A Doctor’s Work

Bedside Rounds is a medical podcast by Adam Rodman, MD, about fascinating stories in clinical medicine rooted in history. ACP has teamed up with Adam to offer continuing medical education related to his podcasts, available exclusively to ACP members by completing the CME/MOC quiz.

Adam Rodman (00:00):

This is Adam Rodman, and you're listening to Bedside Rounds, a monthly podcast on the weird, wonderful, and intensely human stories that have shaped modern medicine, brought to you in partnership with the American College of Physicians. This episode is called A Doctor's Work. I've now had five episodes about the history of diagnosis, starting with the origins of pathological anatomy, meandering through the development of statistical and a epistemological uncertainty and a diagnosis. And we, through the seemingly mundane, but hopefully I've convinced you very important ideas around data collection that have influenced how we approach our patients. But there's a parallel thread that runs alongside all of this. Diagnosis is both indisputably important and at the same time something that we physicians spend relatively little of our actual time on. This shouldn't be controversial, but your average internist spends far more time interacting with the electronic medical record, uh, talking to our patients or coordinating care than the mental gymnastics of diagnosis in the same period that modern diagnosis has developed, let's say roughly the middle of the 19th century through today, 2022, the daily work of a physician has changed dramatically.

Adam Rodman (01:10):

But the stories that we tell ourselves about our work, stories that illustrate both our ideas about our own field, but also reflect greater cultural understandings of the work of physicians have stayed remarkably the same on bedside rounds. I talk a lot about how our imagined history's, uh, nostalgia, if you want to call it that, as opposed to the messy actual history of modern medicine came to be, can be so harmful to physicians' wellbeing and how we care for our patients. In this episode, I'm going to dig deep into this nostalgia, how imagined ideas about our work have conflicted with the changing realities of clinical practice, especially with the introduction of the problem-oriented medical record and the electronic helper medical record. But I am not a cultural historian, so I've invited some friends along on this journey. We are going to be talking about detective novels and the actual work of solving crimes, the development of the electronic medical record, what it means to be a virtuoso and the actual work of the physician. Would you guys like to introduce yourselves?

Lakshmi Krishnan (02:13):

Um, I'm Lakshmi Krishin. I'm a cultural historian of medicine and hospitalist at Georgetown.

Mike Neuss (02:19):

And I'm Mike NOIs. I'm a hospitalist in historian of medicine at the University of Pennsylvania.

Adam Rodman (02:25):

So I'm so excited to talk to you guys today cuz we're gonna talk about the piece you just published in BMJ Humanities. Um, and the title is what Vir uh, virtuosic Craft or Clerical Labor. And this is a really unfair question, uh, I guess de Lakshmi, can you sum up the gist of the argument and about like 30 seconds?

Lakshmi Krishnan (02:44):

<laugh>, this is an unfair question, Adam. I

Adam Rodman (02:47):

Know, I I knew I was gonna do this to

Lakshmi Krishnan (02:49):

You. Yeah, no. So I think the gist of the argument is that we were really interested in the rise of the electronic health record, um, specifically the computer based record and the transition from paper charts to that and how this is bound up in issues of physician professional identity and how we think about the work of physicians. Like what do we do? How do we define it, what are the metaphors?

Mike Neuss (03:15):

You know, this is a very contentious topic. This is a topic that attracts a lot of people's attention. There's a lot of inks built on the question of, you know, what, what really does the electronic health record do to the nature of physicians work? How does it change things? And for us, looking at this historically was really exciting, really important, I think, to reorient that discussion a little bit around the ways throughout time that people have conceived of their work vis-a-vis the electronic health record or the computer-based patient record, um, to avoid in an acronym. And so I think we thought at the outset as we were devising this paper, an exciting way to add to this, um, sometimes contentious discussion.

Adam Rodman (04:02):

What I find really interesting is though, I mean, you scope, you scope your discussion starting, you know, at the beginning of the P L M R starting in the 1950s, even before, but you're drawing on metaphors that are much older, in particular, detective metaphors. Right. And lock me, I guess this question is for you, actually, this question's for both of you, the physician as detective, when does that first start to enter that metaphor? Start to enter medical discourse?

Lakshmi Krishnan (04:29):

Yeah, I would really say early to mid 19th century in the European and the American context. Thank you. This me, this question is music to my ears <laugh>, because we really do see that delta over time that, you know, i i looking at records on Diagno diagnosis and who the physician is from sort of the 1790s to the early 19th century, we don't see that sort of formation. And it really starts to come about, as I said, early 19th century and conveniently enough that mirrors the, the rise of the detective story in detective fiction and the, you know, the entrance of characters like Edgar Allen pose, detective D Japan, August Japan, who's not a physician, but is clearly modeled upon physicians. So there's something going on there between culture and medicine, um, that I think is really fascinating.

Adam Rodman (05:25):

So I have to ask dpa, uh, I guess is one of the models of the modern detective, right? Or the modern detective and detective stories. Didn't medicine influence detective stories? Did detective stories influence medicine or is it a, an or what an orora Boris, you, you, there's, it's impossible to tell the beginning and the end.

