The Krebs cycle was with me on the crosstown bus this morning. Sitting in the very back of the bus, in my favorite spot, I have my first cup of coffee of the day, and work through the New York Times crossword puzzle (progressively harder as the week goes on, by Thursday my brain literally hurts from it). At one point I looked up, and as usual, almost everyone was on their phone, laptop, or tablet. Lots of swiping through music, Facebook, Instagram, Twitter, playing games killing ogres and popping little colored bubbles, even a few folks watching movies or TV shows. I happened to glance down at the iPad a young woman in front of me was holding up, on which she was scribbling, flipping through websites, cutting and pasting. And there it was: the Krebs cycle. Apparently a premed student on her way to class, she was downloading information from various biochemistry websites about all the enzymes and their roles in oxidation and phosphorylation. She was using the Apple pencil to hand write notations in different fonts and different colors at various points on that all-too-familiar circular graphic, short comments about the movements of protons and ATP and CO2. It brought me back to those days in biochemistry class during my first year of medical school, where we all found a different way to learn it, some needing to write it over and over again, someone turning it into a song, some using multicolored pencils and highlighters, some creating their own flashcards so they could drill the details into their brains. The Krebs cycle is currently running in all of us, churning and turning away, generating energy for all the activities our bodies need to do to get us through the day, from moving muscles, to digesting food, to pumping blood, to excreting waste, to moving air, to thinking. Each and every one of my patients has a Krebs cycle, but I'm often struck by the imbalance between how important this was in our medical education, and how freakishly infrequently it comes into play in the clinical care we provide. For many years there been challenges to what we include in the medical school curriculum, competing needs and demands, and often there are efforts and initiatives to re-create and refocus the material that these young doctors of the future are being forced to learn. You can imagine that once someone decided this basic biochemical foundation was necessary since we were, long ago, mixing up medicines and ministering pharmaceuticals in a way that we needed to know, in excruciating detail, the underlying processes that make our bodies function. Biochemistry leads to physiology leads to pathophysiology leads to life, illness, health, death. This probably still has some utility for those heading into anesthesiology, or on a path towards a lab as a clinician-scientist. But is this the correct foundation we need to give our students, our trainees, our young doctors for a 21st century patient-centered healthcare system? Once we hit the wards and started taking care of patients, a lot of this stuff faded into the background, and we began to see how clinical care was provided. Talking to patients, examining them, putting things into a clinical context, reviewing labs and imaging, collaborating with colleagues. Today there is also a push towards abandoning some of the things that we as a generation of providers used to glean the most information from our patients. The history and the physical examination were the tools we used more than the Krebs cycle, and more than any high-tech artificial intelligence algorithms, implanted sensors, or personalized genomic medicine. I remember standing in the CCU for bedside rounds early one morning after admitting a patient overnight with the cardiology fellow, an elderly gentleman with a severe exacerbation of his congestive heart failure set off by a salty holiday meal and a few days of missed medications. I had given my presentation, and the fellow and senior resident had chimed in some extra things that they wanted to point out, and the final plan was to get a repeat echocardiogram that morning. The attending, who had patiently listened to our presentations, walked over to the patient, asked him a few questions, laid his fingers on the patient's wrist to feel his pulse, examined his neck veins, listened to his heart and lungs, all the while calling out his findings and showing us with our own hands and ears how to capture this data, and then asked the fellow what we had learned from the history and physical exam. While we learned that the patient was in heart failure, the attending knew enough from his exam skills to know pretty much what the patient's ejection fraction was, and by teaching the fellow how to do this, he showed that there was really no need for another test. We knew what was going on, and we knew how to treat it, the best we could. As we moved away from these "days of the giant" medical maneuvers, it feels like we've created a healthcare system with the patient funneled in at one end, chopped up into little pieces which are fed into the electronic medical record, run through another computer system that finds out what their insurance will cover in terms of labs, imaging, and treatments, and out the other end pops a final state of sickness or health. We are all spending so much time satisfying the hungry gods of the electronic medical record, the bureaucratic requirements layered on top of us, and the endless measures we need to satisfy, that we've lost those important central tenets of taking care of our patients. There has to be something between the Krebs cycle and some computer algorithm telling us how to provide care. Things have gotten so complicated, that the patients and the providers are no longer at the center of care. It's no surprise that our patients feel like the healthcare system isn't listening to them, and isn't really taking care of them. And it's no surprise that the doctors trying so hard to work in this system don't really feel like they're getting to do what they so very much want to do. I'm all for building systems that can help us recognize patterns of disease, decide on the best treatments, figure out which imaging study to order, avoid errors, help our patients overcome barriers to care, follow-up on medications, monitor health out in the world away from our practice. But as we build this patient-centered healthcare system, we need to add resources so that we can all practice up to our licenses, really be there for our patients in a way that will let them know that we'll always do what's right for them. If not, we're stuck in a vicious cycle from which we are doomed never to escape. Source
