Back before stem cells and Al Pacino Pizza, physicians dined on white tablecloths while discussing their lives and those of their patients. Of course, it was an era when the doctor was still somewhat exalted. Television programs like "Ben Casey" and "Dr. Kildare" featured utterly devoted clinicians who would spend a whole hour on one single case involving a solitary patient. How quaint. Now the profession has catapulted itself into a volume-based dimension. To make ends meet, doctors have to see more patients faster. There's barely time to eat, much less talk. The docs I see in the cafeteria hasten to carry Styrofoam trays back to their keyboards. Leisure, like doctor's lounges, has gone the way of paper charts. What happened?
Obviously, the voracious insurance industry, builders of the tallest structures in major cities, cut a deal with itself to restrict dole-outs. Costs are galactic, they say. We have to set limits, this can't go on, money doesn't grow on trees. Prove the worth of what you're doing. Here: Fill out these forms.
Enter the electronic medical records. With the original intention of allowing a pediatrician in Utah to more effectively communicate with the endocrinologist in Florida, computers were called in like the National Guard. The bright screens of the electronic medical record (EMR) have eclipsed a doctor's ability and even desire to spend more time with someone who is sick. One hospital spent $60 million on the EMR to keep up with the Joneses down the street. No one I know likes the EMR. It eats up time like a starved animal. And the algorithms that comprise it require decision making that defies any notion of wisdom.
But medical wisdom itself has taken a large hit; wisdom has limited value in today's marketplace. Now, physicians are mere health care providers (HCPs) or primary care providers (PCPs) — bumblebees in unit-based assembly lines of care. Yes, yes, Medicare is trying to reward doctors who have fewer complications in their practices. But we're talking money here, not dignity. The EMR forces doctors to spend inordinate amounts stuck on the limbs of decision trees. Help! Get me down! Well, does your patient have pneumonia, yes or no? Not sure? Unless you check a box, you cannot enter further data. An hour goes by, there's no more fried chicken, or the cafeteria is closed.
EMRs appear to have been constructed by medical computer types who have rarely ever diagnosed anyone. The EMR is a seductive piece of merchandise, sold as an item that will make concrete the art of medicine and eliminate the scourge of non-evidence based practice, as if every intervention by the physician were dangerous witchcraft. The purveyors of EMRs may have their own plush dining rooms in their corporate offices, but the usage of dining rooms for others are not part of their databases. And does the EMR really contribute to the full-blooded communication doctors might have about a difficult patient? I doubt it. Physicians need to be able to talk to others. That's the function of dining rooms. These days, it is difficult just reaching a physician. Interposing messages and menus between patients and doctors are as common as raindrops. E-mails can't convey the complexities of care, the doubts, the worries. E-mails are carefully worded, too much worry about the lawyers sitting on our shoulders. Give us back the doctor's lounges.
I saw an ad for a new hospital portal. Portals make me think of science fiction things through which you travel to a far flung galaxy where aliens speak mumbo jumbo, except in the case of hospital portals, you get to see your largely inscrutable medical chart via your computer. Portals allow patients to see their charts via the computer. How ironic this is. In the old days, the chart was sacred and secret, but you got to see your doctor to discuss your illness. Now, you can see your chart, but not your doctor.
Was it really so bad to make the doctor exalted and give him a white tablecloth to dine on? Maybe we could at least bring back the tablecloth to restore some dignity. The physician might feel good enough to sit at the patient's bedside.
John R. Lion is a physician and psychiatrist; his email is firstname.lastname@example.org.
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