Lakshmi Krishnan (05:44):

No, I think, I think it is a bit of an aura, Boris, but there's definitely a bidirectional component. Um, I mean, one of the things I've been really interested in looking at poses early writing, especially like the murders in the room morgue, like just thinking about that title, that's 1841, um, which is set in pose imagination of like a fictionalized Paris. We know that the Parisian clinics, um, and pathological anatomy, like all of these things are occurring in medicine right before then. So there's, there's clearly a nod. Um, there's a nod to medical knowledge. There's a nod to the idea of the, just the morgue dissection anatomy just built into the title. So certainly the detective story is influenced by medicine. And then once you start to see like toward the mid to late 19th century is medicine, taking on the, the, the, you know, the sort of glamor and the cultural impact of the detective from a literary standpoint. And it just keeps going and going and going. <laugh>

Adam Rodman (06:50):

No, I have to ask, because you've mentioned this so Prepo, let's talk the birth of pathological anatomy. What, so like be shot, uh, lin neck, what sort of metaphors would they have recognized for the cognitive work of the position?

Lakshmi Krishnan (07:04):

Oh, great question. Well, I think Len Neck is interesting because he's a musician. So he uses, um, he uses a kind of heightened musical observation, especially in his writing, you know, this aum about the stethoscope. Um, they're these beautiful musical and literary, um, me like metaphors, um, you know, the tinkling of the harp, the tinkling of, you know, sort of a glass. Um, there's all of that stuff. I don't hear Linac or c Linac using detective metaphors necessarily, but there is this sense of an investigator, I would say almost like a proto detective using the observational skills of an artist or a musician. BHAs an interesting one. I'd be cur I'd be curious for like other Scotts on this, but bal also, I don't think is using the detective or the investigator metaphor. Um, trying to think what metaphors he uses.

Mike Neuss (08:04):

Yeah, I would, I

Lakshmi Krishnan (08:05):

Would sort of, yeah. Mike, do you have

Mike Neuss (08:06):

A, I would venture to say I, I'm not enough of an expert in, in Bik to sort of say concretely what metaphors he didn't did or didn't use. It's, it, it's difficult to escape the impression. I think I had early in grad school reading fuco about bik and that whole move and the notion of like opening up these big books and sort of doing a kind of accounting and doing a kind of close look at the numbers of what was coming into the hospital, what the diagnoses were. And so that lends itself to us maybe creating metaphors about that and, and sort of the hope of describing it better. But I, it's, this is something I think, I wish I knew a little bit better what the answer was, but, but to get back to the original sort of point and, and kind of the question of the detective metaphor and, and the aura Boris, this bidirectional kind of feedback, I, I guess the, the, the takeaway point for me to, to kind of hammer on is what work does that do in the kind of social hierarchy of medicine?

Mike Neuss (09:02):

How does that privilege the work of the physician? And I think it physician, you know, it, it privileges the work of the physician in a very big and very important way. Um, it's somewhat flattering in a way to sort of think of ourselves as detecting at a very high level as having this very cerebral difficult work of being, again, a virtuoso as the title alludes to. And, and yet, and yet, and LMI might laugh at this, you know, we had an earlier version of the title, which was discarded that poked fun at the fact that, you know, there's actually sort of an inversion that physicians do in, in kind of thinking of their work that the actual doctor in, you know, with Sherlock Holmes, it's not Holmes, right? It's it's Watson, it's the Emmanuel Ensis, but we invert that and, you know, come up with terms like I B m Watson, right? But who, who was actually the doctor in this configuration. Um, and so I think there's a lot at play in terms of who has the position of priority in the hi, you know, the medical hierarchy, who has the position of privilege, and how does the computer based record either kind of reify that or actually over time begin to poke holes in physician identity.

Adam Rodman (10:12):

Before we get to, I guess the 1950s, a a question about the reality of the metaphor, right? One of the arguments in the paper, of course of the metaphor is based on it's in or boros, but fiction, and I think we all know the answer to this, but what was the reality, let's say in the 1890s, right at the, the height of, uh, of Holmes? What was the reality of the cognitive work of the physician? What, what were people actually doing during their, their day? Did it at all resemble the fictional homes?

Lakshmi Krishnan (10:42):

I think, I mean, I would say to a certain extent it did. I don't think the metaphor has ever been, has ever quite tracked or mapped perfectly onto the, the, the realities of clinical work. Um, one thing I find interesting about that period really leading up to leading into the early 20th century is the rise and fa the rise of and fascination with forensic medicine and legal medicine. Um, and how those are things that are now a bit more peripheral, right? In medical training. Um, we don't have required courses on medical jurisprudence anymore or forensic medicine anymore, but that was happening, um, in that period. You identified Adam. And so there's something there about the, you know, the very direct mapping of investigation and diagnosis, let's say, of the physician and the detective that's, that is wrapped up, I think more into central physician identity, um, in that time. Does that answer the question in terms of the actual like daily work? No, of course. Doesn't <laugh> of course it doesn't completely track. And what we find is that the media change over time, the genre of physician work has actually not, not changed all that much. So some of the same challenges that we are identifying in our paper for 22 were, you know, were at play in like 1892.

Adam Rodman (12:08):

Oh right. Some of the same complaints from a hundred years ago are made today, which leads to the perception that clinical work obviously has changed, but our complaints haven't changed that much.

Lakshmi Krishnan (12:19):

Yeah. Yeah.

Adam Rodman (12:20):

Do you have, do you have anything to add to that, Mike?

