Yesterday over breakfast a residency classmate described how much he had come to hate medicine as the most “degrading” work he had ever done. As he described the layers of EMR, corporate forms, fears over DEA and malpractice oversight, and outright patient belligerence bordering on physical aggression in his small-town ER, his wife observed that “there just doesn’t seem to be any trust anymore.”
Bingo. Since the mid-1960’s, the transition to a third-party psyche (private and government) in this industry sewed the philosophical seeds of mistrust. The nurses have to document when the doc goes into the room; the docs have a video tracker announcing their efficiency to remote electronic billboards and the front office; the staff has to fill out obnoxious and insulting “core measures” forms to satisfy a mistrustful government; write too many narcs for a frequent flyer and the feds notice you; some hospitals even put GPS trackers on their nurses to track their location! And of course, there is always the threat of malpractice.
A doctor knows how to diagnose and treat bronchitis; a simple chart note, eg “Mrs Smith, smoker, bronchitis, azithromycin” would suffice, in a society that actually trusted the clinician. The vast majority of work now done is not to treat the patient, but to satisfy an overseer. EMR’s, core measures, et al. are merely the tangible fruits of the philosophical mistrust planted four decades ago. As a result we no longer treat patients, but process them.