Americans have become the commodity in their own health care system. A patient has gone from being a person who has a relationship with a doctor to a sheep who is parked, with the corporate medical world making money with every move. Gone are the days of a doctor making rounds to the hospital in the morning, seeing patients in the office, following them into the nursing home, and making home visits at the end of their trip.
“Care” has now become a fragmented network of hospitalists, resuscitators, and mid-level care that far reflects the relationships that were the foundation of the American medical system just 20 years ago.
What is the most substantial impact of this fragmented care? No provider is the only fully accountable caregiver. Medicine has become the great transference, without anyone seeing the full picture of the person in front of them. Patients have become a conglomerate of bodily systems and body parts to be repaired or treated in a fragmented fashion, reminiscent of an assembly line.
Imagine for a moment that you are a patient and going to the emergency room for an acute problem. There the staff just have to verify that you don’t expire within 24 hours, and off you go. If the risk is too high, they will hand you over to the hospitalist who will greet you, but if your condition worsens, there is often another transfer to a resuscitator who manages the ICU. If more than one or two organ systems are affected, sub-specialists will come and examine the computer (rarely the human) to see if the electronic medical record numbers are in their wheelhouse.
Gone are the days of the emergency room doctor going to the intensive care unit the next day to discuss the condition of his other patients with the attending physician and confirm the ultimate diagnoses. Gone are the days when the attending physician saw patients throughout their hospital journey and remained responsible for them upon discharge.
Technical advances – while aimed at improving diagnosis, treatment, and cure – have simultaneously distanced physicians from physicians of other specialties that were once so closely linked. When the X-rays and CT scans were all filmed, doctors would go to the X-ray department (imagine it!) Where I worked every day, and shoot their patients’ films from the night before. Here, physicians of all specialties would often corner our radiologists to discuss the case, review the films together, and both would then see the nuances of the patient from the outside and the inside. The pathologist was also a few meters down a hallway, where questions about the biopsy samples could be discussed. Should we do a different study? Is there any limitation of this stain on the test results? The questions and the dialogue were woven with the patient at heart.
Home care was also the responsibility of the primary care physician, who made rounds, took phone calls, wrote prescriptions and spoke with family. Now, many nursing homes do not have an on-site provider, and for some, the facility’s medical director is in an entirely different state. A separate corporate system has sprouted like a weed and has taken over as a remote “medical director of the case” for nursing homes where there are too few staff and “standing orders” are in place. an automated way to deal with any particular problem that may arise to minimize any thought or analysis of the problem.
We have paid a heavy price for drugs that are both “at your fingertips” and broken and fragmented. Supporters will point out the “best practice tips” and “steps” as our electronic medical records scroll across the screen at breakneck speed. It doesn’t matter if you know that Ms Smith’s emotional eating is driven by her grief for her son’s addiction problem and her 14-year-old cat that she recently shot. All that matters is that you give her approved diabetes medication and have her hemoglobin a1c reached.
We no longer have a system that values attention to the person. We have a system that values a database that can be exploited for profit and publication. Electronic medical record systems weren’t designed for patient care, but for billing and legal risk mitigation. Plus, today’s young vendors don’t know anything about generating orders in their minds and then putting them on paper. The computer provides (often inaccurate) suggestions with every click for dosage, drug options, and diagnostic tests. It took years for our own system to stop giving lactation warnings to my 90 year old patients. When ransomware hits a medical system, vendors must scramble to learn how to generate orders and doses without a computer prompting them.
Often in medicine there is an invisible pendulum that swings in wide arcs. It has a strange resonance to the story of Edgar Allen Poe, with the patient at the edge of the slide. Our automation and convenience come at a price. As our country grapples with obesity, depression, anxiety and drug addiction, we must seek to reconnect with those in our care. You have to resist the urge to “click on the box” and remember to look up at the person.
Unfortunately, the engines of the corporate medical system are no longer physicians. We are at the mercy of overlapping federal and state bureaucracies with big data companies and the pharmaceutical industry. They are all present with you in the doctor’s office, manifested by the sound of the endless clicking, reflected in the light of the computer screen. Every day I miss the paper file, the simple file that never got between me and the patient, who not once told me how to improve someone and just allowed me to practice the art of medicine.
Kathleen A. Hallinan, MD, MPH, is an internal medicine specialist in Corning, New York, and a graduate of the American Board of Obesity Medicine.