Mike Neuss (12:22):

I guess I would would push back a little bit at, at the notion of like a lack of change, just in the sense that there are these things that, you know, we, we, we take the reader down the pathway of what did Eugene Stead say at Duke? And this was sort of fun, I think, for two dookies to do what

Adam Rodman (12:39):

Did El obviously, full disclosure, I went to Carolina, so

Mike Neuss (12:43):

<laugh>, so we,

Lakshmi Krishnan (12:44):

We, we won't hold that against you.

Adam Rodman (12:46):

My wife is a dookie, so you should love this

Mike Neuss (12:48):

<laugh>. That's a, that's a funny conversation. My godfather's actually from, from went to unc. Um, and there's, there's kind of illusion to this in the abstract and sort of early in the paper, there is at least a kind of optimism about the computer at various points. And this gives way, I think, much more recently to much more pessimism. And so the way that people were complaining about their work and their labor, particularly around the computer and how the computer might have changed that, right? Didn't change it yet. Cuz people were still paper based largely through the 1960s, seventies and, and onward. Um, there was this optimism at play, right? We can really change the way clinical decision making happens. We can really support it differently. Now that doesn't really pan out as people really envision. There's some promise to some of that. You, Adam, live in a very interesting system where you, you're one of the last holdouts of

Adam Rodman (13:45):

The, from this optimistic period Yeah,

Mike Neuss (13:46):

Yeah. Of this homegrown e h r, which, which people often look at wistfully and, and to a degree romanticize, which is another interesting dynamic cuz I don't know what it's like to use, to use it, but I'm sure there are things that are wonderful and there are things that are probably much less than wonderful.

Adam Rodman (14:04):

I would agree with that. That is a great explanation of, uh, what we use as we call O M R, which is the descendant of Vitech.

Mike Neuss (14:11):

And so certainly some of those homegrown EHRs bare, um, I guess I you could say artifacts of this, this period of optimism where people are trying very, um, assiduously at times to support clinical decision making. But a lot of that kind of seems to fall out, or at least as perceived as falling out as time goes on. And I think that that dynamic, which is something we, we talk a little bit about in the paper, um, is interesting in terms, again, of how people complain, so to speak, about their work as physicians.

Lakshmi Krishnan (14:43):

No, I just wanted to, I just texture that a little bit in the sense that, you know, I, I completely agree, um, in terms of the specific technology we're discussing, but do think contextualizing this a little bit in the broader sweep, there are these alternating cycles of technological optimism and pessimism. I mean, we see this in the his, in the history of various medical technologies. And I think what's interesting, what I think is really interesting about our paper is obviously we're talking about the E H R, which is a polarizing and important current entity, but this paper is also a bit of a blueprint for thinking about why technologies create such angst for physicians. And I think this question of what we become when we interface with technologies and how it, you know, how this raises questions about who we are, what is even the point of us <laugh>, do we have a future as a profession seems to occur? You know, it occurred with, I keep saying the stethoscope. Yeah,

Adam Rodman (15:42):

That was exactly what I was thinking. The stethoscope, the X-ray,

Lakshmi Krishnan (15:45):

The X-ray, exactly. When our senses are replaced or augmented or amplified, um, or we're extended in a kind of bionic fashion, what happens to us as physicians. And so for me, like real, that's a really cool blueprint, um, to pull from this paper as well. Would you agree with that, Mike?

Mike Neuss (16:04):

Absolutely. So I, I don't have much to add.

Adam Rodman (16:08):

That's uncon well, an uncontroversial statement. I, I mean, X actually in particular, like the, uh, the optimism and the fear was so out of line with the actual reality of what X-rays and say like 1905 were actually capable of doing.

Mike Neuss (16:20):

Yeah. And I guess that's, I mean, we live in a moment of, of yeah, particularly acute fear. Again, the, the clerical labor part of the title alludes to that, the kind of criticisms that you might characterize sometimes as romanticizing the past. Um, you know, that this is, this is a really important dynamic and, and sort of parsing that out a little bit is part of what the paper did. And I think a big part of, you know, the wider discussion that we're engaging with

Adam Rodman (16:46):

Before we get into the nitty gritty of anachronistically calling it the E H r where this, this professional identity, right, this professional identity formation of the physician as, as virtuoso as a physician, as detective, um, clearly it's been around well over a century. Do you feel that it's explicitly taught part of the culture, the hidden curriculum? Is it modeled in the media? Like where, where does this idea come from? Because I don't think anyone ever sat me down and explained this to me, but I certainly by the time I was an intern, it'd been well ingrained.

Mike Neuss (17:20):

It is something that we end up learning. It's something that we end up sort of perceiving and appreciating in a lot of kind of our work. I think we all kind of have that, that sense as medical students that, you know, as, as we're sort of early on, that people seem to have insights into things. People seem to know things that, that seem sort of very exciting, very difficult, very challenging, but it also appeals at some level to our own egos and it appeals to our own sense of self and sense of status to think of ourselves in these terms, right? These terms have real meaning and real significance within the wider professional community. And I think part of what the paper does is contextualize a little bit some of this, right? We, we hint, or more than hint at this, particularly in the conclusion that there's a lot of change.

