At the beginning of internship year, even the simplest tasks take forever.
A dismaying chunk of our more limited time and brain space is occupied with logistical quandaries: What tabs do I click on to order an EKG for my patient? Where on earth are the consent forms for a blood transfusion? Who do I have to call to get a cast boot around here?
And then, we have to make clinical decisions. Sobered by the new-found power of our prescription pads and ordering privileges, we deliberate and chew over everything from “laxative or stool softener?” to “what are the chances this patient is having a heart attack and how aggressively should I evaluate it?”
Of course, such decisions are shaped (and sped up) by experience and by our deepening knowledge of the clinical literature, as I’ve seen even in my few weeks working in inpatient medicine.
As our habits develop, I’ve also come to appreciate the less celebrated influences on them -- the incredibly varied habits of the senior doctors we work with, the so-called "cultural" practices specific to institutions (MGH carries one sort of blood thinner, the Brigham and Women’s Hospital another; or certain Doctors Who Don’t Do Weekends). We act in the interest of saving time, of catering to our patients’ preferences (though not often enough), and of saving health care dollars.
There are a few studies that suggest that residency training is incredibly influential in physicians’ practice habits. One cited by Shannon Brownlee in her book Overtreated examined internists’ training sites and their scores on board exams. They found that doctors from residency programs at hospitals known to overtest and overtreat did more poorly than their counterparts on questions in which the correct clinical decision was to do nothing.
It’s hard to see the impact with any one click of a mouse or signing of a prescription, but accrued over years and across states, these varied habits create the practice variations that Jack Wennberg and others have found to have an enormous impact on American health and health care spending.
Of course, habits serve an important purpose -- they are adaptive shortcuts that let me get on with my job and take care of patients efficiently. But as they form in the coming months and years, I can at least be aware of their influences and try to separate out the good ones from the bad.
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