Reviving the Doctor-Patient Relationship

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The woeful present and hopeful future of high-tech medicine.

By Robert Wachter | In 2011, a seven-year-old girl in Providence, Rhode Island, accompanied by her mother and her older sister, went to see her pediatrician for a routine exam. The child later sent the doctor a crayon drawing depicting her visit. Many pediatricians have a corkboard in their office on which they post their young patients’ artwork. But I’m guessing that this one, in which the doctor is engaged not with his patient but with his computer, didn’t make it onto the doctor’s Wall of Fame.

essay_exerpt_drawingHow times have changed. In his famous 1891 painting, The Doctor, Luke Fildes set out “to put on record the status of the doctor in our time.” This evocative painting was inspired by the death of Fildes’s own son 14 years earlier from tuberculosis. Sadly, Fildes’s doctor could do little to save the boy from the ravages of the tubercle bacillus (effective treatment for the infection would not become available for another 75 years). Yet there is little doubt that the child in the painting, as well as his parents by the window, knew that the physician’s sole focus was on his patient.

In contrast, how can the little girl in Rhode Island—and her mother—not conclude that this doctor cares more about the demands of his computer than about the child’s health? If The Doctor captured the essence of being a physician in the twilight of the 19th century, is this crude and charming child’s drawing destined to be an equally iconic representation of the doctor’s world in the early years of the 21st?

The idea that our technology could distance us from our patients is not new—nor is the computer the only culprit. From the time of Hippocrates, the practice of medicine was personal and intimate. Physicians could do nothing more than listen to patients and examine them through touch. But in 1816, a French physician named René Laennec, frustrated by the practice of listening to heart and lung sounds by placing his ear on a patient’s chest, rolled a sheaf of paper into a tight cylinder and listened to a young woman’s thorax through it, creating a crude version of what would later become the stethoscope.

The new diagnostic tool would soon revolutionize the practice of cardiology. But, in its early days, the general public and the media were skeptical of the stethoscope. “That it will ever come into general use, notwithstanding its value, is extremely doubtful,” wrote The Times of London. “Because its beneficial application requires much time and gives a good bit of trouble both to the patient and the practitioner; because its hue and character are foreign and opposed to all our habits and associations.”

In hindsight, of course, we can now see that the stethoscope was small potatoes: it separated Laennec from his patient by a mere 18 inches. Today’s clinician can diagnose and treat patients based on reams of data collected through cameras and sensors. And while the people (and not all of them are doctors) analyzing these data may be in the next room, the advent of high-speed networks and wireless connectivity means that they may be across the street, or even across an ocean. This is progress, of course, but the cost of this progress is only beginning to be fully appreciated, by both patients and their doctors.

Over the past decade, Abraham Verghese, an infectious disease specialist and bestselling author, has become increasingly concerned about how technology is cleaving the sacred bond between doctor and patient. “I joke, but I only half joke, that if you came to one of our hospitals missing a limb, nobody would believe you until they got a CAT scan, an MRI, and an orthopedic consult,” he likes to say. In a 2011 TED talk, Verghese lamented that when we stop talking to and examining patients, dangerous things start to happen, including overlooking simple diagnoses that can be treated if they’re caught early.

As computers muscled their way into the exam room in the early years of the 21st century, Verghese noticed that his trainees and colleagues gradually adopted a fundamentally new approach to the practice of medicine. In an influential 2008 article, he described what he called the “iPatient,” an entity clothed in “binary garments.”

“Often, emergency room personnel have already scanned, tested, and diagnosed,” Verghese wrote, “so that interns meet a fully formed iPatient long before seeing the real patient.” While the real patient keeps the bed warm and ensures that his folder remains alive on the computer, “the iPatient’s blood counts and emanations are tracked and trended like a Dow Jones Index, and pop-up flags remind caregivers to feed or bleed.”

“The iPatient is getting wonderful care all across America,” Verghese said in his TED talk, “but the real patient often wonders, Where is everyone? When are they going to come by to explain things to me? Who is in charge?