Mike Neuss (18:05):

There's a feeling of upheaval whether you invoke different legislative action, whether you invoke covid 19, when you think about the imposition on people's workflow and time that the computer might impose. These are all things that feel very challenging to physician identity and most of us entering this profession, I, I would think, and this is hopefully not an unfair generalization or an untrue generalization, have been exposed to certainly even before medical school and before this, you know, the quote, hidden curriculum might, might be something that we're exposed to a lot of these tropes, a lot of these really sort of significant figures in popular culture that hold up this image of, of genius, of something like a virtuoso of somebody who engages almost in a kind of wizardry mentally. And, and that's, that's ultimately, I I think sort of a, an exciting and satisfying way to sort of think of your profession and your status within the medical hierarchy.

Lakshmi Krishnan (19:10):

Yeah, I I couldn't have said it better. I absolutely agree. Um, I will add some anecdotes. Actually just recently I had a conversation with a medical student who heard about this work. Like, and the fact that I'm writing a book looking at the history of the doctor as detective paradigm and using literary sources. And he said, I can't wait to read this. Which is wonderful and gratifying to hear because I wrote my admissions essay on how, um, reading detective fiction got me really excited about becoming a doctor and the, and the intellectual work that goes into being a doctor. And this is not an exceptional story. I've, I've come across this, I've talked to very like senior seasoned folks who say, who describe Sherlock Holmes as a kind of gateway drug to getting into medicine. And what I felt, the reason I conceived of my book was because as a resident, I noticed that though it wasn't explicit, it was sort of, this metaphor was sort of permeating everything we do.

Lakshmi Krishnan (20:14):

I mean, I really think it structures the case-based learning that we do things like mystery, medical case conferences. We had something at Duke called Chairs conference. The whole point was to present a diagnostic dilemma. Uh, you know, I had some attendings when I was coming up who, who said things like, well, we're detectives, like think like a detective. And I, I was really, I found that very alluring. Um, it's one of the reasons I went into internal medicine and the idea of being a cognitive doctor was, was, you know, sort of as Mike was saying, glamorous too. So Adam, to answer that kind of first question, I do think it's part of our medical educational structures. It's part of how we test physicians and licensed physicians had an interesting conversation the other day with someone I won't name, but talking about how the, how test questions are written, right? Um, and, and they use the clues based investigation as a model. They think about and talk about red herrings. I think you and I have had a conversation about this too. Um, so they're using literary narrative structures and case-based structures to, uh, yeah, to, to test and license and certified physicians. But of course, as Mike alluded to, there's this significant downside. Um, there is all sorts of labor and work and thinking and well, those three things that get dismissed, right, as unemploy,

Adam Rodman (21:41):

Right? That's what we, that's what we call it, Scott, is what the, the name that we call non,

Lakshmi Krishnan (21:44):

Yeah. Yeah. And I see this with my medical students, right? They get a certain curriculum and then they hit the wards and are surprised because there's a shadow clinical reality that's not a shadow at all. It's what we do, um, and is just as important, if not more important. So there's that. And then also taking this position of a virtuoso, of an expert, of an authority, um, sets us up for all kinds of issues with bias disparities, uh, you know, not perf not doing patient-centric care, all of that. And I, we can get into that in more detail cause I think that's an important other thrust of our paper as well. But yeah, I'll, I'll stop there.

Mike Neuss (22:25):

That, that was lovely and we'll, well put. And I guess I would add by way of the anecdote and personal story, and I hope I I'm not overstepping by also invoking the great Dan Kaplan at Duke, if you've never seen him on Twitter, he's not very active. But if you really dig down into his Twitter feed, you'll find his haiku's <laugh> about being on the wards and being the triage attending. And I, I actually copied them and I share them with my teams because they're full of wit and wisdom and they're, they're just hilarious <laugh>. Um, but the reason I bring up Dr. Kaplan, who, who really is one of the biggest reasons I'm an internist, sort of, and it's funny to talk about this in the setting, uh, is he, he said this really sort of funny thing and very deeply insightful thing when I was a young and impressionable impressionable medical student, which is, you know, we don't order things in medical school by some hierarchy of relevance.

Mike Neuss (23:18):

We do it by a hierarchy of, you know, what's interesting? And so you spend all of this time learning about porphyria, but then you'll never actually see porphyria. And I said to my dad, who's a retired he monk doctor, how many times in your life did you see porphyria? And he said, you know, it's an interesting question. I think I might have seen it a few times. My partner Doug Holly had a few patients, these old women who he said had porphyria, but I'm pretty sure he just, just kept them around because they were nice ladies,

Adam Rodman (23:47):

<laugh>.

Mike Neuss (23:48):

And so there, there really is a lot of emphasis put on learning things that are esoteric. I certainly entered a residency in internal medicine with this illusion that I would be diagnosing vasculitis again and again and working it up. And I distinctly remember my dad saying, you know, the thing about being an internist is you always want to know, even if the patient's not doing very well, you just want to know the diagnosis. And there is clearly this big emphasis on it. But as LaMi was saying, ultimately, our day-to-day work is made up of things that seem, if this is the way you're conditioned to think about your work, much less glamorous, much more mundane. But in actuality, that doesn't make them any less essential. They're, they're absolutely essential to the work that we do and to, to providing patients with really, really safe care. Um, but they're, they're just not the kinds of things that we're conditioned to think are important early on, or that we talk about in a way that, that values them. If we talk about them at all,

Adam Rodman (24:50):

Uh, we're definitely gonna get back to this subject, what the actual, uh, cognitive work of an internist is. If, if you guys are ready to move on, I wanna talk about challenges to the virtuosic model and in particular who you write about in the paper with Larry Weed.

