and changing conditions. Software is not. It is complex, but it does not adapt. That is the heart of the problem for its users, us humans.
As an example of attempts at adapting the computer to humans and the withering pace of office practice, the next section of the article is about the introduction of “scribes.” Atul “shadows” a scribe who supports a very well known academic PCP at the MGH. The next level of evolution is to electronically send the “audio” from the visit to a service in India where the “scribe” is a computer savvy physician who works for even less than the stateside scribe who is in the exam room. Gawande is sensitive to the possible ethical issue of employing foreign physicians in a way that takes them away from providing care in their own countries. The logical end to this evolution is to use AI as the scribe.
Gawande is concerned that as we improve systems to become augmented to reclaim the extra hours that are being invested at home and reduce burnout, the system will ask us to see more patients. This has already happened to some emergency physicians.
With the time that scribes freed up, the system simply got doctors to take on more patients. Their workload didn’t lighten; it just shifted.
What Gawande never discusses is the role of finance in relationship to the impact that computers have on practice. If we are to be paid based on the sum of all the things that we do and the intellectual process behind what we chose to do, then we must record everything we do and all we considered. The computer facilitates this. Gawande spends some time bemoaning drop down lists, notes constructed using information “copied and pasted” from other notes, and all the tricks we have learned in our struggle to meet the requirements for documentation that are thrown at us. I have always thought that it would be interesting to see how we would use the computer if it were not a part of the finance process, and we were able to move away from our fee for service finance structure.
In the last major section of the article Gawande presents us with a story from his own experience with an insightful patient. Gawande feels that the computer has distorted their encounter. Gawande is painfully aware that he is interacting with the computer more than with the patient. The patient eventually lets him know that he understands the importance of the computer based on his own experience managing large construction projects.
The scene leaves us thinking that there is hope that thoughtful clinicians will mitigate the negative impact of computers and eventually understand how to take advantage of their ability to improve care. Near the end Gawande’s writing is inspiring as he expresses his hope for a better day. I think he is saying that we must move away from just complaining about computer systems and learn how to incorporate them into our care of patients without letting the computer come between us and what is most important, the relationship with the patient.
