Attending

A few separate passages I’ve combined from Dr. Ronald Epstein’s Attending: Medicine, Mindfulness, and Humanity:

Altogether, I saw too much harshness, mindlessness, and inhumanity. Medical school was dominated by facts, pathways, and mechanisms; residency was about learning to diagnose, treat, and do procedures, framed by a pit-of-the-stomach dread that you might kill someone by missing something or not knowing enough.

Good doctors need to be self-aware to practice at their best; self-awareness needs to be in the moment, not just Monday-morning quarterbacking; and no one had a road map.

The great physician-teacher William Osler once said, “We miss more by not seeing than by not knowing.”

The fast pace of clinical practice—accelerated by electronic records—requires juggling multiple tasks seemingly simultaneously. Although commonly thought of as multitasking, multitasking is a misnomer—we actually alternate among tasks. Each time we switch tasks we need time to recover and, during the recovery period, we are less effective. Psychologists call this interruption recovery failure, which sounds a bit like those computer error messages we all dread. We increasingly feel as if we are victims of distractions rather than in control of them.

Outside of the OR (and not always even then), it’s rare to find an environment that promotes the space for deep focus and self-awareness. Mindfulness, insofar as a daily approach to medical practice, is something that goes against the grain of one’s surroundings.

Good doctors need to be self-aware to practice at their best; self-awareness needs to be in the moment, not just Monday-morning quarterbacking.

I like that. Medicine is generally ripe for Monday-morning quarterbacking (and radiology in particular due to the permanent, accessible, and objective nature of the imaging record).

But doctors don’t work in vacuums. We are humans.

Consider for a moment the discipline of human factors engineering:

Human factors engineering is the discipline that attempts to identify and address these issues. It is the discipline that takes into account human strengths and limitations in the design of interactive systems that involve people, tools and technology, and work environments to ensure safety, effectiveness, and ease of use. A human factors engineer examines a particular activity in terms of its component tasks, and then assesses the physical demands, skill demands, mental workload, team dynamics, aspects of the work environment (e.g., adequate lighting, limited noise, or other distractions), and device design required to complete the task optimally. In essence, human factors engineering focuses on how systems work in actual practice, with real—and fallible—human beings at the controls, and attempts to design systems that optimize safety and minimize the risk of error in complex environments.

(I first found that passage plagiarized on page 8 of the American Board of Radiology’s Non-interpretive Skills Guide.)

Despite the rise of checklists and evidence-based medicine, humans have been almost designed out of healthcare entirely. Rarely is anything in the system–from the overburdened schedules, administrative tasks, constant messaging, system-wide emails, the cluttered EMR, or the byzantine billing/coding game–designed to help humans take the time and mental space to sit in front of a patient (or an imaging study, for that matter) and fully be, in that moment, a doctor.

Organization Habit Loops

From Charles Duhigg’s The Power of Habit: Why We Do What We Do in Life and Business:

That’s when [Alcoa CEO Paul] O’Neill’s education in organizational habits really started. One of his first assignments was to create an analytical framework for studying how the government was spending money on health care. He quickly figured out that the government’s efforts, which should have been guided by logical rules and deliberate priorities, were instead driven by bizarre institutional processes that, in many ways, operated like habits.

Healthcare in a nutshell, from the tippy top of Medicare and the FDA down to the hospitals and institutions. It’s all path dependence. We are where we are because of where we’ve been, but we’d never choose to be here doing it like this in the first place.

Bureaucrats and politicians, rather than making decisions, were responding to cues with automatic routines in order to get rewards such as promotions or reelection. It was the habit loop—spread across thousands of people and billions of dollars.

This has always been true, but the optimist in me always hopes that a big event–like a generation-defining pandemic–might shock people into cohesive collective action focused on outcomes instead of the typical saber-rattling over competing values.

