To the Editor:
It is easy for residents like me to take care of patients with diabetic ketoacidosis. All we have to do is type “DKA” into the order entry system and choose the preassembled order set. This will instruct the nurse to begin a continuous infusion of insulin, specify how and when to titrate this insulin based on serial measurements of blood sugar, and provide algorithmic protocols for the repletion of fluids and electrolytes. There are multiple phases, dictating a series of coordinated changes that occur as the blood sugar lowers and the body recovers.
Order sets are best suited for conditions like DKA where the diagnosis is known and the treatment is standardized. When used properly, they can increase efficiency and decrease the chance of oversight or error. But as this type of automation proliferates, inevitably physicians will become dependent on it. I personally do not always know the detailed steps of the care I deliver, placing my signature on orders that I may not completely understand, trusting that the system I work in is appropriately designed and updated.
This is a concept that is inherently disturbing to many physicians, and I would expect for many patients as well. What if the computer system goes down or is hacked? What if a doctor who was trained in a technologically advanced environment goes to work in a setting with significantly less electronic support? Shouldn’t doctors know, inside and out, what they are doing?
When my grandfather was a young physician, he had almost none of the powerful laboratory and imaging techniques that provide me with a wealth of clinical data. For his generation of practitioners, the physical examination was the key source of information, and they spent a lifetime becoming experts at looking and listening to the human body in a way that my generation of doctors will never approach.
Research and technological advances have driven, and will continue to drive, dramatic changes in how we learn and practice medicine. What medical providers are capable of knowing will change, and therefore, so will what we need to know. It will not benefit us to be sentimentally tied to the past, but neither do we want to blindly allow our practice to evolve without considering the consequences. Moving forward, the goal will be to strengthen our systems of care without losing the essential understanding and critical thinking skills that inform that care.
Benjamin Wolpaw, MD
Resident, Department of Internal Medicine, University of Washington, Seattle, Washington; [email protected]