Doctors or Technicians?
"I don't feel like I'm a person anymore, just a bunch of numbers. All she wants to talk about is tests and drugs."
That's how patients describe some of their doctors these days - technicians. Bright, intelligent, often concerned, but technicians - purveyors of tests, gatekeepers of other technicians who will eventually if arbitrarily address the real problems patients feel they're facing.
When I visits the hospital wards I watch nurses transfixed before their monitors, clicking, screwing up their eyes trying to figure out what that ice cream cone symbol means. They'll be there hours after their shift is ended, "charting" into the electronic health record while their patients lie alone in their beds listening to the eccentric bleeps of their monitoring equipment, louder than the blaring TV.
When doctors become patients they frequently feel disaffected. One of my oldest friends is going through radiation and chemotherapy and surgery, then more chemotherapy for a locally invasive tumor. Blessed with a fine sense of humor, she jokes that to herself she calls her oncologist "Dr. Mengele." Instead of talking to her, he discusses CEAs and CT scans like an engineer describing a rehabbed building.
Last year when I was suffering from a bout of chronic pain that left me screaming at night, my visit to one of my physicians felt like a New Yorker cartoon. When I told him I was waking up writhing in bed, he paused, looked carefully at my record and said, "well, you have some problems, but you're really in great shape. Your blood pressure is low, your HDL is higher than your LDL, your numbers are good."
The numbers may be good but we've lost our way. And thanks to the wonders of medical technology, the future appears yet less attractive.
Dr. Michael Balint would have recognized the problem. The son of a Hungarian GP, he fought at the front in World War I, qualified as a doctor when he was twenty-one and proceeded to study biochemistry and psychology. When the Nazis began their take-over of Mittel Europa he fled to Britain, where he worked as a GP. He found that many of his patients suffered as they could not talk to their physicians about what truly bothered them. Balint started groups of GPs who discussed how to best talk to patients and help them. His statement to them - "What is the drug you use with patients all the time?"
Balint's answer - "The doctor is the drug."
Studies over the last 60 years have shown over and over that the doctor-patient relationship is a major part of the "Placebo factor" that gets patients well. The power of that relationship applies to all medical personnel, nurses and PAs and therapists. It may represent 30-40% of the general therapeutic response.
These days we're letting it slide.
Verghese, now a professor of medicine at Stanford, is an excellent writer whose novel "Cutting of Stone" depicts medical care in Ethiopia over the decades from the 1950's. His doctors are personally flawed but entirely dedicated practitioners of a heroic form of medicine that saves desperate patients from continuous suffering.
Last week Verghese wrote an article in the New York Times "Treat the Patient, not the CT scan," pointing out how American doctors were now more concerned with information "throughput" than physical exams. He noted that American docs missed critical diagnoses because they had not carefully examined the patient. He brought back, with minor modification, the refrain that drives the plot of his "Cutting of Stone" - "what therapy is always administered by ear?" The answer - "words of comfort."
Words of comfort are about to become less common.
The Coming of the Electronic Health Record
Coming soon to a doctor's office near you will be a new behemoth - the EHR, or electronic health record. Tens of billions a year will be spent "wiring up" all the medical practices in the US. It's all mandated to take place by 2014.
Trying to stop the EHR is about as feasible as King Canute stopping the waves of the sea. Information will pace freely around the world, allowing much better knowledge to all physicians of everything that has happened to their patients.
Or so our IT companies would like us to believe. Much of their future profits are riding on providing EHRs, profit margins that may put the old pharmaceutical margins to shame.
We don't have a national health system like most European countries have long possessed. We do not emphasize public health. Completely sensible public health advise which potentially could save large sums, like when Michelle Obama calls for mothers to breast feed their infants for six months, are attacked by the Sarah Palins of the world as partisan statements. For a nation priding ourselves on our business sense and pragmatism, we talk like senseless fools when it comes to public health.
EHRs work well when they're the same across a country. We will spend tens of billions to create competing systems that will not communicate well with each other and will kill much practitioners' time. Unless paying out of pocket, you may soon not again experience long discussions with your nurse or doctor - she'll be fighting with the different EHR systems riding through the medical community. And then there's the not small issue of privacy, a problem that will not go away.
The doctor as a drug will fade - unless we simplify our technology systems and get them to easily talk to each other. Until we tame runaway medical inflation where money goes to tests and procedures that bring big bucks to device and diagnostic equipment manufacturers, hospitals and large medical groups. Until we recognize that doctors are treating people not patients, and that when close cooperation between patient and practitioners is not valued we then lose a large part of the therapeutic effectiveness.
The doctor is a drug. It's time to remember how to use that drug so that everyone can benefit.
It might a lot of us feel better, too.