Wednesday, February 26, 2014

Of impersonal statements and meaningless use

Since becoming a full-time medical school faculty member again, I've volunteered to interview about two applicants each month from September through March. When I first started doing this, I was surprised that the admissions office did not provide me with a copy of the applicant's resume and essay until the time of the interview, carried in a manila folder by the applicant. But I quickly realized that it wasn't necessary to receive this paperwork in advance; reading it afterwards added very little to the sense of the applicant's personal qualities that I got from talking with him or her for half an hour or less.

In fact, the "personal" essays, which should be the most original parts of applications, are usually pretty formulaic. I don't doubt that a few students are called to medicine after falling in love with biology (or physiology, or organic chemistry) in a lonely laboratory but then realizing that they thrive around people (while changing soiled hospital bedsheets, or reading to kids in an emergency waiting room), leading to a eureka! moment when they decide to pursue medicine. The rest of them are likely playing it safe rather than sharing more complicated stories. (Here's mine.)

Writing in Annals of Internal Medicine, internal medicine residency director Turi McNamee bemoaned the the impersonal nature of so-called personal statements:

The overwhelming majority of personal statements are excruciatingly boring. It seems that our standardization of the medical school curriculum has led to a generation of physicians who feel the need to be standardized people as well, even when making statements that are by their very title intended to be personal. [Good personal statements] demonstrate a feature that is still key to being a doctor: humanity. How else are we to know about this side of our candidates if not for their personal statements?

It isn't just medical school and residency curricula that are being standardized. So is clinical practice, via the transformation of guidelines (emphasis on "guide") into performance measures that can be extracted from electronic medical records, if physicians are trained to standardize their office notes in EMR-friendly ways. At my practice, we always collaborate with patients about treatment plans (even if only one option makes any sense); we always examine at least 10 organ systems during a moderately complex initial visit (even if there's no reason to examine most of those regions); we always provide voluminous patient education handouts (desired or not); and we always, always, ask about tobacco use and document counseling smokers to quit (even if the patient has expressed no interest in doing so).

Perhaps these electronic exercises collectively known as "meaningful use" will someday improve care and outcomes. Until then, I know it's only a matter of time before I read a personal essay from an earnest medical school applicant who once aspired to be a professional coder but decided he could have his nonsensical documentation requirements and treat patients, too.

Oh, the humanity!