Mike Neuss (25:03):

Yeah, so I'm really glad you asked about this, and I, I think this, Lawrence Swed is a character who attracts a tremendous amount of attention among people in informatics, and certainly among many folks in internal medicine as he's a pioneer in many respects. Uh, and certainly portrayed as such in the area of computer-based patient records. The criticism that he mounts against the current, you know, the current system of, of his day, I think is a really important one, right? He takes aim squarely at this, the so-called source based patient record, and he says, this is really messy. This is not a way to organize your records. This is not a way to write things about a patient that allow you to conceptualize them over time, right? If you really want to understand chronicity of illness, if you really want to be able to intervene in a patient's illness in a way that modifies it, this is not how you should be doing things.

Mike Neuss (25:58):

And so he takes aim at the idea that people have very good clinical judgment, right? That people inherently have this sort of brilliance and they're able to conceptualize the patient seamlessly and says, no, that's not the case, but I have a solution. And the solution is the computer pays patient record here with the aid of the, the computer. You'll make much better insights into what's going on with your patient. And of course, that that doesn't play out in a way, uh, that's quite so seamless, um, or quite so clean. But I, that criticism in the way that he offers the computer as a solution to this problem is I, I think a really important intervention and captures, uh, an, an important sentiment at this moment around the 1960s.

Lakshmi Krishnan (26:46):

Mike's the weed expert, so I'm gonna leave

Adam Rodman (26:48):

<laugh>,

Lakshmi Krishnan (26:49):

I'm gonna leave that.

Adam Rodman (26:50):

I guess the first thing that I would ask is, weed is not the first person to make this argument. Um, I mean, you can, you can read going back to the 1920s, similar arguments being made about physician clinical judgment. What makes weed's argument the one that sticks? What makes him so influential?

Mike Neuss (27:07):

You know, that's a, that's a great question. That's an interesting question. I think it's, it's a few things. I think that, one, he's making this claim in a way that's fairly prominent, fairly public. He's tied into the right folks. There's the joke made at Duke about, uh, a weed in the wine garden cuz wine garden at that point was the chair of medicine and weed would come down to give grant rounds, um, uh, and, and was mingling with this, this group. Um, he also is developing the promise system, and that's promise spelled without an E at the end, which, uh, is one of the early computer based pa patient records and has some success and some prominence. He's also publishing widely in a way that I think is very readable, very accessible and, and mounting this criticism, uh, and, and sort of plotting a, a way forward in a way that reaches audiences successfully.

Mike Neuss (27:58):

Certainly there had been a number of people developing computer-based patient records and, and kind of the computer languages to do that successfully up until this point. And one thinks of, you know, the mum's language at MGH h uh, not too far from you, Adam, as one of these, you know, exemplars of this. Um, but I think things are crystallizing for him at a moment when more of the technical capability is there. He is a relatively prominent figure. He has the kind of rhetorical ability and the ability to sort of explain the problem in a way that is accessible and visible, um, that that really counts. And, and those things come together to, to push him forward as this exemplar of a computer-based alternative, so to speak.

Adam Rodman (28:50):

This is a question for both of you. Um, I have my opinions, but I wanna know what you guys think weed gives you. I mean, he gives a very prescient vision of what he thinks the cognitive work of the position is, which really stands in contrast with what we've been talking about as the virtuoso. How would you describe that or what's your opinion of the vision that he had for physicians', cognitive work or physicians' work in general?

Mike Neuss (29:13):

We've been dancing around this a little bit, but I think to flesh this out more con you know, more clearly weed says very distinctly, um, and in I think no uncertain terms that, that there's a problem, right? There's a problem with clinical judgment and that when we think we have it, we in fact don't, we don't have good insight. And there are some marked inadequacies in physician's ability to, to think about their patients. So using the kind of optimism or pessimism framework, he's in some sense a pessimist about how positions think. And again, this is where he's proposing tools, this is where he's proposing interventions and his interventions are ultimately technical and computer-based. I would add too, that he also centers a lot of his criticism on the composition and the media or the medium with which patient records are kept, right? That, and again, we've referenced this a little bit, but to flesh this out, this idea of the, the so-called source-based record.

Mike Neuss (30:13):

And this is mentioned I think also in the literature on the HR and criticism about the HR within the informatics community, now that people spend a lot of time talking about kinda the innovation that was the problem-based patient record that weed offers. And that weed spends a lot of time kind of articulating and flushing out that this is really juxtaposed and alternative to the source-based patient record, where you're taking and aggregating all of this data and rather than organizing it according to some sort of synthesis of what you think is going on diagnostically with the patient, these problems, right? They have dyspnea or the dyspnea is related to a pulmonary embolus. You're organizing the chart really by source. Here's laboratory data, here's radiographic data, here's the pathologist notes and their reports, here's the nursing notes. And the way this is portrayed is, is it's all just a mess, right?

