I scream in frustration as the flickering screen creates another required check box. Silently of course. I am on the hospital ward, and broadcasting the doctor’s frustration will not help patients or nurses. “Who created this tool?” I wonder for the thousandth time. Why don’t doctors make their own tools?
Contemporary philosopher Daniel Dennett ponders thinking tools. “Like all artisans, a blacksmith needs tools, but — according to an old observation — blacksmiths are unique in that they make their own tools.” Blacksmiths may make their own tools, but not doctors. We allow everyone else to make our tools. And when someone makes your tools, you have been defined, able to function only in the way the tool intended. Some of the doctoring tools designed by others are incredible, and have helped me immeasurably to provide better patient care: on the technological side, the MRI machine; on the human side, the private rather than shared patient room. But what tools would I invent?
Initially, as a profession, doctors created dissection to learn anatomy, the stethoscope to hear the internal processes of the body, then clinico-pathological correlation, and eventually evidence-based tools for creating and interpreting studies. But now someone else creates our tools. Insurance companies create quality metrics, employers create production incentives, and of course: software engineers create electronic records. But if you could make your own tool in the service of patient care, would it look like any of the ones we are now given?
An “intuition pump” is a thinking tool coined by Dennett, as a “handy prosthetic imagination-extender… that permits us to think reliably and even gracefully about really hard questions.” An intuition pump is an exercise in making our own intellectual tools, and freeing our profession from all the intermediaries who have encroached on physician autonomy over the years: third party payors, electronic medical records, patient experience consultants, quality metrics …
Dennett illustrates the concept by describing the Whimsical Jailer, who every night, unlocks all the cell doors for a few hours while the prisoners sleep. Then he asks, “Are the prisoners free?” …Hmmm. Busy clinicians often dismiss such speculations as trivial in the face of heart failure and cancer. But I find that the Whimsical Jailer mirrors my own position as a doctor: the Bemused Prisoner. The electronic record contains a pathway for entering the correct order, I know it; I just cannot usually find it. Am I free? Am I in control? Am I managing the patient’s care? What does freedom mean in this setting? The intuition pump bends current in order to free our minds from thought traps and straitjackets.
Perhaps using intuition pumps to imagine a better medical world will only serve to increase frustration and burnout in medicine. But I believe that imagining a better world, created by providers, will be the first step in wresting control back from parasitic external controllers and financers, back to where it belongs with the front-line caregivers. Go to your work everyday, in the clinic, or hospital, and “pump it up.” Don’t just slog through the day, but imagine a day opening before you with the tools you need for your patients.
Medicine was at one time, or at least was once conceived, as an intellectually vigorous profession, attracting the best students who wanted to meld their hearts and minds in the service of patient health. Medical school meant a ticket into a life of never-ending learning and inquiry. Now, it appears to lead to a career of never-ending conformity, bending ourselves to the next outside influence so we can take our spanking. Let’s stand up and take back the profession; don’t just complain but instead pump up your intuition.