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Analysis Essay

Humanism in the time of metrics—an essay by David Loxterkamp

BMJ 2013; 347 doi: (Published 19 September 2013) Cite this as: BMJ 2013;347:f5539

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Humanism in the time of metrics—an essay by David Loxterkamp
BMJ 2013; 347 doi: (Published 19 September 2013)
Cite this as: BMJ 2013;347:f5539

True family physicians could applaud Dr. Loxterkamp's reiteration[1] of what makes family practice a unique healing discipline.  What can it hurt to remind ourselves of what we believe in from time to time?  This seems reasonably less painful and more nourishing than Thomas Jefferson’s call to perennially nourish our tree of liberty with the blood of freed men.  While we may applaud the BMJ for publishing what they have allowed, something feels lost in the blandifying peer review process which sifted Dr. Loxterkamp's radically traditional creative vision into a somewhat milquetoast final loaf.

Dr. Loxtercamp outlines the abysmal average performance of some physicians but not the family care which I and my peers practice.  Likewise free, simple, open source EMRs allow family physicians to practice the healing we teach our residents.[2]  Contrary to the general criticism, such sensible EMRs ease documentation and proper coding, not upcoding, and they contribute nought to the high cost crime of North American medicine.  To this day we know good doctors who care only for patients and do not give a d-mn about metrics.

Computers are simply abysmal at collecting data.  Yes, they can store, sort, transmit and receive simple symbology, but too-often-ignorant programmers and their computer machines hack and cut short our richly symbolic qualitative human interactions with our patients. Furthermore physicians work far below our training level when dow our machines’ work by checking boxes. Should we return to a legible, organic,and creative written note when care is complex? Perhaps we should as paper was a better solution for many.  We live in the Apple age of WYSIWYG so let us scan our scribed art from every large patient encounter into the magic EMR boxes we bow down to.  

Only when our machines can record conversation, parse stories, and extract qualitative data for auto-indexing will we have EMRs without checkboxes and data fields.  Only then will we free the many enslaved physicians who have been shanghaied into doing a machine's work of cataloging for their machines.  The powerful EMR promise cannot be met by our stone age technology. PollyAnnish marketing aside, our technology remains inadequate to create EMRs that replace paper charting and perceptive chart reviewers.

The author recites old saws about the severe limits of outdated biomarkers and the real health benefits of prudent wholistic care. A medical science which must so repeatedly remind practitioners of our best evidence suggests that we do resemble Feinman’s cargo cult.[3]  At the same time Dr. Michael Fine's rigorous analysis[4] of health in community is more persuasive than a reference to the popular writer Wendall Berry.  In the end Dr. Loxtercamp suggests that physicians become what Family Practitioners have always been.

He also cites psychosocial health relationships commonly understood in the complex systems science literature.[5]  A rigorous analysis suggests there is no “rule” of "three degrees of influence.”[6] We appear rather to swim in a more extensive influence of socio-cultural milieu which extinguishes with distance in a likely nonlinear way.  By analyzing neither closer parental relationships nor network relationships beyond 3 degrees, the 3 degrees become an artifact of study limitations. Every scientific discipline benefits from more rigor and an awareness of complexity in the phenomena which we study.

Physicians may also benefit from not exagerating their effect size. We are observers more than the actors we may wish to be.  Once we recognize our powerlessness we may still become catalysts for patients ready to make the effort to change through the motivational interview.[7]  We prepare little and manage less of our patients' health travels, and we should take little credit when patients hit bottom and decide to change their walk towards healthier life.

In conclusion Dr. Loxterkamp encourages all healers again to join together in designing our future.  YES, let us add qualitative data fields to hold the heart of our healing practice, but NO, EMRs cannot process that data towards supporting new research agendas. The same-old-as-always extensive human analysis is still required.  YES, we re-affirm the heart of family practice, and NO, we will not earn as much or more in the process as Topol[8] suggests.

There exists this fundamental decision point which every healer must face between breathing the rich life of the village healer or counting our gold. The author cites olleagues who continue chasing the dragon of central power and wealth found as easily in modern Hollywood as ancient Babylon.  Dr. Oz has made his choice but we all make our own.

YES, physicians have already retooled with computers if they chose wisely without the snake-oil cacophony of a thousand EMR vendors.  NO, all fads do come and go as biomarkers also will. Sooner or later biomarkers will not be central to medical care if they affect not a whit of health outcomes.  YES, our Dr. Oz-type televised talking heads are not educated in cutting edge classical medicine.  NO, the answer is not so simple as a humanistic appeal to submerge our EMRs under our medical practice - and YES, we some of us have already done so.

[1] Loxterkamp, D. (2013). Humanism in the time of metrics--an essay by David Loxterkamp. BMJ, 347(sep19), f5539.

[2] Spikol, L. (2005). Purchasing an Affordable Electronic Health Record. Fam Pract Manag, 12(2)(Feb), f31.

[3] Feynman, R. P. (2005). Classic Feynman: All the Adventures of a Curious Character (Har/Com.). W. W. Norton.

[4] Fine, M., Peters, J. W., & Lawrence, R. S. (2007). The Nature of Health. Radcliffe Publishing.

[5] Sturmberg, J. P., McWhinney, I. R., & Martin, C. M. (2007). The Foundations of Primary Care.

[6] Christakis NA, Fowler JH. (2008). The collective dynamics of smoking in a large social network. N Engl J Med, 358,f2249.

[7] Satre, D., & Sterling, S. (2013). PS1-19: Impact of Motivational Interviewing to Reduce Alcohol Use Among Depression Patients. Clinical medicine & research, 11(3), 167, f1.

[8] Topol, E. (2012). The creative destruction of medicine: How the digital revolution will create better health care. New York: Basic Books.

Competing interests: Chief programmer and developer of the nonprofit 501(c)3 EMR project CottageMed, c. 1999-2013, which was the first free, open-source, and cross-platform (PC, Linux, Mac) EMR distributed worldwide.

04 October 2013
Stefan A. Topolski
Country Doctor
U. of Massachusetts Medical School
1183 Mohawk Trail