Mike Neuss (31:10):

It's all just a morass of paper. It's not something that anybody has a good sense of what's going on weed at one point, and some of his writing characterizes this very negatively and says, really what we're doing is forcing people to kind of hand down what's going on with the patient orally. And so nobody really knows what's going on, right? He says this very definitively, very concretely, like nobody really knows, which is pretty negative, right? To say something that that resoundingly bad, right? Nobody really knows what's going on with the patients. Um, and he links us again to the content and composition and the, the medium with which, uh, patient records are kept.

Lakshmi Krishnan (31:53):

Adam, I want, if, if this is acceptable, I wanna actually come back to the challenges, to the virtuoso identity because, and this is the way I think, and this is why it was so cool working with Mike, cuz we think in different ways and use different sources, but I actually have two detective models that are challenges. And the reason I think this is interesting is the very singular streamlined detective model or the virtuoso model that I think has been absorbed in medicine is actually not reflective of detective work, whether fictional or real. Like if you look at, you know, medical jurisprudence records from the early 20th century, or you look at, like, we looked at the, the, you know, the detective Consulary from the 1990s and the uk like they are all saying something very similar that what, you know, that it's hard to know.

Lakshmi Krishnan (32:45):

There's a question of uncertainty and ambiguity. There's very rarely a clear solution. Um, and that it's teamwork, that it's, you know, this idea of this assemblage of tasks and an assemblage of people. So I find that really interesting when we're thinking about what is the work of the physician today, what are the challenges to the virtuoso identity? You know, is it more something like that? Um, you know, kind of assembling the team, being the, being the, like communication, being the, I think weave uses that travel metaphor, right? Being a consultant. So that's one thing. The second example that I would bring up is actually I think an even more robust challenge to clinical judgment and to detective work that exists in literary fiction. And it's, it's a, it's a 1932 detective novel by a radiologist and a Harlem Renaissance figure named Rudolph Fisher, and it's called the Conman Dies.

Lakshmi Krishnan (33:41):

And I'm obsessed with it, it's gonna be in my book. But the reason I think the conman dies is so interesting is that there are not one, not two, but multiple detectives, and they all bring different forms of expertise. Some are community members. Um, it's a murder that happens in Harlem in the black community. Um, and Fisher was very clear about that. He wanted all the characters and all the detectives to be, to be black and to comment on, you know, what was going on in the community at the time. Um, and the doctor detective has no idea what's going on and gets duped over and over again. He's not a comical figure. He's a really smart intellectual sort of, he's set up to be the virtuoso and then he's systematically shown to, to not have, you know, to not be fully tapped in. What I think is very interesting is that we've absorbed one model of the detective, but actually detective work takes so many different forms, both in real life and in the fictional world. So are there ways in which we can, you know, take something from that or, or like lessons that we can learn from those models as opposed to the Sherlockian House md, you know, model, which we think we've, we've established is, is not real or has no, has little bearing on reality,

Adam Rodman (34:55):

Right? Does actual detective work have something to teach internists about how we approach our patients? When we said the word clinical judgment a number of times now weed has his own, I mean, weed is very dismissive of clinical judgment. Um, especially early weed is incredibly cynical about clinical judgment. He thinks it's like he thinks it's, basically, um, weed at the end of his career, begrudgingly, uh, give something to it. Alvin Feinstein, you mentioned Feinstein in the paper, right? Yes. So can you, can both of you speak a little bit about Feinstein's retort and the vision that he has for clinical or cognitive work?

Mike Neuss (35:37):

I love this question and I, I love Feinstein as, as this kind of counterpoint, uh, in, in maybe a simplistic sense, but in a counterpoint to weed. And as an aside, I'll say over time as I've interacted with different folks in, in informatics, you know, weed remains somewhat of a, of a heroic figure.

Adam Rodman (35:57):

I know say anything critical and you

Mike Neuss (35:59):

Get <laugh>, you, you get in trouble. Yeah. Um, and Feinstein is, is sort of, I think for all that he had to offer and, and kind of the, some of the insights that he did make, it may be a little bit unfair to characterize him as persona non grata. Um, but it's, he's not somebody who has the same currency by any stretch within the informatics community. But what he's doing in terms of this discussion about clinical judgment is really engaging with weed and engaging with weed on kind of terms of what it is the doctor does, right? Which is very much what we're interested in. Um, and what exactly does the physician do in encountering the computer-based patient record, the problem-oriented medical record to return to that, that weed proposes relies upon some refinement of diagnosis into problems, some sort of organization, um, and cognitive work by a physician in organizing the patient's chart into things that, again, make sense as problems or diagnoses, right?

Mike Neuss (37:01):

Insofar as we're supposed to understand those things, Feinstein zeroes in on this and says, look, it's actually a very, very high order task to begin to pull out terms in a way that makes sense for epidemiologic study across space and time. When we think of, you know, the electronic health record as a platform, at some level, the diagnoses and problems that we list have to be interoperable, right? Or it doesn't really work, right? Natural language processing and other things maybe can remedy that a little bit today. But in actuality, this is a major sort of issue. Elmer Gabrieli, who's also discussed in the paper, he, he spent a lot of his later career in life, uh, after a very active, uh, and busy life as a pathologist trying to develop this lexicon, right? A lexicon that, that for all time and all places would allow people to sort of have agreed upon terminology.

