MD Enshittification

Enshittification, also known as crapification and platform decay, is a process in which two-sided online products and services decline in quality over time. As some of you may be aware, I was an Infectious Disease (ID) physician for almost 40 years, retiring 3 years ago. My practice was almost entirely concerned with taking care of patients in several acute care hospitals. So […]

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Enshittification, also known as crapification and platform decay, is a process in which two-sided online products and services decline in quality over time.

As some of you may be aware, I was an Infectious Disease (ID) physician for almost 40 years, retiring 3 years ago. My practice was almost entirely concerned with taking care of patients in several acute care hospitals. So everyone whose care I was involved in was sick. ID is unusual in that most of my consults were the odd and usual, infections and diseases, that others could not manage. I once counted 1300 or so pathogens I needed to know for work. Infections can also involve any organ system. It is said the ID doctor has to be the second-best cardiologist, second-best pulmonologist, etc. There was a lot of variety in the cases I saw. If you want an idea of the scope of ID, check out the Puswhisperer, 1300 blog entries I wrote for Medscape. Available on Amazon.

What follows is how I did things, and I do not know how my routine maps on to any other physician.

So I get a consult. Usually a page to a phone number. Here I was kind of a butthead, but I usually asked if they could summarize the need for the consult in 5 words or less. Why fever? Best therapy for Staph bacteremia. Although they often could not, which I took as a sign they didn’t really understand the patient need for a consult. I did this, as I learned long ago that I did not want the bias others accompanying me into the patient’s room. I wanted, no needed, to collect the information my way. Plus, over the years, the ability of residents to give a good presentation had faded. Yeah, I am one of those old geezers who talks about what it was like back in my day, but back in my day we had to be able to summarize the complete patient history is 6 minutes and were only allowed a 3×5 card for reference.

I think the advantage of the 3×5 card limitations was that it really imprinted the patient in the mind, and the mind is where all the thinking occurs. That is going to be the theme of this entry BTW: the more you offload your brain and thinking, the more enshittified the doctor becomes.

Besides, I told the referring doctor, I am going to read the chart and do a history. Why waste time duplicating effort?

In the old days, I would write the name and room on a 3×5 card and go see the patient. With the advent of the electronic medical record (EMR) I would enter the patient into my database.

Before seeing the patient, I would skim the problem list, the admission history and labs. Emphasis on skim. I just wanted an outline of the patient. I wanted to paint the portrait myself. After checking the microbiology (my job was best defined as me find bug, me kill bug, me go home), I would see the patient and do my routine history and physical (H&P), taking written notes.

The process of writing notes helped imprint what the patient was telling me. Then I would go through the chart carefully, because the information therein always made more sense after doing the H&P.

I would always look at all the patients’ labs and X-rays myself. In the old days, that would entail walking down to radiology. With the EMR, I could pull the films right to screen, but if there was any significant pathology, I would review the films with the radiologist. Always. That way I really understood what was going on. Towards the end of my career, I was shocked to discover that most people never looked at the films much less over the films with the radiologist. They just read the report. One aspect of understanding a patient down the drain.

Then I would write up my consult. In the old days, that was by hand, pen and paper, for the assessment and plan. Then dictate the full H&P, call the consulting physician and finally go back to the patient to tell them the plan.

It was a slow, tedious process, usually taking 90 minutes from start to finish. Kind of a pain in the neck to dot the t’s and cross the i’s, but I was always of the opinion that if the day was easy, if the work day was not a pain in the neck, I was not paying attention or doing my job. But the routine was how I acquired information and in the process, thought about the patient.

With the EMR, I would type the assessment and plan and dictate the H&P using voice recognition. The EMR has features that make the job easier: cut and paste and boilerplate. I never used either. Why? Both stopped my thinking about the case and switched to thinking about how to use the EMR. And, being a crutch for the lazy, would lead to either slop in the chart or the perpetuation of errors. I saw plenty of both in the EMR. By good doctors. But in a busy, very time-pressured day, a quick copy and paste or use of boilerlplate gets the work done that much faster.

But I found that active thinking is a limited resource. And for me, if I was focused on the EMR, I was pissing away resources on trying to remember the keyboard shortcut or modifying my boilerplate to fit the patient.

I found interface changes an increasing problem in my final years. I sometimes wondered if I was spending my mental energy on trying to remember Windows, MacOs, Linux, Android, all of which were constantly changing, as was the interface of the numerous apps I needed for work. Another nice thing about retirement: fewer computer interfaces to worry about. And last week I changed my gaming laptop from Windows to Linux. Just feel the tension go away.

Now I see the EPIC, the EMR I used, is adding AI. Of course it is. And I do not see this as a good thing.

I have been skeptical of AI for a while and rarely use it. As best I can tell, AI is not intelligent, but a fancy-schmancy word guessing program, albeit an amazing if unreliable one. The few times I have used AI, I received bad information, aka hallucinations, the current euphemisms for made up bull shit. Besides, I have a bias towards reading the source material, not some LLMs idea of what I am interested in. Too often I found that the summary of a medical paper was in error when compared to the source material, As I will probably note many times, the process of learning and thinking is as important as the outcome.

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