Modern Medicine, Healthcare Fatigue and Our Desire to Avoid Failure

Modern medicine has taken a dichotomous, lewd departure from its noble origins.  Hippocrates, considered the father of western medicine, systematized medical practice and robustly trained physicians establishing it as a dignified and altruistic profession.  Science has advanced our understanding of modernity, but consequently we have relinquished the decorum of our profession through commoditization and standardization. The “complete” physician is a product of the past; our current medical system has been infiltrated by hyperspecialists, numerous referrals, delays in medical care for payment authorization, “work arounds,” and the wonders of the electronic medical record – resulting in ultra-transparency that scares many patients with digital access to all of their records, detailed in verbose medical jargon. Convoluted payment schemes, decentralization, lack of breadth, dogmatic groupthink and the tort system have produced a complex care model that confuses patients and necessitates transportation to myriad locations in hopes that they will find answers to their ailments.

Physician autonomy has disintegrated into compliant bureaucratic servitude; the idea of personalized, individual medical treatment has morphed into a “one size fits all” approach. This loss of autonomy creates an environment of monotony, through “standard work,” circumventing our obligation to think. Instead of thoughtful curiosity to determine manifestation of disease, there are diagnostic and treatment algorithms that have been created; following all the steps to ensure maximum reimbursement and consistency in outcome. This standardization produces a system that allows mid-level providers (NPs and PAs) to perform the same functionality as a physician. This is in no way diminishing the critical role that mid-level providers contribute to our team, but the educational rigor of medical school SHOULD be more profound. Memorization of flow charts have replaced cognitive reasoning. As physicians master and endorse this algorithmitization of their particular discipline, they are rewarded with leadership titles and occasionally compensated for their acquiescence. This doesn’t foster a rewarding work environment; it creates productivity demands, which become even greater as physician reimbursement diminishes and bloating of hospital administration continues.

Medicine has always been intriguing to me and a perfect professional fit for my personality.  I consider this profession to be an intermediary between scientists and the general public. It provides a satiation for my intellectual curiosity, an opportunity to create lasting relationships with patients and colleagues and provide service to patients in need.  Little did I understand the psychological consequences of such a seemingly prestigious position. It has been demonstrated that at the time of matriculation into medical school, depression levels are lower and quality of life is higher than age matched peers, but this deteriorates shortly after medical training begins (here, here and here). Sleep deficits from studying demands, constant competition for residency positions and numerous tests every week was onerous and can lead to significant psychological decline.

“Burnout” is a common term used to describe the demoralization of a physician’s existence. Medical school and residencies have conditioned doctors to be resilient, mentally tough and durable. “Moral Injury” is a much more appropriate term for the condition. Hospital systems and physicians have competing interests in the overall health of the patient. Physicians truly want to improve the health and lives of their patients, prolonging health span and lifespan, avoiding incarceration of patients into our medical system.  Health systems benefit from recurrent customers; therefore it is of no interest to have these patients leave, but rather be tethered to the system, managing chronic disease instead of reversing its course.  This is why there has been such effort and emphasis from the health systems to control physician practices. If they are able to control physicians’ practices, they can control treatment algorithms and ultimately all of the money associated with it.

Traditional methods in the treatment of metabolic disease have failed miserably, but we continue the same course (only introducing new pharmacological therapeutics). For example, treatment for type II diabetes continues to be metformin (a drug that sensitizes tissues to insulin), various secretagogues (stimulating pancreatic beta cells to release excess insulin) or exogenous insulin.  Hyperinsulinemia has always been the underlying problem, not the lack thereof.  Insulin caused the problem, but we continue to pour fuel on the fire through disease perpetuation by sensitizing the tissue to insulin or providing strategies to deliver MORE insulin to the body. As people on insulin recognize, exogenous insulin causes fat accumulation, not depletion.  However, we have concentrated our efforts on decreasing extracellular glucose concentration, but haven’t sufficiently understood that intracellular glucose concentration goes up consequently; this effect results in cellular damage through non-enzymatic glycosylization of functional proteins and cellular oxidation through the metabolism of glucose and fructose. Administering insulin drives glucose into the cell and “hides” it from detection in the extracellular fluid. The disease manifests from too much sugar, not that it’s just in the wrong compartment. Fructose (a 5-carbon ringed carbohydrate) can only be metabolized in the liver and if too much is consumed, can lead to non-alcoholic fatty liver disease and worsening insulin insensitivity.  What is the definition of insanity?  Doing the same thing over and over again and expecting different results.

Medical education is to blame for our lack of understanding. When I started medical school, many professors would say that the flow of information will be equivalent to taking a sip of water from a fire hydrant.  While this is accurate phraseology, it is a defeatist approach that preconditions successful, smart students with the permission to fail.  When dealing with others’ health and lives, it is imperative that we succeed.  Our culture has become too adamant with protecting people from failure, to the point that we are reluctant to allow our children to suffer any sense of defeat.  Winning and losing is an integral component of learning and will help direct important life choices.  Artificial scenarios that protect children or young adults from losing is not adequately preparing them for the harsh reality of the real world.  Inappropriate preparation for the real world only promotes feelings of anxiety, depression and a host of other psychiatric manifestations, as these young individuals have never developed an ability to cope.

There are myriad pathophysiological and biochemical processes that mainstream physicians poorly understand, but can follow algorithms based on laboratory findings. Instead of understanding and reversing disease, our focus has been short-term symptom resolution. We are trained to concentrate on inappropriate outcome measures, but these measures help guide pharmacological treatments; they are not designed to address root cause. This perpetual, progressive decline in our patients’ health, when we are actively trying to prevent it, causes angst, concern and demoralization to physicians. It is the true definition of “insanity” and we are seeing a significant impact of psychological health in our healthcare workers. It is necessary for physicians to better understand the medications we prescribe and alternative treatments that our patients would like to try. Often, we catch ourselves say, “there is no evidence,” but what we really mean is, “I’m not aware of any evidence,” when we are asked about alternative, unorthodox treatments.  It’s incumbent upon us that we search for evidence and answers for things we don’t know.  If we choose to continue to be apathetic in our quest for knowledge, our patient’s health AND our mental health will continue to suffer.