There are people who argue that the only solution to the computer’s intrusion into the exam room is surgical: yank out the wires, exhume the paper, and buy some new three-ring binders. I find such arguments unpersuasive. The answer to what ails healthcare is not going to be found in romanticizing how wonderful things were when your doctor was Marcus Welby. We can—in fact, we must—wire the world of medicine, but we need to do it with our eyes open, building on our successes, learning from our mistakes, and mitigating the harms that are emerging.

When it comes to the doctor-patient relationship, some of the fixes will be technological, and others will involve re-imagining our work. Some clinics and hospitals have already equipped exam rooms with large rotating screens, allowing both physician and patient to see the screen at the same time. Some practices have hired scribes, typically premedical students who type into the computer so that the doctor and patient can make eye contact and focus on the matters at hand. (It’s worth noting that every other industry brings in computers and lays people off. Only in healthcare could we come up with a way to digitize and still add personnel.) Advances in voice recognition and natural language processing may ultimately allow doctors and patients to have a real conversation, the technology transforming the words into digital form and then placing each item into the appropriate part of the record.

It’s only logical for us to be disappointed by healthcare information technology, because we were spoiled by our smartphones. Our daily experience has taught us that all we need to do is turn on our iPhone, download an app, and off we go—whether we’re buying a book, making a restaurant reservation, or getting directions to the nearest Starbucks.

Yet, despite the disappointing start of healthcare’s entry into the digital world, I believe that most of today’s technical problems—not only the challenges of creating the note, but also the hazards of pop-up-alert fatigue and the fact that our current computers don’t talk to each other—will be solved over the next 10 years. Not tomorrow, not perfectly, not everywhere, and not without pain or political dogfights, but incrementally and, ultimately, in a way that truly makes healthcare better.

In the end, though, we will still confront the question of what to do about those messy, imperfect, non-digitized relationships—the ones between clinicians, of course, which continue to feel awfully important (and have also been upended by technology), but especially those between patients and healthcare providers. Even when that wonderful day arrives and we have finally coaxed the machines into doing all the things we want them to do and none of the things we don’t, we will still be left with one human being seeking help at a time of great need and overwhelming anxiety. The relationship between a doctor and a patient does not feel transactional now, and I don’t think it will then. Rather, it will remain vital, scary, ethically charged, and deeply human.

It will take great discipline and all the professionalism we can muster to remember, in a healthcare world now bathed in digital data, that we are taking care of human beings. The iPatient can be useful as a way of representing a set of facts and problems, and big data can help us analyze them and better appreciate our choices. But ultimately, only the real patient counts, and only the real patient is worthy of our full attention.

Robert Wachter C’79 M’83 is professor and associate chair of the Department of Medicine at the University of California, San Francisco. This essay is from The Digital Doctor by Robert Wachter, reprinted with permission from McGraw-Hill. Copyright ©2015.
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    3 Responses

    1. This article really struck a chord with me. In particular, Dr. Abraham Verghese’s observations are spot-on regarding the focus given to the “iPatient” while the real patient asks “Where is everyone?”

      The final weeks of my mother’s life began with my taking her to a hospital ER, on the urgent advice of her GP who had just examined her. She lay there for about 8 hours before finally getting a perfunctory visit from an ER physician. Was this because they were understaffed and swamped with critical cases? Not at all. Instead, as I observed, the ER physicians spent most of their time (easily 55 minutes per hour) glued to computer screens rather than engaged with patients.

      When she was admitted to the hospital, the pattern repeated itself, this time with the nursing staff. They, too, spent the vast majority of their time engaging with computer screens at the nursing station rather than tending to patients. The result was that response times to patient call buttons was abysmal. Not a night would go by when I wouldn’t get one or two frantic calls from her, because she was in distress and the nurses had not responded for a half hour or more. Then I’d have to call the nurses’ station to raise hell on her behalf. Likewise, had I not been available to spend much of the day with her and prod the nurses, I doubt that she’d be seen at all by them. Other visitors expressed the same dismay at the misplaced priorities.

    2. @transitionmd

      Good luck with that Arras! Big Government and Big Medicine, who clinic to know our needs best, regard your search as antiquated. But it is YOU and fellow patients who can redefine DEMAND. As I like to say: ‘Time with patient’ is THE quality measure against which all others pale in importance!!

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