of medicine and false gods...

Medicine is a pursuit that lends itself to the adoption of allegiances to false gods. While right-ordered medicine has as its ultimate goal the restoration and preservation of health and the promotion of human flourishing, the messy side of medicine gets tangled up in human pride and vanity, and often leads its practitioners astray. Sometimes, it’s marketing departments at pharma R&D that channel our Masters-of-the-Universe vibe.  Other times, it’s the marvels of technology and the supposed power over illness that they promise.
What do we mean by ‘false gods’? First, these self-appointed “gods” seek to place themselves as paramount in directing our thoughts and actions. They demand our undivided attention and obedience, and they expect that we become subservient to them. Second, we acknowledge them as “false” because they seek to take the place of the One True God, the Divine Author of the First Commandment: “I AM THE LORD THY GOD: THOU SHALT NOT HAVE STRANGE GODS BEFORE ME.”
Some false gods are deeply embedded in our way of thinking—so deep in fact, that we scarcely notice them. The lies of the modern ‘arc of progress’ that have captured the profession are at the root of many of these. The heady concept that we, as a medical profession, have a duty and obligation to remake society in our own conceited image, is one such lie that we are presented with regularly. Medical societies declare a unipolar stance on issues such as climate alarmism and the unqualified virtue of diversity, all while refusing to defend the ancient Hippocratic concept protecting all human life through its proscription of abortion and physician-assisted suicide. It would seem the irony is lost on them that similar concepts of social progress made movements such as Eugenics quite fashionable among some medical scientists in the last century. The more things change…
While progressive thinking is prominent among the false gods, the particular one that I wish to focus on in this essay is the god of technology in documentation.  It is one of the false gods that is most ubiquitous in modern practice and which many people treat as a panacea on the journey toward the utopian dream of a Highly-Functioning Health Care System. The compulsory promotion of the Electronic Medical Record (who remembers the HITECH Act?) is emblematic of our culture’s broader worship of technology. Seemingly innocuous, the computer has been thrust so forcefully into the practice of medicine that it cannot be ignored nor extirpated from the exam room. Under the effects of our collective retrograde amnesia, one wonders whether Sir William Osler preferred a Mac or PC when he set up his “dot phrases” and “smart sets” in the hallowed halls of Johns Hopkins hospital.
I don’t consider myself to be old, but I do recall a time (very early in my practice life) when computers were not a mainstay of medical practice. One day early in my career I came into the clinic and noticed workmen on ladders, threading cables above the drop-down tile ceilings of the exam rooms. When I asked what was going on, the workmen responded rather casually that they were running wiring for the computers that were to be installed in every exam room in the practice. I was incredulous.  I asked myself silently, “Do they propose there will be a computer in EVERY exam room? What if I want to see a patient in the overflow room down the hall; or what if the connection goes out?”
Since then the computer has taken center stage in physicians’ daily struggles with disease. It is a vain practice companion, as evidenced by the amount of time and attention it commands every time there is a software update, workflow change, or order-set development. Like all false gods, it is self-serving and inwardly focused in its orientation. The EMR preens in email messages about scheduled software updates, displaying its technological plumage to attract our attention to its time-saving novel workflows. It seeks to reassure us that it alone can protect us from human error; can prevent dangerous drug-drug interactions and overdoses; can enhance cost-effectiveness of our therapeutic decisions; and can streamline all aspects of doctor-patient interactions through secure messaging and instant results release to patient portals without the unnecessary drag of physician-mediated interpretation. In a sense, the computer promises to save us from ourselves.
In reality, EMRs distract us from the patient in front of us, while instead promising to increase physician productivity through the application of templated office notes; capturing data and text that enhance the billable value of our patient visits; and include valuable tools to facilitate the inclusion of detailed Reviews of Systems and physical exams.  While these enhancements seem like unqualified goods, the demands of rapid documentation compel doctors to adopt the reflex of heading to the keyboard and screen while in front of patients. As an additional slight to physicians’ professional integrity, often these electronic shortcuts compel us to prioritize “enhanced insurance coding” over truth in patient care. A brief example will illustrate what I mean by this.
One morning as I prepared to assume coverage of our group’s hospital service, I reviewed the chart of one of our patients, an elderly man with advanced lung cancer who had been admitted to the Intensive Care Unit. The unfortunate patient had presented with respiratory failure requiring emergency intubation, and his condition was guarded.  As I read through the notes of one of the consultants who had seen the patient the day prior, I scrolled through the automated text blocks that were generated to maintain compliance with some billing or documentation regulation.  The tiresome compliance-speak that comprised more than 50% of the note caused me to scroll even faster to the portion of the note containing the consultant’s assessment and recommendations. However, what I read at the bottom of the note sent chills up my spine. The final piece of boilerplate text read as follows: “Internal Medicine Quality Measure: Patient is counseled on smoking cessation and routine lung cancer screening recommendations with annual low-dose CT scan.” Based upon the patient’s poor clinical condition and his already advanced disease, one can only hope that the admonishments attested to in this final act of documentation did not accurately represent the events of the doctor’s visit to the bedside.
I mention this example to highlight a point. The clamoring of the Electronic Medical Record threatens to remake our thought processes. It compels physicians to become distracted by concerns about billing, regulatory compliance, and legal concerns at the expense of the interests of the patient. Inasmuch as it demands our obeisance and distracts from the first principles of our professional vocation, the EMR is a false god which offers solutions to worldly concerns at the risk of turning us into liars and cheats. As physicians, it is incumbent upon us to keep technology at bay as we go about the daily human work of caring for the people who entrust themselves to our care. 

​--James Breen, M.D.