It’s easy to say that some things in health care never change. Disease states remain fairly constant, and a few perennial tools, such as the stethoscope or the reflex hammer, can be reassuring for older physicians who see their younger colleagues still using these handy icons.
But sometimes these perennials - and our own habits - can obfuscate how we view the changes that are not only occurring around us, but hopefully, we are incorporating in our own lives and practices as well.
What remains the same in medicine only looks familiar in a sea of changes. For example, appendicitis requires the same prompt trip to surgery as it did when even the oldest of us started practice, but what awaits the patient in the operating room and thereafter has changed dramatically over time. In just a few years laparoscopic surgery has radically improved how we accomplish the age-old goal of removing the appendix - which nevertheless still must come out. More generally, minimally invasive surgical procedures have touched just about every surgical specialty.
Sometimes knowledge and technology radically alter our entire epidemiological outlook on a disease process, requiring not only new tools and techniques, but radically new perspectives. For example, I still remember when AIDS was a mysterious anomaly, characterized by rare and inexplicably fatal skin lesions, which affected a subset of the population. Just a few years later it became an acute scourge that consumed our attention but left patients and ourselves as health care professionals virtually helpless. Later, technology and knowledge morphed acute AIDS into the chronic HIV many of us are managing today - (but let’s not forget that our colleagues and victims in the Third World still face an uglier reality).
Technology has driven much of the change we see. Improvements in diagnostic imaging, i.e. ultrasound and computerized tomography, have altered our behavior as we face age-old disease processes. I am sure that our staff president, cardiovascular anesthesiologist Kent Garman, can affirm how advances in OR monitoring have improved the quality of care and safety for patients. In my field, neurosurgery, new diagnostic imaging techniques, such as magnetic resonance imaging, let us plan our surgeries with confidence before we or the patient enter the operating room.
Society and economic realities sometimes drive changes - and benefits - as significantly as those wrought by science and technology. When I first trained in the 1970’s, we would admit patients for diagnostic tests and surgical procedures that are now routinely performed in an outpatient setting. In my training days, patients routinely remained hospitalized seven days or so until their sutures were removed. Now many patients are discharged one to three days following even major surgical procedures. And significantly, these reduced lengths of stay are yielding documented improvement in outcomes, largely because patients are mobilized and rehabilitated earlier.
Some important changes speak to the more mundane mechanics of what we as physicians do every day. Many of us were trained to use q.d. for each day, q.o.d. for every other day, cc for cubic centimeter, sq or sc for sub cutaneous, u for units, µg for microgram, etc. But we have documented that handwritten abbreviations such as these can be misinterpreted by other personnel, leading to medication errors. So now, in the interest of safety, we must change our practices to provide better care for our patients. Please refer to the Stanford Hospital and Clinics unapproved abbreviations list found on the hospital web site www.stanfordhospital.com/PDF/shcDangerousUnapprovedAbbrev040203.pdf A summary of abbreviations is published periodically in this newsletter [see pdf].
Computers have and will continue to bring great changes in the practice of medicine. I still remember how as an intern I found it so amazing that I could go to a specific computer terminal in the hospital and find my patients’ lab results. Now it is possible not only for us to check labs on our patients, but also to look at renditions of radiologic studies, write orders - and soon progress notes - remotely on the units, in the clinics, and in our offices. One of the great advances for some of us has been viewing x-rays and scans from home with high speed internet connections and appropriate software.
Using a new computer system, Carecast, our nurses have been placing vital signs, their notes and medication orders on computers. Nurses on patient units have just about “gone paperless.” With the transition during the next few years to the hospital’s Epic information system, all physician notes will be entered on the computer as well, and we will be on our way to a completely electronic medical record.
I am aware that some of our medical staff members have been resisting the change to Last Word or Carecast order entry on their patients. Computerized order entry has now been fairly standard for most of our patients except on certain units for many years. When we do fully implement the Epic system, physicians who do not use the computerized electronic medical record, including order entry, will find it difficult if not impossible to practice medicine at Stanford Hospital and Clinics.
Change is inevitable in our world, especially in medicine. That certain underlying values and even some technology and techniques have remained constant - or at least familiar - over years and centuries is no excuse for the reality that medicine is a dynamic profession requiring innovation, flexibility and adaption. No one is suggesting that we make change for change’s sake, that all change is good, and that tradition is inherently bad. But we are professionally - and I would argue ethically, morally and personally - charged with practicing medicine in the safest, most effective and ultimately best manner possible. Physicians who dig in their heals and refuse to change may find themselves becoming extinct as progress and a dynamic world alter our profession, health care and society itself. Don’t let yourself be bypassed.