Old Guard Medical Wisdom? Rest

From Rest: Why You Get More Done When You Work Less:

Neurosurgeon Wilder Penfield, for example, warned medical students that unless they cultivated other interests, “your specializing will expose you to an insidious disease that can shut you away from all but your occupational associates” and “imprison you in lonely solitude.” Penfield’s mentor, William Osler, warned that without care, “good men are ruined by success in practice,” and that “ever-increasing demands” can leave even the most curious person “worn out, yet not able to rest.” It was essential to develop “some intellectual pastime which may serve to keep you in touch with the world of art, of science, or of letters.”

These statements came from an era when residents literally lived in the hospital and Osler’s famous surgical colleague William Halstead’s work ethic was fueled by cocaine.

And even they thought it was important for doctors to be well-rounded, have hobbies, and get a life.

Honestly, I’m more interested in what you do for you than what boxes you’re just checking to impress me.

The good-reason-to-be-a-doctor police

From Insider’s Pre-Med Guidebook: Advice from admissions faculty at America’s top medical schools:

Every year, hundreds of thousands of students pursue premedical studies at four-year universities across the United States and the world, and they, too, want to become physicians for a myriad of reasons. Many will find their reasons to be mature and well-reasoned. These students will find the motivation and strength to succeed as pre-med students, medical students, and physicians, and they will live happy and productive lives. Others will pursue medicine for reasons that are immature, underdeveloped, or untested. For these students, there are two major possibilities: they will struggle through their pre-medical studies and drop out, or they will end up dissatisfied with their life-long careers as doctors.

Before you pursue medicine as a career, you must be sure medicine is a good fit for you. If your motivations are poor or false, you will not have the drive to succeed during the long and difficult road ahead. You will lose time, money, and the opportunity to pursue whatever your passion truly is. If your motivations are genuine and well-developed, you will find this path to be easier and infinitely more rewarding. Not only that, but your passion will shine through the activities you pursue. Medicine is a pursuit that is simply too long, too difficult, too costly, and too important to pursue for the wrong reasons.

I would like to call bullshit on these bland truisms.

Someone show me some data.

I think there are plenty of folks who choose medicine for the “right” reasons and then get burned and churned through the medical training gauntlet. It’s hard, and the difficulty varies for different people for different reasons. It’s a specious argument that unhappiness with a medical career stems from flawed motivation as opposed to, say, a toxic training paradigm or a flawed healthcare system.

And, I think there are lots of folks who choose medicine because it’s a challenging well-compensated job where you generally have a meaningful positive impact on other humans on a daily basis.

Your pure soul can be exclusively motivated by humanistic altruism but actually have zero idea what it’s actually like to be a doctor day in and day out. Because shadowing isn’t the same as doing it for years.

You can be passionate about “medicine as a career” for all the “right” reasons even though the “career” you’ve chosen is actually a broad umbrella under which there lies a huge variety of professions from diagnostic radiology to general surgery to psychiatry?

I’ve never been convinced by the idea that good successful doctors are mostly a bunch of 18-year-olds who have a singular understanding of their lifelong “passion” let alone a meaningful understanding of medicine.

I’ve known wonderful failed pre-meds who would’ve made excellent physicians but didn’t make it through the gauntlet, and I’ve met plenty of self-satisfied doctors who got through but probably shouldn’t have.

Show me some data that the process selects for the right reasons and not just the right boxes checked.

 

Slim pickings high up on the ladder

From Nobel laureate economist Richard Thaler’s Misbehaving: The Making of Behavioral Economics:

A competitive labor market does do a pretty good job of channeling people into jobs that suit them. But ironically, this logic may become less compelling as we move up the managerial ladder. All economists are at least pretty good at economics, but many who are chosen to be department chair fail miserably at that job. This is the famous Peter Principle: people keep getting promoted until they reach their level of incompetence.

I wrote an article called Academic Medicine and the Peter Principle back in 2019, and the mismatch between merit for admission, merit for promotion, and skill at a given position explains so much about so many rudderless institutions.