Mike Neuss (38:00):

But I think this is very much what Einstein is getting at that actually it's very hard to use the right terms. It's very hard to sort of put people in the right boxes, even at the level of what age you're at, what decade of life you're at, is that really the category that we want to use in describing this person and this disease state. Um, this is actually a very difficult cognitive task and this is something that weed is kind of missing. And this is a major shortcoming and something that we contend with a lot in terms of how we enter things into, into the computer and how we as physicians put things down onto the screen, not onto paper about our patients.

Lakshmi Krishnan (38:39):

And that kind of taxonomic work is like it's historical work, right? In a way, I mean, I'm thinking through, also, I'm still thinking about this metaphor, metaphor question. Like, are we, are we historians? I mean I think that's actually how we open the paper. Are we historians? Um, but Mike, as you were speaking, I was thinking about that, that it's not, and, and the sort of shades of ambiguity as, as we're trying to classify things that have real ramifications for billing,

Adam Rodman (39:08):

They have huge

Lakshmi Krishnan (39:09):

Ramification,

Adam Rodman (39:10):

Right? We see this in clinical practice all the time, all the time. You can call someone, you can call an 88 year old who's been falling at home, severe protein calorie malnutrition and think about, oh, do I need to do supplemental feeding? Or you can recognize that it's a human being near the end of life and how do I, you know, like these, the way we have taxonomies have real effects on human beings

Mike Neuss (39:30):

With and well, and I, I'm, I'm very, I mean, it's great that we brought up the term taxonomies and I'm, I I'm glad blockchain mentioned that too, cuz that again is very much what Feinstein seizes on. Um, and actually Adam, that that's a really, um, that's actually a very kind of touching and, and I think meaningful example you brought up. Yeah. Because we are forced in many ways to document about patients in a way that, and this is part of I think what people are responding to when they're so negative about the electronic health record, we feel, for lack of a better word, coerced in sort of saying things and writing things and doing things in the chart that serve other means. And at some level that's okay. And so far as we, we think it's valuable to produce data that's usable for research, right? That we, we do think public health is important, which

Adam Rodman (40:24):

Feinstein, I mean, he's a clinical epidemiologist, right? Yeah. He's supportive of that.

Mike Neuss (40:27):

Absolutely. And so he's very much interested in doing that in a way that's successful, but it, it makes people feel as though they're being pulled away from what they envision their, you know, their work to be. And, and this is something again, that we talk about with the, the kind of clerical comment that, uh, Abraham Verghese makes that to romanticize and kind of idealize the past a little bit. We feel as though we're pulled away from the bedside. We feel as though we're pulled towards a computer screen and we're serving these other means that, that we don't really sort of see or interact with

Adam Rodman (41:02):

Doctors in the 1950s rounded like 30 seconds on a patient. Anyway, <laugh>.

Mike Neuss (41:07):

Yeah. And, and that's why I think it's sort of, it's so hazardous to kind of think in this way and to be pessimistic in this way cuz you're, you're sort of, there wasn't, you know, this idealized pass. It, it never really existed the way people, people say it did,

Lakshmi Krishnan (41:21):

But I, yeah, exact. And, but I think the reason for the nostalgia is worth, it's worth unpacking, which is what we're doing here and thinking about, as you said, ese and other successors. I mean, it feels like there are these schools now that in some ways map upon like the historical actors we're talking about. Like there's the kind of, there's the bedside folks and then there's the, you know, the AI and the EHR can be leveraged, um, to address health disparities. Folks like, you know, there's, there's technological optimists I guess, um, and so on. So I find that really interesting too. Um, and how, like those conversations are happening between those groups and where do we fall as sort of historians in this discussion.

Adam Rodman (42:03):

LaMi, do you wanna talk a little bit about how the physician as Virtuoso has perhaps worsened health disparities?

Lakshmi Krishnan (42:09):

Yeah, I, that's a phenomenal, phenomenal question. Um, I think that, look, there are lots of ways to, there are lots of angles, um, to take this question i i, one, one place is, you know, how do we center patients when the patient is the object of inquiry or the, or, you know, and, and is decentered in a way, um, which I think is inherent in the physician virtuoso model. Um, even like, look, even if you're well-meaning, um, there is that you assume a sort of power hierarchies is very fuco as

Adam Rodman (42:43):

Well. I was gonna say it's very fuco. The patient is very

Lakshmi Krishnan (42:46):

Fuco

Adam Rodman (42:46):

Ence of the disease.

Lakshmi Krishnan (42:48):

<laugh>. Yeah. Yeah. Um, so, and it's interesting, right, that Fuco is commenting on this time when sort of these models are arising and yeah. And now they're kind of consolidated and ossified in medicine. I think that's one place where sort of expertise like experiential and patient expertise then gets glossed over or, um, you know, doesn't make it into the chart in certain ways or we become the interpreters of that. Um, I, I think that's probably my biggest focus. And then of course that is gendered and raced and classed in the ways that that already shake, you know, shakes out. Yeah. I think I'll stop there, but if you wanna, if you, if you want me to expand on anything, Adam, lemme know.

Adam Rodman (43:31):

Mike, you have anything to add?

