An article by Caleb Gardner and John Levinson
The practice of medicine is a subtle art. Doctors need to give patients their undivided attention.
Of the many problems facing modern medicine, the deterioration of the patient-doctor relationship is one of the most pernicious. Today our health-care system is losing its humanity amid increasingly automated and computer-driven interactions between doctors and patients.
The signs and symptoms of this pathology are everywhere and have been described in these pages: Primary-care appointments are now as short as five minutes, and the physician must spend much of that time typing instead of attending to the patient and performing a physical examination. Medical students and residents are spending more time with screens than with patients. A 2013 study from Johns Hopkins showed that first-year physicians spent a meager eight minutes a day with each of their hospitalized patients while spending hours at the keyboard describing and quantifying those fleeting moments. Meanwhile, fewer doctors would like to see their children enter a career in medicine, and escalating health-care costs are crippling families and the economy without improving public health.
The electronic health record (EHR), once a promising new medical technology, is a major cause of this disconnect. Not long ago, doctors dreamed of a time when unwieldy paper charts would be replaced by streamlined computer systems, freeing them up for more direct patient care. But now these computer systems are distracting and burdensome. Senior physicians are retiring early because of the EHR, while young doctors feel the humanity draining from a profession to which many were drawn because of a desire to interact and connect with people.
How did we get here? One cause is the development of third-party health-care financing, which grew out of the Great Depression and eventually led to the ascendance of insurance corporations with the ability to influence the clinical practice of hospitals. Similar economic forces have decimated private medical practice, as physicians become employees of hospitals and larger hospital systems. Medicine has become corporatized.
In 2009, with this stage set, Congress passed the Health Information Technology for Economic and Clinical Health (Hitech) Act. The act was designed to improve the U.S. health-care system by promoting and standardizing the use of computer technology by physicians. It prescribed, in great detail, a set of federal standardized instructions for how doctors must use computers in medical practice, such as what data to collect from patients. It also provides a mechanism by which hospital systems can prompt doctors to make decisions that are more in line with the hospital goals and practices. These instructions, enforced by financial incentives, are collectively called “meaningful use.”
Computer programs and one-size-fits-all rules for medical practice have thus become central to the care process. Through the EHR, a physician is pushed to start a “preferred” medication, or not to order a test that the computer program deems unnecessary. The system forces doctors to choose from a set of tens of thousands of billable diagnosis codes before making any clinical decision, no matter how nuanced the individual case and circumstances may be.
Even though the rules reflect clinical guidelines produced by medical societies, they can’t be used as unmodified recipes to care for complex and diverse individuals. Computer algorithms don’t result in higher quality care because the practice of medicine remains a subtle art. Careful listening and undivided attention are important, and the incessant electronic reminders and check-boxes that divert a doctor’s attention while the patient sits on the examination table are a distraction equivalent to texting while driving, and will end up hurting patients.
The patient also suffers because medical records are now used primarily as management tools for billing compliance and population-data collection. This hurts communication among doctors who must struggle to find the information they need for basic patient care buried in piles of clinically irrelevant data. Meanwhile, growing medical specialization and restrictions on resident work hours have led to more shift changes and transitions of patient care from one doctor to another, moments when clear and efficient communication is most vital.
According to Arthur Kleinman, a professor at Harvard Medical School, the “great failureof contemporary medicine to promote caregiving” in favor of market efficiency has “diminished professionals, patients, and family caregivers alike.” In reality, however, there isn’t even a trade-off: Medicine is both losing its humanity as Dr. Kleinman observes, and buckling under the weight of massive, ill-designed electronic information systems.
The answer isn’t to resist technology. Information systems are central to the future of good doctoring, and industry professionals should continue designing electronic systems to enhance medical care and facilitate the connection between patients and physicians. Meanwhile, however, medical practices should be allowed to turn off the “meaningful use” software prompts and return to the job of taking care of real people. Doctors have an obligation to act as stewards of the medical profession and with humanity toward patients and should insist upon the undivided attention necessary to do so.
Dr. Gardner is a physician and resident at Cambridge Hospital in Massachusetts. Dr. Levinson is a cardiologist at Massachusetts General Hospital and Harvard Medical School.