A General Practice not far from my neck of the woods has sent out a text message to its flock of patients, advising that for a period of three consecutive days later this month, the practice will only be open for emergencies, and that during this time, patients will not be seen for “routine matters”, and repeat medication will not be issued. The reason for this disruption is that the computer server requires an essential upgrade.
Well!
Nothing could be more redolent of the fact that computing, information technology, and the digital world have completely taken over our lives, than this passive assumption that general practice, or any other form of medical practice, becomes impossible just because you can’t switch the computer on. I dare say the particular practice who has sent out this text will not be alone, and indeed I imagine this idea that outage equals paralysis has already been normalised. When you crash, you close. It’s de rigueur.
But on the other hand I’m sure I’m not alone when I say I have seen all this coming since the start of the new millennium. Champions of IT systems targeted medicine as a potential market, just as they targeted education, banking, policing, and any other public service you care to name. Early on, I remember I questioned whether we actually needed the latest sophisticated program, and a colleague said to me, “It’s coming, James. You can’t turn back a tidal wave.” I was a Luddite. I was King Cnut down on the beach sitting on my throne with the waves lapping around my ankles. Some people think Cnut had an exaggerated sense of his own powers, others have suggested he was merely demonstrating to his people the futility of resisting the inevitable. Either way, the tide was going to come in.
Actually I never had any problem with going paper-light, or even paper-less, so long as we had some sort of back-up system that could kick in when the systems crashed or the server required an upgrade. At its simplest, the back-up could be pen and ink. What I objected to was the way in which the purveyors of data processing would foist elaborate systems on us that we really didn’t need. We needed something that would fulfil the function of the patient record. That would contain some demographic data, and then a narrative, comprising a sequential record of doctor-patient interactions, correspondence between health care professionals, laboratory and radiological results, and a record of therapeutic interventions. That’s all. In that sense, the digital record didn’t offer anything substantial over and above the paper record, or, in the jargon, it wasn’t “value-added”. Oh sure, it was, or could be, quicker to use, the record would likely be more legible, and perhaps more accessible (unless the server was being upgraded). And that’s fine. But look what happened. The systems themselves rapidly developed delusions of grandeur. They were not merely a record of the medical consultation, they began to direct the way in which that consultation would be conducted. The sanctity of the doctor-patient relationship, a confidential interchange in an atmosphere of absolute trust, was disrupted, and entirely altered, by the presence of a third party in the room, the computer screen.
Then, scurrilously, the systems became inextricably linked with emolument. Adoption of computerised systems got written into the contract. Doctors had to tick boxes to make money. One was required, for example, to record whether or not a patient had the smoking habit. I don’t recall being rewarded for getting anybody to kick the habit, nevertheless I usually attached some health advice to the tick box exercise. “Do you smoke? Yes?” Tick! “Just in case nobody has ever told you, it’s very bad for you.”
The designers of the new contract with these contractual obligations clearly had no idea how good doctors would be at jumping through hoops. But most doctors have been performing gymnastics of one kind or another since they were groomed for medicine while still at school. No matter how outlandish the hurdle, the GPs leapt over it, and mostly fulfilled 100% of the prescribed tasks.
So the systems got more complicated. Before long, the medical consultation got drowned out by the incessant jibber-jabber of the computer’s pop-up screens. Have you done this? Have you done that?
Information Technology worked its way into continuing medical education. Doctors went on courses, not to learn more medicine, but to learn how to operate increasingly complex computer systems. The sessions were dismal in the extreme. Scroll down the page to find the drop down menu. Click on blah. Right click on blah-blah. We were put into “break-out groups” that usually had a thinly-disguised political/managerial motive. Consider three ways in which you might be able to reduce your rate of referral to hospital. As if we were making these referrals on a whim.
But I can’t say the doctors were exempt from blame. After all, we accepted it all. We just said, “It’s coming. You can’t turn back a tidal wave.”
But that was profoundly fallacious. General Practice is, or could be, a very powerful body. All we needed to say to the sharp-suited computer whizz kids was, “No, we’re not doing that.” All the English docs needed to say to erstwhile Health Minister Matt Hancock, when he insisted all routine general practice went on line was, “No, we’re not doing that.” But I’m afraid we are not very good at sticking our heads above the parapet. Why not? Maybe the medical leadership is too preoccupied in pursuit of a gong.
For myself, I finally snapped. I remember once in my previous life as an emergency physician attending a Morbidity & Mortality meeting in Middlemore Hospital in South Auckland, New Zealand. There had been a tragedy. A child, a victim of abdominal trauma, had been transferred from Middlemore to Auckland Hospital. Auckland had taken a “conservative” approach to the child’s management, and had not operated. The child died. With the aid of the so-called “retrospectoscope”, an operation would have been the better option. At the time, relations between Auckland and Middlemore Hospitals were not that good. I remember a friend of mine in Middlemore, an intensivist, got up and delivered a “speech” – I won’t say of denunciation – but of sharp criticism. There is no more intimidating audience than a sophisticated medical audience, and I remember thinking at the time, “I could never have done that.”
Fifteen years later I found myself in Scotland at a medical meeting which was championing a computer system for so called “Whole Systems Working”. I got up and delivered a “speech” – I won’t say of sharp criticism – more of denunciation. It was met with a stunned silence. The meeting came to an end. I thought, “That went down like a lead balloon!” I think it was at that precise moment that I realised that I needed to get out. In fairness, a colleague came up to me afterwards and said, “I’m sorry I didn’t support you. You were only saying what we were all thinking.”
But I did think of my friend in Auckland. I’d thought I’d never make a speech like that, but in effect I did. Subsequently, another colleague told me that my “speech” came up for discussion at another medical meeting, and a young GP had said, “Oh that guy. He’s a legend.” Of course that could mean anything, but I take it as a compliment, and if it is indulgent of me to record this, then as mitigation I can only say that that was the proudest moment of my medical life.
jamescalumcampbell 