Internship is a stressful and life-altering experience. Demands from patients, consulting staff, and paperwork can dehumanize the new physician and make him or her feel like an automaton. The constant exigency of being an intern is further compounded by the increasing use of algorithms and computers. Guidelines for care have existed since the Hermetic books of Thoth in ancient Egypt, but strict “cookbook” medicine limits the intern’s decision-making and individuality. Pressure for electronic record-keeping and redundant documentation further reduce the new physician into not much more than a data entry-and-retrieval terminal. With the intern spending more time with patient records than actual patients, the physician-patient relationship invariably suffers as the intern becomes a small part of the machinery. Consequently, house-staff are constantly searching for a conceptual framework to better understand and cope with their unusual existence.
Isaac Asimov, the visionary science fiction writer and one-time biochemistry professor at Boston University School of Medicine, wrote an entire corpus of work around robots and the three “Laws of Robotics” starting in the 1940s.1 It seems the laws of robotics might also apply to interns as the Three Laws of “Internotics” (original text in parenthesis):
- First Law: An intern (robot) may not injure a patient (human being), or, through inaction, allow a patient (human being) to come to harm.
- Second Law: An intern (robot) must obey orders given it by attendings (human beings) except when such orders would conflict with the First Law.*
- Third Law: An intern (robot) must protect its own existence as long as such protection does not conflict with the First or Second Law.
Ten years after the creation of these laws, Asimov developed a “Zeroth” Law: An intern (robot) may not injure humanity, or through inaction, allow humanity to come to harm.
The First Law
Isolated interpretation of the First Law is the modus operandi of robots and interns. This law is a re-wording of the basic tenet of medicine: First do no harm, or primum non nocere as quoted from Hippocrates in Epidemics. On its surface, the First Law may seem easy for the intern to interpret and follow. However, when the patient’s own perception of benefit and harm deviates from the established norms in medicine, the intern is faced with dilemma of patient autonomy versus beneficence. This may not be a novel phenomenon in the modern consumer-based healthcare system, as Will Mayo, MD, from our own institution once said during a speech at Rush Medical College in 1910: “The best interest of the patient is the only interest to be considered.”
The Second Law
The Second Law explicitly states that the intern must follow the orders of the attending physician, but much rests in the intern’s additional obligation to reconcile obligatory recommendations with their own knowledge and patients’ idiosyncrasy. This may quickly become problematic for the intern, as few orders in modern medicine are considered absolutely risk-free.
The intern must undertake two levels of risk-benefit analysis: They must first determine what type of harm the patient faces in the setting of inaction—as spelled out by the First Law—if the attending’s orders were not carried out; he then must balance such hypothetical harm with the risks associated with the attendings orders of action. If such analysis were to favor inaction, to question the attending’s order is to challenge the attending’s own interpretation of the First Law and to risk the intern’s own existence (Third Law).
Therefore, the best solution for the intern is often to not question whether such order is necessary, but to do whatever possible to protect the patient. An example might be a consultant’s request for a CAT scan in a patient at high risk for contrast-induced nephropathy. In such a case, N-acetylcystein, adequate hydration or urine alkalinization may provide optimal protection against nephropathy. As such, the intern fulfills his or her obligations to the First and Second Laws without testing the limits imposed by the Third.