June 2009 Archives
I had the pleasure of being in the East Wing of the White House on Wednesday, one of about 160 people in the audience as President Obama appeared on national television, fielding questions about health care.
It was my first look at the President at close quarters. I came away with the impression that the President was possibly the most knowledgeable person in the room when it came to the current health care crisis. That's no small thing given the people who were there. We have had Presidents whose understanding of issues seemed confined to the precise talking points prepared by aides in briefings. This President knew his material well and was improvising as smartly as a jazz pianist, in response to questions.
The other thing I sensed was the President's tremendous passion for this cause. If there is something more important on his agenda, I don't know what it is. What also came across is that compared to everyone else who was there (physicians like me, the CEO of Aetna, the head of the AMA), the President was probably the only one whose interests in the health care debate were not self serving. His sole motivation seems to be to head off disaster, which seems inevitable if reform does not take place.
An important moment for me personally came when a young woman asked the President the very question that I had been prepared to ask. She wanted to know why we could not emulate the example of other advanced democracies that manage to cover all their citizens for about half what it seems to cost us. The President's answer was revealing; he pointed out that most of those countries had a one-payer system whereas we in America, "...have an employer based system that has grown up over decades. For us to completely change our system, root and branch, would be hugely disruptive and I think would end up resulting in people having to completely change their doctors, their health care providers in a way that I'm not prepared to go. This is one-sixth of our economy. I think that we can build on what works, fix what's broken, and still have some substantial money."
The obstacles in the President's way are considerable: 1) people and businesses who are profiting hugely from the status quo; 2) a general fear of government interference; 3) fear in Congress about the amount of money to be spent on health care reform and finally, 4) the fact that legislators who have to make change happen often serve the interests of the people who gave them the most campaign money--pharma, insurers, organized medicine. These contributions are what taint our political process--call it first world corruption.
I got back to my hotel room at 10pm, just as the session (which had been recorded "live to tape") was finally being aired. I was surprised to see that one commercial shown during the health care debate was on behalf of "Patients United Now"--a group I know little about. The ad was sowing seeds of fear by having a Canadian patient talk about the difficulties of that system. They couldn't wait to hear what the President had to say it seems.
Oh yes, and the other thing on television competing on the other channels was the news of Governor Sanford's whereabouts. As to that . . . less is more.
Our costly health care system is unsustainable for doctors like Michael Kahn in New Hampshire, who, as he puts it, spends 20 percent of each day supervising a staff explaining insurance problems to patients, completing authorization forms, and writing appeal letters; a routine that he calls disruptive and distracting, giving him less time to do what he became a doctor to do and actually care for his patients.
The President's speech even quoted Newt Gingrich:
As Newt Gingrich has rightly pointed out, we do a better job tracking a FedEx package in this country than we do tracking a patient's health records.
The speech reminded me of a conversation a few days ago with a close friend who said casually, "Face it, Abraham, medicine is corrupt." I paused. I sputtered. I was about to say something. But I shut up. I shut up because (as the President explains) whether I like it or not, I am a beneficiary of a system of :
. . incentives where the more tests and services are provided, the more money we pay. And a lot of people in this room know what I'm talking about. It is a model that rewards the quantity of care rather than the quality of care; that pushes you, the doctor, to see more and more patients even if you can't spend much time with each; and gives you every incentive to order that extra MRI or EKG, even if it's not truly necessary. It is a model that has taken the pursuit of medicine from a profession - a calling - to a business.
We can quibble on the ways the President proposes to fund the changes he proposes, but I don't think we can quibble on the moral imperative to change the way we do business. As the President says,
"You entered this profession to be healers - and that's what our health care system should let you be."
(For another take on the speech from a thoughtful physician who also happens to be in New Hampshire, see KevinMD.com)
What always strikes me when I come back to being on the in-patient wards is the mountain of data that exists on each patient. It's a surprise every time, a feeling analogous to revisiting Bombay or Madras after years of being away and finding that a city you did not think could get more congested, has done just that.
For example, if we admit to our service a patient who once had a transplant in our hospital, that guarantees records from many prior admissions--a veritable encyclopedia in the computer. Add to that everything generated in the hours that they were in the emergency room before making their way up to the ward (ER attending's note, blood tests, imaging studies, nurses' notes, consultants' notes) and you find that the real patient under the sheets is dwarfed by the labels and data that precede them. The task of sifting through that pile of information seems to get more challenging every year.
