When I give third-year medical students their first didactic lecture of the clerkship, I implore them to ask, “Where does that come from?” “Who is the exception?” “Why?” Our patients expect us to be able to think, to understand why we do what we do, to realize who the outlier is or may be. Otherwise, why get a medical degree?
Patients often consult a physician out of fear of being the numerator. Maybe only 1 in every 305 women 35 years old will deliver a chromosomally abnormal baby. Or maybe only 3 to 7 of every 100 postmenopausal women who experience uterine bleeding will have endometrial cancer. The odds may be in the patient’s favor, but she is afraid that she might turn out to be that 1, or those 3 to 7, in the numerator of the equation.
Enter the EHR
With so much of clinical practice designed to be carried out by algorithm, our students are learning what to do but not why—so who will design newer and better algorithms in the future? The likely source of those new algorithms: the electronic health or medical record.
Computer experts, who need to know little or no pathophysiology, will be able to mine outcomes databases. For instance, they might analyze an institution’s last 3,000 cases of proven ovarian torsion, including dozens of parameters such as white blood cell count, size of the mass on ultrasonography, body temperature, and number of hours the patient experienced pain. Then they will perform a regression analysis on this data and develop a receiver-operating-characteristic (ROC) curve with the best “fit” for a manageable number of parameters. The physician will plug the data into a handheld device and, depending on which side of the curve the patient falls, will take her to the operating room or manage her expectantly.
There will be little need, or even tolerance, for judgment or experience.
When I describe this scenario to a colleague—he’s the safety officer on labor and delivery—he says we need protocols to protect patients because so many clinicians who rely on judgment and experience are doing a mediocre job. I argue that medicine by protocol narrows the bandwidth. It may bring the bottom up, but it also brings the top down. More people will get better care, but the outlier probably won’t.
But why do people go to the doctor? For fear of being the outlier!
Can we fix this problem?
Probably not.
The entire medical field is moving toward enhanced care for the majority at the expense of the few. Patient-safety systems and algorithms are the wave of the future.
A drop in the bucket
I still give that pep talk to third-year medical students as they enter our rotation, in the hope that it will resonate with even one or two of them, who may resolve to develop and cultivate judgment and experience even within the system that is enveloping us.
As for the rest of the students, they’ll squirm uncomfortably in their seats, or get confused on morning rounds—and, maybe, assert that cancer indeed causes menorrhagia.
We want to hear from you! Tell us what you think.