Americans have become the commodity in their own healthcare system. A patient has gone from being a person who has a relationship with a physician to a sheep that is herded through, with the corporate medical world making money off them with every move. Gone are the days when a physician would do rounds in the hospital in the morning, see patients in the office, follow them into the nursing home, and do home visits as they came to the end of their journey.
“Care” has now become a fragmented web of hospitalists, intensivists, and mid-level care that only remotely reflects the relationships that were the bedrock of the American medical system just 20 years ago.
What is the most substantial impact of this fragmented care? No one provider is the sole caregiver with total responsibility. Medicine has become the great handoff, with no one seeing the whole picture of the person in front of them. Patients have become a conglomeration of body systems and body parts to be fixed or addressed in a fragmented fashion, reminiscent of an assembly line.
Pretend for a moment you’re a patient and you go to the emergency room for an acute issue. There, staff need only to verify that you will not expire within 24 hours, and out you go. If the risk is too high, then they hand you off to the hospitalist who will admit you, but if your condition worsens, there is often another handoff to an intensivist who manages the ICU. If more than one or two organ systems are affected then subspecialists will come and pore over the computer (rarely over the human) to see if the numbers in the electronic medical record are within their wheelhouse.
Gone are the days when the ER doc would come up to the ICU the next day to chat with the primary physician about how their other patients are doing and confirm the ultimate diagnoses. Gone are the days when the primary physician would see patients though their entire hospital course and remain responsible for them on discharge.
Technical advances — while aimed at bettering diagnosis, treatment, and healing — have simultaneously distanced doctors from physicians in other specialties who were once so closely linked. When X-rays and CT scans were all on film, physicians used to walk into the radiology department every day (imagine this!) where I worked, and pull the films on their patients from the day prior. Here, doctors of all specialties would often corner our radiology physicians to discuss the case, pore over films together, and both would then see the nuances of the patient from both the outside and the inside. The pathologist likewise was a few feet further down a hallway, where questions about biopsy specimens could be discussed. Should we do a different study? Is there a limitation of this stain on the results of the test? Questions and dialog were woven together with the patient at the core.
Nursing home care was also under the purview of the primary physician, who would do rounds and take phone calls, write orders, and talk with the family. Now, many nursing home facilities have no on-site provider, and for some, the facility’s medical director is in another state altogether. A separate corporate system has sprouted like a weed, and has taken over as the remote “medical director of record” for nursing homes where there are too few staff, and where “standing orders” are an automated way of caring for any particular problem that may arise so as to minimize any thought or analysis of the problem.
We have paid a heavy price for medicine that is at once “at your finger tips” as well as broken and fragmented. Proponents will point to “best practice advisories” and “metrics” that our electronic medical records blip across the screen with dizzying speed. It does not matter if you know that Mrs. Smith’s emotional eating is driven by her grief for her son’s addiction problem and her 14-year-old cat who she recently put down. All that matters is you put her on the approved diabetes medications and her hemoglobin a1c is at target.
We no longer have a system that values attention to the person. We have a system that values a database that can be mined for profit and publication. Electronic medical record systems were built not for patient care but for billing and mitigating legal risk. Moreover, the young providers of today know nothing of generating orders in their mind and then putting them to paper. The computer provides (often inaccurate) proposals at each click for dosing, drug options, and diagnostic testing. It took years to get our own system to stop giving lactation warnings for my 90-year-old female patients. When ransomware hits a medical system, providers must scramble to learn how to generate orders and doses without a computer to prompt them.
Often in medicine there is an invisible pendulum that swings in wide arcs. It has an eerie resonance to the story by Edgar Allen Poe, with the patient at the edge of the blade. Our automation and convenience has come at a price. As our nation grapples with obesity, depression, anxiety, and addiction, we must seek to reconnect with people in our care. We must resist the urge to “click the box” and remember to look up at the person.
Unfortunately, the drivers of the corporate medical system are no longer the physicians. We are at the mercy of federal and state bureaucracies overlapped with big data companies and the pharmaceutical industry. They are all present with you in the doctor’s office, manifested in the sound of the endless clicking, reflected in the light of the computer screen. Every day I miss the paper chart, the simple folder that never stood between me and the patient, that not once told me how to make someone better, and simply allowed me to practice the art of medicine.
Kathleen A. Hallinan, MD, MPH, is Internal Medicine Specialist in Corning, New York, and a Diplomate of the American Board of Obesity Medicine.