The Patient and I

This is part of the series from What Tech Bros Don’t Tell You about Healthcare. See the world from the view of The Contrarian.

Disclaimer: This does not represent the views of AWS or my past jobs.

I still remember the night that I held onto Child M tightly as I struggled to find a vein. If venepuncture was a Mario game, adult veins would be level 1 and kid veins is like fighting Bowser. Chubby little arms don’t generally have muscleman-like veins and you have to find the vein purely through tactile sensation. Sweat dripped down from my forehead, absorbed by the mask that I had been wearing since the call started. Child M was abandoned at birth because she had Apert Syndrome, a rare congenital disease characterized by a fused skull and fused fingers. By the time she came to us for treatment, she was already beyond the golden window of opportunity, but we wanted to give her a fighting chance to find a good foster family and get adopted. Child M had undergone multiple reconstructive surgeries to open up her fused skull to enable her brain to grow. After the beautiful hand surgery that opened up her fused fingers, Child M’s hands were wrapped up in thick crepe bandages. She struggled hard while the nurse and I continued our desperate search for a juicy vein on her feet. Her cry sounded distinctly like a wounded cat. As I washed my hands after successfully inserting a plug and the nurse hooked up her IV antibiotics, I thought to myself that her IV would only last one more week before we would have to repeat the search for the next juicy vein. And we still didn’t know why she was having a fever. The thirty bottles of tissue and blood samples that I collected from the operating theatre after the infectious disease referral consult all came back negative or inconclusive.

People often asked why I chose medicine. I could describe in detail the moment Child M saw her hands for the first time after we unwrapped her hands like a Christmas present and used her three reconstructed fingers to make a primal grasping gesture in a Netflix slow-motion camera pan sort of way, but that’s not really why I spent four years of my life learning the craft of medicine. It was those nights - the nights that you weren’t sure if the patient was going to ever make it even if your team did something life-changing. The nights when you and the nurses were the patient’s only comfort under those dim ward lights. The nights when people needed miracles, but also a human touch to gently lead them out of the fear and paralyzing anxiety of the unknown. If you polled my medical school classmates, they would have told you that I had the surgeon personality and crazy intensity. But the work ethic and willingness to sacrifice me for the greater good was not enough in a broken healthcare system. Ok, so the Singapore healthcare system is nowhere as broken as the American one, but it is still, to a very large extent, dysfunctional in multiple aspects. Being the lowest rung on the totem pole helped me see that the processes and technology in healthcare were not helping us to transform care, but were instead slowly grinding away at healthcare workers’ passion for their work. No one came into medicine to become a glorified secretary, but that was what I was doing day-in and day-out.

What took away the face time we had with patients?

If you talk to my family medicine professors, they would tell you that they did not build careers, but relationships with patients. They see their patients as babies, giving them vaccinations, assessed developmental milestones, and years later, the same patients come back with their babies. It’s the true circle of life. In healthcare, there is an unspoken social contract between doctor and patient. If you find a doctor that you love, you stick with them forever. You bring your kids to see them. You recommend your friends and family to see this doctor. It was essentially the first word of mouth marketing strategy.

That was disrupted by the first electronic medical record system (EMR), which was introduced in 1972 by the Regenstreif Institute. EMRs not popularized until the early 2000s when personal computers became cheap enough to be widely available and making their way into the hospitals as COWs (computer on wheels). Growing up in Silicon Valley, I was very fortunate to be an early adopter of PCs and my middle school even offered speed typing courses. It was one of those super boring one-hour classes where the teacher gave you a stack of A4 papers with short stories printed on them and asked you to type them word for word in a plaintext text editor on a black and white Macintosh. The whole class was a sound bath of typing autonomous sensory meridian response (ASMR). It was oddly calming for hormonal teenagers. Back then, the computer was not connected to the modem or the internet, so you had no choice but to type for one-hour. It was the OG focus hack. I still can’t believe that they paid a teacher to sit there and watch people type furiously.

Funnily enough, the word “disrupted” is often associated with innovation. In the case of typing versus talking to the patient, EMR ironically disrupted the consultation by introducing administrative work for the clinicians. If you have ever seen your 80-year-old doctor typing with two fingers and spending 10 minutes typing two lines, you would ask who in the world thought it was a good idea to introduce a computer next to the patient’s bedside. When I started medical school, I was writing patient notes in hole-punched-lined progress notes in binders. By the time I was done, we were typing our way through rounds, clinic consults, and operative notes.

I know you are going to ask this, so I am going to answer it: Isn’t it impossible to read a doctor’s handwriting? Won’t typing solve all the woes of illegible handwriting? Illegible handwriting is not a problem. Humans are curious creatures. Just like London cab drivers overdeveloped their hippocampus to remember all the roads, doctors and nurses became proficient at reading illegible handwriting. At the very least, there was a common point of reference where everyone just wrote in the same binder. There were different folder tabs for different roles. Nurses had their dedicated section to draw beautiful temperature and urine output charts with red, blue, and black officially approved ink colors. Things were in harmony. You knew you could find a ruler in a nurse’s pocket. You knew you could count on a junior doctor to have five pens in his or her pocket. There was a set of rules that no one talked about, but everyone knew and obeyed in the medical world. Then the toughbook destroyed that balance and harmony. A toughbook is a personal laptop that has a strap for easy carrying and a handle at the bottom of the laptop so a junior doctor could hold it like a plate while the consultants rounded the wards in the morning. Over the course of housemanship, the first year of being a junior doctor our left biceps grew bigger than the right from holding the toughbook with our left while we typed furiously with the right. It wasn’t uncommon to apply NSAID gel or slap on a Salonpas patch to our strained golfer’s elbow from repetitive use of our wrist flexor muscles. The only other option was pushing the COW around the crowded corridors, risking the COW running out of battery at any point in time. You picked your own poison and had to choose wisely based on the morning ward rounds route. Like real COWs, COWs were tied to a hospital ward. Any morning rounds that required you to visit another level meant that the COW was abandoned hastily near the entrance of the ward while you ran ahead to press the elevator lift for the rest of the team.

A “tech-enabled” world

Before I dive any deeper into my story about why tech is so messed up in the hospital, I must provide more context. Clinicians have a fixed way of doing something. Nurses have their own processes. Running an inpatient service is like a musical. Everyone knows when it is their time to come on stage and when it’s time to hastily depart. Different roles use different props and no two roles are quite alike. But the problem is that technology designed for the hospital just imagines all of us as one big group of “users”. In the real product management sense of the world, we would have different markets that a product would target to satisfy each market’s needs. What ends up happening is that the people who build healthcare software just want to “tweak” what they have to suit the users and ask us to compromise on the user experience. After all, software development can be expensive and it takes time to build things that are catered to the various types of healthcare workers in the hospital. This effort is usually abandoned halfway because, by the time one product finally gets things right, the process has changed as the payment and the processes are often disease-specific and have changed along the way. In a way, the traditional waterfall development would never be able to catch up to the speed at which things are changing on the ground. Although change is slow within the hospitals, process change can be implemented within weeks. In the grand scheme of timelines, the order of how fast things can change are as follows: process, policy, technology, payment, and lastly infrastructure.