I’ve come to feel that a system that promised to increase my mastery over my work has, instead, increased my work’s mastery over me. I’m not the only one. A 2016 study found that physicians spent about two hours doing computer work for every hour spent face to face with a patient—whatever the brand of medical software. In the examination room, physicians devoted half of their patient time facing the screen to do electronic tasks. And these tasks were spilling over after hours. The University of Wisconsin found that the average workday for its family physicians had grown to eleven and a half hours. The result has been epidemic levels of burnout among clinicians. Forty per cent screen positive for depression, and seven per cent report suicidal thinking—almost double the rate of the general working population.
…Doctors are among the most technology-avid people in society; computerization has simplified tasks in many industries. Yet somehow we’ve reached a point where people in the medical profession actively, viscerally, volubly hate their computers.
…The upgrade cost $1.6 billion. The software costs were under a hundred million dollars. The bulk of the expenses came from lost patient revenues and all the tech-support personnel and other people needed during the implementation phase.
…Questions that doctors had routinely skipped now stopped them short, with “field required” alerts. A simple request might now involve filling out a detailed form that took away precious minutes of time with patients.
…Each patient has a “problem list” with his or her active medical issues, such as difficult-to-control diabetes, early signs of dementia, a chronic heart-valve problem. The list is intended to tell clinicians at a glance what they have to consider when seeing a patient. Sadoughi used to keep the list carefully updated—deleting problems that were no longer relevant, adding details about ones that were. But now everyone across the organization can modify the list, and, she said, “it has become utterly useless.” Three people will list the same diagnosis three different ways. Or an orthopedist will list the same generic symptom for every patient (“pain in leg”), which is sufficient for billing purposes but not useful to colleagues who need to know the specific diagnosis (e.g., “osteoarthritis in the right knee”). Or someone will add “anemia” to the problem list but not have the expertise to record the relevant details; Sadoughi needs to know that it’s “anemia due to iron deficiency, last colonoscopy 2017.” The problem lists have become a hoarder’s stash.
…Piecing together what’s important about the patient’s history is at times actually harder than when she had to leaf through a sheaf of paper records. Doctors’ handwritten notes were brief and to the point. With computers, however, the shortcut is to paste in whole blocks of information—an entire two-page imaging report, say—rather than selecting the relevant details. The next doctor must hunt through several pages to find what really matters. Multiply that by twenty-some patients a day, and you can see Sadoughi’s problem.
…The Tar Pit has trapped a great many of us: clinicians, scientists, police, salespeople—all of us hunched over our screens, spending more time dealing with constraints on how we do our jobs and less time simply doing them. And the only choice we seem to have is to adapt to this reality or become crushed by it.
…A longtime office assistant in my practice …said that each new software system reduced her role and shifted more of her responsibilities onto the doctors. Previously, she sorted the patient records before clinic, drafted letters to patients, prepped routine prescriptions—all tasks that lightened the doctors’ load. None of this was possible anymore. The doctors had to do it all themselves. She called it “a ‘stay in your lane’ thing.” She couldn’t even help the doctors navigate and streamline their computer systems: office assistants have different screens and are not trained or authorized to use the ones doctors have.
“You can’t learn more from the system,” she said. “You can’t do more. You can’t take on extra responsibilities.” Even fixing minor matters is often not in her power. She’d recently noticed, for instance, that the system had the wrong mailing address for a referring doctor. But, she told me, “all I can do is go after the help desk thirteen times.”
Jacobs felt sad and sometimes bitter about this pattern of change: “It’s disempowering. It’s sort of like they want any cookie-cutter person to be able to walk in the door, plop down in a seat, and just do the job exactly as it is laid out.”
…Because of his scribe, he was able to give his patient his complete attention throughout the consultation. In recent years, he’d found this increasingly difficult.
Shteynberg said she was all in favor of scribes: “Because now Dr. Goroll will come right up in front of my eyes, and he listens.” She explained that he used to look at his screen, instead of at her, and type while he spoke.
“That bothered you?” he asked, surprised.
“Oh, yes,” she said.
…I needed to log into the computer to check the original lab reports. He watched me silently click one tab after another. Minutes passed. I became aware of how long it was taking me to pull up the right results. Finally, I let go of the mouse and took Cameron to the examining table.
…“Any questions?” I asked, hoping he’d have none.
“It’s a lot to take in,” he said. “I feel normal. It’s hard to imagine all this going on.” He looked at me, expecting me to explain more.
I hesitated. Let’s talk after the new tests come back, I said.
Later, I thought about how unsatisfactory my response was. I’d wanted to put my computer away—to sort out what he’d understood and what he hadn’t, to learn a bit about who he really was, to make a connection. But I had that note to type, and the next patient stewing across the hall.
…I had more time for his questions now, and I let him ask them. When we were done and I was about to get off the phone, I paused. I asked him if he’d noticed, during our office visit, how much time I’d spent on the computer.
“Yes, absolutely,” he said. He added, “I’ve been in your situation. I knew you were just trying to find the information you needed. I was actually trying not to talk too much, because I knew you were in a hurry, but I needed you to look the information up. I wanted you to be able to do that. I didn’t want to push you too far.”
It was painful to hear.
…The technology is more precise, but it’s made everything more complicated and time-consuming.