Ilana Yurkiewicz, M.D.
It’s a cliché to say that American health care is broken. Ilana Yurkiewicz, M.D., a Stanford University oncologist and internal medicine physician, says journalists should be more specific. The central problem, she argues, is that health care is fragmented.
“Fragmented” is the title of a new book in which Yurkiewicz, who’s written about medicine for such publications as Undark and Hematology News, describes barriers that prevent physicians from seeing a patient’s full medical narrative.
Health systems can’t easily share records. Electronic health records bury information. Payment systems de-prioritize follow-up. Grueling 28-hour shifts for medical residents discourage accountability. Primary care is underfunded. Sub-specialization is emphasized at the expense of holistic care.
I asked Yurkiewicz about her takeaways for journalists.
(Editor’s note: Responses have been lightly edited for brevity and clarity.)
Do you think the public is aware of how inefficient the system is?
People who are not well connected with the health care system are not aware of it. When I try to explain to my patients about how to get data from another health care facility to me, they are frequently astounded when I run through the steps.
One of my patients sent me a message with an attachment of lab tests that she had done outside my facility. She said, “Can you upload this to my chart?” The short answer was, I can, but it wouldn’t be connected with the rest of your data. I wouldn’t be able to directly compare them or graph them out like I would if the patient had had her blood drawn within my system.
How can journalists help the public to understand the pitfalls and how to protect themselves?
I encourage patients to have something like an elevator pitch of their own medical histories to bring to any provider they see. I would encourage journalists to also encourage the public to repeat these histories. [Marketplace republished her patient’s checklist.]
What is happening to patients who can’t keep track of their own medical stories?
There are patients that are falling through the cracks. Recently in my clinic, I saw a woman who was in her late 60s and had been diagnosed with mild cognitive impairment. I came up with this list of to-do’s, and in our fragmented system, that list was actually quite logistically complicated. I went through this list, and by the end of it, she said, “Okay, thank you very much. Now, what are the steps?” I could see the gulf of fragmentation enveloping her.
It was 2015 when Bob Wachter published his book about how implementation of electronic health records was bungled. That was the year you started your residency. Do you think there’s been much improvement?
I don’t think there has been large-scale improvement in how our records are organized and transmitted to one another. This is still a huge under-recognized issue of how errors and near-misses and [administrative] burdens actually happen.
As a young physician, how do you think your expectations of the system differ from those of older physicians who remember the days of paper records?
It was really stunning to me when I started out that some of the things that were just so well taken care of in other sectors of society were not being taken care of in medicine, where the stakes were so incredibly high.
Do you think artificial intelligence can help?
I think the potential of AI is not to replace doctors but to replace the tech that isn’t working and clean up the messes that the technology has created.
Do you trust AI to do that accurately?
I think there are going to be errors and pitfalls, but there are errors and pitfalls in our tech right now.
The topic of long hours during medical residency has been debated for years without much movement. Do you think that journalists have dropped the ball on this issue?
There was movement back and forth for about five decades between 16-hour calls and 20-hour calls. In 2017, the [Accreditation Council for Graduate Medical Education], which is the organization behind residency hours, went through all of this data and put out a memo saying it was pretty clear that 28-hour calls were no worse, and so the issue is essentially decided. At the time there were articles in the mainstream press, but once the decision was made, I do feel like momentum disappeared.
For the most part, the controversy in the lay press has revolved around how your decision-making as a physician is impaired when you’re working those hours. I make the argument that it’s very ironic that 28-hour calls were framed by the [Council] and others as ways of fostering seamless continuity of care. In reality, long shifts cultivate an ability to only focus on the highest acuity breadcrumbs in front of you, just keeping patients alive over the course of that shift. It diffuses accountability over the bigger questions — for example, if a patient lingered on a ventilator perhaps longer than they should have because there was no one saying, “This person has been on a ventilator for four days, it is time to get them off.”
Do you think there is renewed interest in working conditions of residents since the pandemic?
There are a lot of places where residents have unionized, which I think is a step in a good direction. I’m hopeful we can add these long shifts back into the dialogue about working conditions.
You write that primary care needs more funding and specialization in terms of serving patient populations with special needs. Do you see any advances that give you hope?
My clinic is primary care with a focus on patients who have had cancer or are living with cancer, so I am managing their bread-and-butter primary care issues but with that special focus on the cancer history. My patients are often stunned in a very positive way that this clinic exists. I think there’s a lot of energy and room for innovation in primary care.
I reported in the book on another clinic that gives me hope, which was Stanford Coordinated Care. Their focus was on chronically ill patients with multiple comorbidities. I think there are other places that are looking at models similar to this, where the focus is on value. That requires a different reimbursement model, which is a bigger question.
What other stories should journalists be telling about our fragmented system?
I think talking more about unintended consequences of specialization is important. If you visit any hospital or are chronically ill, you’re going to have dozens of faces on your care team. You can have a pulmonologist thinking perfectly about the lungs and a kidney doctor thinking perfectly about the kidneys, but I think we need to talk about how physicians can take ownership of a patient’s full story, and that goes back to having a primary doctor.
If I could just add, tying burnout to the real reasons for burnout. Surveys have consistently shown that it’s bureaucratic tasks [that are burning out physicians]. We have a primary care shortage because primary care doctors are quitting after a decade of training, and that is really, really tragic for the whole country.