Mike Neuss (43:32):

So I would pose the question of what does the electronic health record do in terms of either an instrument that begins to kind of ossify tobar to borrow Watching's word, reify reaffirm, um, class difference, social difference, different hierarchies. In what ways is it sort of nearing that? And I guess I would sort of pose a question rather than give too concrete an answer. And maybe this is not the right analogy, but I think back to a conversation I had with Lindy Braun about a paper that she wrote in Chest on race correction and spirometry. And I think for her, you know, the question was less, you know, what do we do about this specific problem? It was more what does this particular technology, which we can see in it very important ways that it's biased, that it, that it really kind of codifies and then puts down into a, you know, an algorithm, uh, racial difference.

Mike Neuss (44:37):

Does that raise a, a set of questions about this particular particular technology and the intervention that we need to make to fix that? Or is the discussion that we should be having really about how that's an expression of so many other problems, right? How that's really sort of a statement about healthcare writ large in the United States today that ultimately has much, much, much deeper, much more ingrained issues around race and class and disparities in outcomes. And at some level, I would say with the electronic health record as a, as technology, should we conceptualize it in those terms? In what ways does it mirror difference? In what ways does it reaffirm support difference? And I think it's sort of a mix of these things.

Lakshmi Krishnan (45:24):

You know, we went back and forth on this title partly because clerical is used, disparagingly clerical work is dis is. Yeah. And, and, and we discussed this and we cite some of the literature on how clerical work is gendered raced in class and, you know, all of that. But I think it was important to us, Mike, feel free to weigh in to actually to put that in there, to put it front and center, um, because we need to rethink what we, we need to rethink class in our relationship to physician work. And that's, that's part of it. And so it's important. I think, I think that's a great point. It's not just class when it comes to patients, it's class when it comes to healthcare workers. Does what? Yeah, exactly.

Adam Rodman (46:07):

My mike actually wrote a a paper, uh, while back, uh, in J M I A that talked about how so many interventions to make the EHR better just shift work from physicians onto other members of the healthcare team, which is, I haven't,

Lakshmi Krishnan (46:19):

Those are solutions paper yet.

Adam Rodman (46:21):

I've talked to so many people like, oh, well just hire scribes. Uh, you're just shifting your, you're just shifting work to, to somebody else.

Lakshmi Krishnan (46:28):

Yeah, that's, yes,

Mike Neuss (46:29):

That's, that's right. And I, it's, I think they're, they're referred to frequently in Weeds writings. Oh,

Adam Rodman (46:34):

He, he, yeah, exactly.

Mike Neuss (46:36):

P paramedical workers

Adam Rodman (46:37):

Paramedic, that's what he says. Paramedic, paramedic,

Mike Neuss (46:39):

Paramedic

Adam Rodman (46:39):

Nurse to do a pelvic exam on every single patient every single day. That

Lakshmi Krishnan (46:44):

The one thing I wanna, one more thing, I just wanna, again, sort of like texture this a little bit though. What's hard and what I find very rewarding and challenging about this virtuoso question in this, in this work is that sometimes patients want an expert, right? There's, and I, I know I've been a patient, sometimes I want, when I go to the doctor, I don't want a lot of shared discussion. To be frank, I'm not that kind of patient. I'm going to you because I, I sort of want the virtuoso or I want the proceduralist who's, you know, whose volume is so high that they can't mess up. So how do we, how do we incorporate that into the discussion while still acknowledging, as Mike said, this very unequal landscape that reflects our nation and our world as a whole. Right.

Adam Rodman (47:29):

You guys wanna get a coffee break and then we'll be right back.

Speaker 4 (47:32):

<laugh>. Exactly.

Adam Rodman (47:33):

I'm gonna pause the recording. I'll see you guys in a second. I'm getting coffee too.

Adam Rodman (47:39):

We are actually going to take a break right there. This was a conversation that spread over two hours and we actually honestly did need a coffee break. I will be back in two weeks with the rest of the discussion. Thank you so much to Lakshmi, Christen and Mike Noy. They're both wonderful people, and I don't know even better scholars. Their piece is entitled Virtuosic Craft or Clerical Labor, the Rise of the Electronic Health Record and Challenges To Physicians' Professional Identity, 1950 to 2022. It's published in BMJ Medical Humanities. Of course, I have the link in the show notes. CME is available for this episode. If you are a member of the American College of Physicians, uh, that's at www.acponline.org/bedside rounds. All of the episodes are online@www.bedsiderounds.org or on Apple Podcasts, Spotify, Google Podcast, or the podcast retrieval method of your choice. The Facebook page is at slash bedside rounds.

Adam Rodman (48:35):

Who shows Twitter account is at bedside rounds. If you want amazing bedside rounds swag designed by Security Vania. The official merchandise store is at www.tpublic.com/store/bedside rounds. And I'm personally on Twitter at Adam Rodman md, uh, as long as Twitter continues to exist. All of these sources are in the show notes and a transcript is available on the website. And finally, while I am actually a doctor and I don't just play one on the internet, this podcast is intended to be purely for entertainment and informational purposes and should not be construed as medical advice. If you have any medical concerns, please see your primary care practitioner.

 

Contributors

Adam Rodman, MD, FACP

Lakshmi Krishnan, MD, PhD, ACP Member

Michael Neuss, MD, PhD

Reviewers

Jordon Talan, MD

Those named above, unless otherwise indicated, have no relevant financial relationships to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. All relevant relationships have been mitigated.

Release Date: January 19, 2023
Expiration Date: January 19, 2026

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