A few days ago my brother sent me a paper quoting the psychologist Herbert Simon who in 1969 lecture said:
"the wealth of information means a dearth of something else: a scarcity of whatever it is that information consumes. What information consumes is rather obvious: it consumes the attention of its recipients. Hence a wealth of information creates a poverty of attention and a need to allocate that attention efficiently among the overabundance of information sources that might consume it."
Simon anticipated by 40 years the issue I've been wrestling with this week: is the information extant per patient, the sheer mass of it (measured not in stacks of papers, but in searchable gigabytes) at times detrimental to patient care? Data = mass = gravitational pull so that any of us opening a patient file enters a force field and find ourselves sucked in. For the interns' generation which has grown up on computers, the force is perhaps stronger or the nature of that kind of work is familiar.
Being a good doctor does involve carefully studying the old records. In the old days, one had to make an effort to go to the file room and get the dusty old charts, or if they were not there, track them to the cubbyhole where they awaited someone's signature. There was virtue in the effort simply because less conscientious physicians might not bother and they therefore might duplicate tests that needn't be done, or might miss the boat altogether in terms of what ailed the patient.
Nowadays, as I watch us all scour the digital records (no dust to inhale, no rubber bands that snap in your face) the task is so much easier. The new issue is that the information can detract and distract; we can wind up sitting too long in the chair staring at it. To paraphrase T.S. Eliot, knowledge can get lost in information, just as wisdom can get lost in knowledge.
On several occasions this week, I've felt that my time at our patients' bedsides, examining them (because only the exam can tell you if there is pain and if it's better than yesterday, and they seem more or less anxious today), learning who exactly they are, getting to understand what they want and most importantly listening to what they can tell us about their body, has helped make sense of confusing test results and contradictory stories piling up in the computer (and they pile up thanks to the cut-and-paste function which perpetuates misinformation).
So, in response to my brilliant student who is performing at the very highest level but who asked me this morning how he might get even better on the wards, I quoted Herbert Adam's words --poverty of attention-- which is going to be my new mantra, and I unveiled my Special Theory of Attentivity:
I suggested to him that Ac and Ap should at least be equal; preferably we should err to much more of Ap--time at the bedside. I suggested that he try to meet the patient in the flesh first before he shook hands with the patient's data; I suggested he work on getting as much as he can from listening to the patient, from sounding the body and only then turn to the computer. It's the opposite of how we now do things. I told him he might be humbled by what the records will show him he has missed, and he might be proud of what he has found that is not in the record or is wrong in the record.
I hope he'll find that his interaction with the patient will feel different, truly new because he will approach them without bias or labels.
Let's see what he reports. I have no doubt we will both learn something.
A newsletter from our Stanford medical school library reminds me that fifteen years ago, if I wanted to get the latest scoop on a disease, I'd have had to walk through the stacks where our library displayed the 3,600 journal titles its owns. Then, once I collected the bound volumes containing the articles I wanted, it was off to the photocopier area. An hour later (provided my coins and the machine lasted), I'd be done.
These days, my medical library (fittingly called the Lane Medical Library and Knowledge Management Center) has 6,500 journal titles available on line, along with 8,150 eBooks and 680 databases. Since this virtual library never closes, I can 'walk' through the stacks at three in the morning.
This ease of access characterizes so many aspects of medical practice: I can access x-ray images of my patients from any computer; I can write my progress note in the patient's chart from wherever I am, even from home, because we use an electronic medical record and not a paper chart.
Progress is great! Who wants to go back to the old ways of hunting in the file room in radiology for an x-ray image, only to find someone checked it out for a conference and didn't return it. No more hunting for the right image in a thick manila folder in which the films are out of order.
But . . . I find I do miss visiting my colleagues in their dark dens, their lairs in the radiology department; similarly, I miss the camaraderie of seeing and interacting with colleagues from other disciplines as we congregate around the chart rack at the nurses' station; I miss the serendipity of running into a student in the library. I miss the hush of the stacks, the miasma that speaks of old books and collected wisdom, and how so often it was the book parked next to the book I had come to find that turned out to be the real treasure. Will I ever make that kind of discovery in a virtual library?
Abraham Verghese
