Ossification of Medicine

Every specialty has its inventors, and a surprising number of them are still alive.

The Epley maneuver was one otologist repositioning particles in the inner ear with his hands, years before anyone published it. Endoscopic sinus surgery came into this country through a handful of people who thought a scope could do what a scalpel had been doing, and taught each other. Transoral robotic surgery was two surgeons at one institution deciding that a device built for the pelvis could reach the throat.

That's just my field, ENT. Yours has its own list.

Some of the people on it are still operating. You can go to a meeting and shake their hands.

Now ask yourself, honestly, whether a surgeon your age could do what they did.

Not whether you're capable of it. But whether you'd be allowed.

You'd need IRB approval for the concept. Device approval for the instrument. A credentialing committee to let you use a technique the hospital hasn't credentialed anyone for, which is very unlikely to happen. A risk-management review of the first case. A malpractice carrier willing to cover something with no literature behind it. And a schedule that leaves you the time, and the ownership of your own OR, to try anything at all, which almost no employed surgeon has.

Some of that oversight exists for good reasons. As they say, “regulations are written in blood.” People have been significantly hurt in pre-oversight eras, and by-and-large modern medicine, especially surgery, is better off for it. But the net result is that the surgeon-inventor, the person who used to be the source of so much of what was new in this field, has become nearly obsolete.

Innovation still happens. It just happens somewhere else. It happens in device companies, maybe with surgeons as consultants, and eventually arrives in the OR as a product with a rep standing behind you, teaching you how to use it.

What changed is that every one of those restraints, the IRB, the credentialing committee, the risk review, the carrier, was somebody's good idea. Usually it was a good idea written down after something went wrong, so that it wouldn't go wrong again. Each probably made sense at the time, and maybe was even done in service of patient care, but ultimately they all created a system that benefits institutions and minimizes risk. 

There's a name for that process, and every doctor has heard of it: Ossification.

You can see it everywhere in medicine once you start looking for it.

Someone has an idea. The idea gets written down so that people who never had it can act as if they did. A checklist, a protocol, an order set, a template. It's how a hospital survives losing its best attending. Then the person who had the idea leaves, or dies, or just stops being asked.

The reason behind the rule is forgotten, but the rule stays. And eventually people start following it because it's the rule. Why risk a peer review when it’s just easier to comply?

You can see the fossils if you know where to look. I saw them most clearly when I practiced solo in the rural South, because for a while I was the entire ENT department.

When you're the only one there, you find out pretty fast which rules have a reason behind them and which are just sediment. Some of what I'd been trained to treat as sacred turned out to be a fossil. Some of what I'd been trained to skip turned out to be the only thing holding the place together. And past a certain point, calcification is what a system does instead of thinking.

I want to be careful here, because in August I argued something close to the opposite.

In Crash-Only Medicine, I said the problem with academic medicine is that it doesn't write enough down. Clinical judgment lives in individual heads, gets lost every July, and has to be re-derived from scratch by whoever's left.

Now I'm saying that writing things down is what turns them to bone.

Both are true, and I think the reason they're both true is the more interesting part.

Medicine ossifies the wrong tissue.

It has a perfect, obsessive institutional memory for billing, for compliance, for liability, for anything that protects the institution from the outside. Every keystroke of that gets codified, hardened, made load-bearing. And it has almost no institutional memory for the thing that makes someone a good doctor: the "here's what I'd actually watch for" knowledge that never makes it into a note.

That part stays soft. Then the person who had it leaves. So the skeleton ends up backwards. We're rigid where we should still be able to flex, and we leave the things that actually matter to individual memory, where they disappear as soon as the individual does.

The part of the profession that could grow, the part that used to invent things, has hardened.

The part that should have been preserved - crucial generational knowledge, the hidden curriculum -  was never written down at all.