Last month, the New England Journal of Medicine published a thoughtful essay by David Rosenthal and Abraham Verghese on the many changes in how doctors are trained and how they practice medicine. Efforts to improve efficiency and accuracy — including the introduction of electronic medical records — offer benefits, and pose some complicated problems.
Doctors need to learn and do more, more than ever
The health care system strives to deliver better care while keeping costs down. Advances in medical science and technology mean there is ever more information for a doctor to know, and policies to curb waste have limited the amount of time we have to learn it all. Monique Tello wrote about this issue last month; it's why your doctor is always at the computer. But more than that, these competing goals have had real consequences for how doctors work, how we think, how we relate to our patients and colleagues, and how we feel about our profession.
An example: I'm a hospitalist. It's a relatively new field in medicine, a product of exactly these forces. Two decades ago, when patients were hospitalized, their primary care doctors would see them in the hospital, in the morning, before returning to clinic for the day. Residents or nurses, often without immediate supervision, managed minute-to-minute affairs. But the culture and standards of practice have changed. We've decided that it's better to have fully-trained doctors in the hospital all day. In an emergency, I can be at the bedside in an instant. Residents and nurses get more active supervision. Primary care doctors, who have seen their reimbursements cut, can spend more time seeing patients. But there are downsides. The people I see in the hospital often don't know me, and I don't know them. And when a person leaves the hospital, his doctor may not know what I've done and why. So, we've replaced one set of challenges with another: making sure that there's good communication between hospitals and clinics.
Electronic medical records can make that communication easier. When a patient comes to me in the hospital, I have immediate access to their entire chart. I can see records from every clinic visit, lab test, x-ray or CT scan, a list of all their possible diagnoses and the medications prescribed to treat them. It's useful to look at this information before I meet someone new. After all, if you're sick and uncomfortable, you don't want to have to repeat the same story to every new doctor you see. And it's reassuring to know that the doctor you're meeting for the first time has taken the time and effort to get to know the particulars of your situation. What's more, those records make my job easier. My patients may not remember the names and doses of all of their medications. No problem, I can look it all up.
But the things that make us more efficient may challenge the ability to develop and maintain personal connections
But something valuable gets lost. Maybe there's a reason a patient can't remember the names of her medications. Sometimes digging a little bit further can turn up a clue that there's something more going on. But those clues come up in face-to-face conversations, and over time, not with a glance at a computer screen. Dr. Jerome Groopman describes another challenge in his book How Doctors Think. Seeing what other doctors have written about a patient can trap us into thinking about their illness in the same way, and blind us to alternative diagnoses. Sometimes the best way to work is to start fresh, and to let your patient tell her story from the beginning.
And then there's the problem of distance. We have more and more tests that promise more accurate diagnoses, but require time to coordinate and review. Computerized notes and emails make it easy for doctors to communicate with each other, but have replaced conversations between colleagues. As doctors are increasingly isolated from both patients and each other, they have become demoralized and burned out.
At its best, being a doctor is an extraordinary and intimate privilege. We build relationships with our patients and see them through times of both joy and suffering; our relationships with each other help us through the same. It's hard to do that in a way that's truly satisfying when we spend most of the day at the computer screen. Rosenthal and Verghese don't see an easy fix for these problems. They are largely structural and built into the practice of medicine. But they charge us to remember that the meaning of medicine is in its human connections. Whatever comes next, both doctors and patients should fight to hold on to that.