An Epic Struggle for the Soul of Medicine

  • Martin A. Samuels
    Requests for reprints should be addressed to Martin A. Samuels, MD, MACP, Massachusetts General Brigham Health Care System, Hale Building, 60 Fenwood Road, 4th floor, Boston, MA, 02115.
    Miriam Sydney Joseph Distinguished Professor of Neurology, Harvard Medical School, Boston, Mass

    Department of Neurology, Brigham and Women's Hospital, Boston, Mass

    Massachusetts General Brigham Health Care System, Boston, Mass
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Published:September 25, 2022DOI:
      I was ordered to attend an all-day training session in a new medical record system. I thought it was interesting that the experience was called “training,” which prompted me to remind myself of a few useful definitions.
      Education, from the Latin root meaning a drawing forth, implies not so much the communication of knowledge as the discipline of the intellect, an intracerebral process aimed in large part at creating principles on which new knowledge may be elaborated. Instruction is that part of education that furnishes the mind with knowledge. Teaching is often applied to practice as in teaching a dog to do tricks. Training is an element of education in which the chief characteristic is exercise or practice for the purpose of imparting facility, as in training for the marathon. Breeding relates to manners and outward conduct as in standing when elders enter a room is a sign of good breeding. Regimentation is the prescription of a particular way of life or thinking usually involving the imposition of discipline. The term, arising from military regiment, is related to the medical usage of regimen, as in the patient keeps her prescription medications in separate compartments of a plastic container to accurately adhere to the regimen. Propaganda is the systematic propagation of a doctrine, cause, or information reflecting the views and interests of those advocating such a doctrine or cause, as in ACCME is propagating the view that elaborate recertification maneuvers will improve the lives of patients.
      A cheerful instructor started the session by asking each of us to introduce ourselves and reveal a secret guilty pleasure. Mine is to create elaborate cocktails. If only I had had one of my famous Marty's Beerjitos with me, the whole experience could have been much more pleasant. In addition to the instructor, there were several “super-users” in the room to facilitate the process. It was immediately obvious to me that the super-users hovered behind my chair. These friendly young people had correctly identified me a “super-loser.” Had I been litigious I would have reported the experience to our ombudsperson as blatant ageism. But, alas, they were correct. I was hopeless. Besides, I don't believe in ombudspeople. I believe one should speak for oneself.
      The experience transported me back to the Northwood Elementary School when my parents decided to enroll me in clarinet lessons. They rented a metal clarinet. The teacher, Mrs. Strickland, traveled among the elementary schools in the district, spending a half-day in each, introducing kids to music. The emotional memory remains vivid. I just couldn't make a sound with the thing—not even a squeak! I also didn't know where to put my hands and, of course, could not read the music. It was a horrifying experience. Now, at the age of 77 I was back in the same situation; infantilized in a windowless room with 16 computers, behind each of which was a doctor who should have been seeing patients. There were only 2 differences between then and now. One, I now have many more things that I should be doing than I did then. Two, at least the end product of what I was doing then was inherently meritorious—namely, making music. Now I was playing a video game, and what was even more horrifying was that some of the people around me were actually enjoying it.
      I know all the rationales for an electronic medical record, such as bringing our supposedly chaotic medical system into line, reducing medication errors, and improving communication, which are all meritorious goals. There is nothing inherently good or evil about an electronic record. After all it is just a computer program, basically a machine. The fact is that a machine has no soul. It has no feelings and no commitment to the practice of medicine. To allow the machine to dictate the rules reminds one of HAL from Stanley Kubrick's film, 2001: The Space Odyssey. “Just what do you think you're doing, Dave?”
      The electronic medical record does not adhere to any natural laws, such as the laws of biology. The rules are arbitrary. They are created by people. Playing with the machine is nothing more than a video game. In fact, at the end of my day in training, I was told to go home a use the “playground”—a simulated electronic medical record that would help me to become more facile at following the unnatural rules of what is really a billing machine. But this is not play for me. It is tedium that distracts me from the job for which I am educated, namely, reducing suffering in human beings. I only have a finite number of days when I can use my skills. One day in the windowless room is one fewer that I have left. If we are not careful, we might even convince society that the electronic medical record, and what it represents, is an end in itself, more important than taking care of the sick, training our successors, and finding cures for human disease. Or, is it already too late? Has the door already closed behind us?
      “Do you read me, HAL?
      Affirmative, Dave.
      Open the pod bay doors, HAL.
      I'm afraid I can't do that Dave. This mission is too important to allow you to jeopardize it.”
      Over and Out!