By Samyukta Mullangi, MD MBA
I was a medical student when Dr Joel Katz, then the internal residency program director of the Brigham and Women’s Hospital, asked me a question I have never quite stopped answering. We were talking about his program, and at some point, he asked what I thought the mission of his hospital actually was. I said something earnest, but ended on a California question mark: the mission was to provide great patient care?
The mission of the hospital, he said, was to be the best training ground in the country for the next generation of physicians.
I remember being a little thrown. It sounded, on first hearing, like the kind of thing that should bother a patient, should one be in earshot of our conversation - as though the people coming through the doors of the hospital were raw material for someone’s education, rather than the point of the whole enterprise. But a moment’s reflection later, I understood that Dr Katz wasn’t claiming that patients came second. He was claiming that if you build the finest possible place to train and support physicians, you do not have to choose. Great care falls out the other end. Solve for the doctor and the patient is taken care of, because a well-trained, well-supported physician is the mechanism by which good care happens at all.
I come back to this conversation whenever I find myself encountering this false dichotomy.
Because most of the way we talk about these stakeholders is that the physician and patients are separate constituencies, sometimes even opposing ones. We fund the patient experience and physician burnout from different budgets, assign them to different committees. Perhaps because of the longstanding notion that being a physician is not just a career, but a calling, we sometimes behave as if making the doctor’s day easier - whether that is through limiting work hours in residency, enforcing time off from the patient inbox, allowing residents to unionize, name your issue - must mean a patient lost something in the bargain.
A decade before I had the language for it, Dr Katz was telling me that this is a false trade. The smallest, most fundamental grain of care delivery is neither the patient nor the doctor as individuals. It is the two together, in a room, and the quality of what happens there depends enormously on what the physician walks in carrying, how much they know, how supported they are, how much of their attention the system has already spent before the visit even starts.
So many of our enterprise quality improvement initiatives are run through payment architecture innovations like value-based care models, or payment bonuses and withholdings tied to payor metrics. But the more fundamental lever is the one that Dr Katz pointed at, and one that we keep mistaking for a soft benefit instead of the main event.
Part of why we mistake it, I think, is that we have so little evidence of what it looks like to get it right. We say we want to support physicians, and then hand them the tools that do the opposite. For all the talk about physician burnout - the ‘doctor’s day’ cookies in the physician lounge, the gift certificates to Massage Envy - remarkably little of the technology we hand physicians were designed with the physician as the user in mind.
The electronic health record, far from being built to help doctors think, or make the visit better, or surface the right information at the right moment, is at its core, a billing instrument with a clinical interface bolted on. It transformed the nature of the physician-patient interaction such that the key thing that physicians were now reimbursed on was no longer the quality of their decision making or the care they put into formulating a treatment plan, but whether their documentation held up in terms of revenue capture. It transformed physicians into data-entry labor to make the real transaction go through.
That distinction is the whole thing, and it is the one I care about most in the work I do now. OpenEvidence has always treated the physician as the ultimate customer, not the labor force and not the data source, but the person the tool exists to serve. We aim to support the actual decision-making, not just improve the quality of documentation (though of course, one leads to the other). Even as we move toward enterprise integrations, into the systems and the contracts and the institutional plumbing, that is the commitment I watch most closely, because it is the easiest one to lose. The moment the real customer becomes the enterprise instead of the clinician, you have built another EHR, however good the technology underneath. The physician experience is the North Star or it is decoration.
Dr Katz had it right. You take care of patients by taking care, seriously and by design, of the people who care for them.