Order Sets & the Art of Medicine

When I was part of Jeff Neilson's illustrious Informatics Research panel at SAEM in Dallas this past spring (we were recently invited back for San Diego next year) I spoke on the topic of simple clinical decision support projects, particularly evidence-based order sets. I also talked about incorporating clinical calculators into orders, so trainees could enter discrete patient data into the EHR and see if the test they were considering was appropriate.

These are feasible research projects that can have measurable impacts in utilization or even care, don't require big budgets, and can be done in a resident-friendly timeframe. 

There was a question from the audience. Someone wanted to know if order sets and clinical calculators were antithetical to the idea of resident education - that organizing tests and meds by complaint, and building calculators into the EHR, made it too easy to be a doctor. Might we consider abandoning order sets and focusing on memorizing doses and appropriate indications for tests? By focusing on these things, were we failing to train doctors in the Art of Medicine? 

I was surprised by the question. Perhaps it's because I'm in a bubble - surrounded by colleagues who know as much (or more) than me about patient safety, bedside teaching, EHR usability, and evidence-based guidelines for care. 

I don't remember exactly how I responded. I said something about how order sets and clinical calculators are here to stay, unquestionably reduce errors, improve efficiency and encourage appropriate resource utilization (when implemented well) and the only challenge remaining is making them as current and easy-to-use as possible. 

That was a start, but I should have also pointed the audience member to the Checklist Manifesto, which covers the evidence, obstacles and psychology behind getting doctors to put their ego aside, be humble and make sure everything worth doing is getting done. After all, there was probably a time where pilots complained about losing the artistry of flying, but the public cared about their planes not crashing. Similarly, in an era where we are trying to get 100% compliance on core measures, when we're asked to do more, and see more, with less time and less support, it's imperative we make the EHR work for us as best it can. 

The Art of Medicine may have once involved regaling patients and staff with feats of memory; now it seems more appropriately about forming a fast rapport with patients, and explaining Bayesian algorithms for risk stratification. Let computers do what they're good at - lists and calculators - and let doctors have meaningful conversations with patients. This seems like the new state of the Art.