Never Alone - A True Story

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Burnout seemed to vary by specialty. Surgical professions such as neurosurgery had especially poor ratings of work-life balance and yet lower than average levels of burnout. Emergency physicians, on the other hand, had a better than average work-life balance but the highest burnout scores. The inconsistencies began to make sense when a team at the Mayo Clinic discovered that one of the strongest predictors of burnout was how much time an individual spent tied up doing computer documentation. Surgeons spend relatively little of their day in front of a computer.

Emergency physicians spend a lot of it that way. As digitization spreads, nurses and other health-care professionals are feeling similar effects from being screen-bound. There are messages from patients, messages containing lab and radiology results, messages from colleagues, messages from administrators, automated messages about not responding to previous messages. The rest she deletes, unread. As I observed more of my colleagues, I began to see the insidious ways that the software changed how people work together.

None of this was possible anymore. The doctors had to do it all themselves. As the chief clinical officer at Partners HealthCare, Meyer supervised the software upgrade. An internist in his fifties, he has the commanding air, upright posture, and crewcut one might expect from a man who spent half his career as a military officer. He still sees patients, and he experiences the same frustrations I was hearing about. Today, patients are the fastest-growing user group for electronic medical records. In one project, Partners is scanning records to identify people who have been on opioids for more than three months, in order to provide outreach and reduce the risk of overdose.

And the ability to pull up records from all hospitals that use the same software is driving real improvements in care. Meyer gave me an example. A recent study bolsters his case. Researchers looked at Medicare patients admitted to hospitals for fifteen common conditions, and analyzed how their thirty-day death rates changed as their hospitals computerized. The results shifted over time. In the first year of the study, deaths actually increased 0.

But after that deaths dropped 0. Indeed, the computer, by virtue of its brittle nature, seems to require that it come first. Brittleness is the inability of a system to cope with surprises, and, as we apply computers to situations that are ever more interconnected and layered, our systems are confounded by ever more surprises. By contrast, the systems theorist David Woods notes, human beings are designed to handle surprises. Last fall, the night before daylight-saving time ended, an all-user e-mail alert went out.

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The system did not have a way to record information when the hour from 1 A. This was, for the system, a surprise event. The only solution was to shut down the lab systems during the repeated hour. Fetal monitors in the obstetrics unit would have to be manually switched off and on at the top of the repeated hour.

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.

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Adaptation requires two things: mutation and selection. Mutation produces variety and deviation; selection kills off the least functional mutations. Our old, craft-based, pre-computer system of professional practice—in medicine and in other fields—was all mutation and no selection. There was plenty of room for individuals to do things differently from the norm; everyone could be an innovator.

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But there was no real mechanism for weeding out bad ideas or practices. Computerization, by contrast, is all selection and no mutation. For those in charge, this kind of system oversight is welcome. Gregg Meyer is understandably delighted to have the electronic levers to influence the tens of thousands of clinicians under his purview. He had spent much of his career seeing his hospitals blighted by unsafe practices that, in the paper-based world, he could do little about. A cardiologist might decide to classify and treat patients with congestive heart failure differently from the way his colleagues did, and with worse results.

That used to happen all the time. But those processes cannot handle more than a few change projects at a time. Artisanship has been throttled, and so has our professional capacity to identify and solve problems through ground-level experimentation. The answer is that the two systems have different purposes. Consumer technology is all about letting me be me. 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.

William Hersh, MD

And it sort of works. Not long ago, I spent a day following Lynden Lee as he scribed at a Massachusetts General Hospital primary-care practice. Lee, a twenty-three-year-old graduate of Boston University, is an Asian-American raised in Illinois, and, like many scribes, he was doing the job, earning minimum wage, while he applied to medical school.

He worked for Allan Goroll, a seventy-two-year-old internist of the old school—fuzzy eyebrows, steel-wool hair, waist-length white coat. Goroll can spend more time with you instead of typing at the computer. Goroll, in private, I can certainly leave the room.

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The first patient was Zoya Shteynberg, a fifty-seven-year-old immigrant from the Soviet Union with copper-red hair and red-rimmed glasses. Goroll faced Shteynberg across his desk. To his left, his computer sat untouched. To his right, Lee stood behind a wheeled laptop stand, his fingers already tapping at the keys. The story Shteynberg told was complex, and unfolded, as medical stories often do, in pieces that were difficult to connect. She had been having sudden, unusual episodes. They sometimes made her short of breath, at other times nauseated. While driving her car, she had an attack in which her heart raced and she felt so light-headed that she feared she might pass out.

She had a history of high blood pressure, and she had frequent ear congestion. Goroll probed and listened, while Lee recorded the details. He paused to tell Lee how to organize the information: to list faintness, high blood pressure, and ear congestion as three separate problems, not one. When it came time for a physical examination, Lee and I stood behind a curtain, giving Shteynberg privacy.

Goroll called out his findings for Lee to record.