Recently my 97 year old father was readmitted to his local hospital in North Carolina with another episode of CHF and aspiration pneumonia. He was discharged to the rehab facility at his life care community on a Monday. My sister from Birmingham drove over and spent most of the week visiting with him and relieving his wife who really needed a break, and then my wife and I arrived on Saturday to give the whole operation the “Good Housekeeping Seal of Approval.”
I was surprised to see that he looked better than he had looked to me when I had last seen him in March, when my sibs and I gathered, as we do every year on our mother’s birthday. See died five years ago, two months short of 94. My sibs and I are delighted that both of our parents have had very long lives and have maintained exceptional intellectual function even as their strength declined. Clean living and an active life lifestyle are good operational strategies. Pacemakers, angioplasties, timely surgery, good meds for hypertension and hypercholesterolemia, and virtually free access to more than adequate care have also helped extend their years substantially beyond what their parents enjoyed. I like the trend and hope it continues!
Despite the fact that I spent many hours with Dad, I could sense that we were not talking about the right things. Our talk remained somewhat superficial and about the nuts and bolts of his rehab. I assumed his improvement was due to a combination of better PT, an increase in his diuretic dose, and an increase in protein in his G tube feedings since I had seen him. I must admit that I had been apprehensive that our dream of a family reunion on Father’s Day was in jeopardy. He has four children, thirteen grandchildren children with eleven spouses, and seventeen great grandchildren, and that does not include my brother’s new wife who also has a son and two grandchildren or my father’s new wife who has a son, two granddaughters and two great grandchildren. It is a big family and most of us are coming to see him on the Father’s Day weekend. The hotel rooms are reserved, the airline tickets have been purchased and the catering has been set. I spent most of the time in a self serving presentation of all he had to motivate his attention to his rehab. He has only seen my two grandsons who live in California in pictures and on video. Let’s push that walker down the hall one more time.
Back in New Hampshire it is my routine to call several times a week. I can follow his progress on line when he is in the hospital by reading labs, imaging studies, and the doctor’s notes online through Carolinas Health’s wonderful web portal. When he is in rehab I am cut off from that day to day opportunity and must depend on second hand information.
Last weekend during one of our calls I was surprised by a comment and a request from him. He said, “I don’t know what has happened to me. I don’t understand what is wrong. Will you write me a letter that describes what my problems are?” I promised to do it. That was when I began to think back over all my years of practice and ask myself how often had I failed to give patients what they needed to know. What were the barriers to meaningful dialog? Over the last ten years have doctors and nurses been enabled to do a better job informing their patients than we did before I moved from seeing patients ten or twelve hours a day to leading an organization?
In retrospect I was not surprised by his request. He had led complex organizations during his professional life. He had always paid great attention to the details of what he managed. The more complex the situation the more information he wanted. Long ago he had told me that I should always remember that most people were smart enough to understand anything that you could take the time to explain. I wondered how many medical professionals have the time and the support to be an adequate “explainer” for either their patients or their patients’ families.
As I wrote my letter to Dad, I remembered many times when at the end of an appointment when I thought my work was done and my hand was on the doorknob, my patient had said, “Oh Dr. Lindsey before you go may I ask you one more question?” That is when the appointment really began.
I think that through the first 15 or twenty years of my career as I “practiced” practicing medicine I did get continuously better at what I did. I became increasingly confident in my fund of knowledge, my ability to get to the important issues more efficiently so that there were fewer times when the appointment really began when I thought it was over. The last fifteen or twenty years of practice were a slow downhill slide. By then our organization was no longer able to shield its clinicians from the realities of external financial pressures. By then I was no longer trying to be a more effective doctor. I was trying to learn how to be a more efficient typist.
It was the sense that my “joy in practice” was slip sliding away that made me an organizational activist. I soon realized that I was being asked to construct my medical records more to facilitate finance than the delivery of care. It was a shame because it was clear that there was much to be gained from an effective electronic medical record. We had worked with a very effective, albeit rudimentary, electronic record since 1969. The difference was inputting information that would justify a billing code versus creating a note that would be of use to guide a subsequent visit with me or a colleague. The goal was more the transfer of resources from a payer to our practice than a transfer of useful clinical information. There is no reason that the two objectives must be mutually exclusive, but in the real world they seem to be at increasing odds. Even of more importance, than the creation of understanding within the medical record that I value so much, could it be that the focus on finance is at the expense of the more important exchange of information and understanding between the clinician and the patient and family? Was my father’s lack of understanding due to a cognitive problem he had, or an inputting burden that the hospitalists that he has seen over his recent admissions had? How much of the issue of his readmission been a function of the quality of his interactions with the staff in the hospital? To paraphrase him, I know from personal experience with him that he can understand anything that someone will take the time to explain.
Recently an interested reader and former colleague sent me a Wall Street Journal article about using AI to guide conversations with terminally ill patients. I do not have a subscription to the WSJ so I was very happy to get the PDF from him. As I was reading the article I noticed that in the same series there was an article by Robert Wachter, Professor of Medicine, inventor of the concept of “hospitalist” and the author of The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age (2015). I had heard him speak at the IHI Orlando meeting a few years ago and was curious to read his current thoughts. My friend sent the article to me. There is great insight and hope in the article, “How Tech Has Undermined—and May Now Save—the Doctor-Patient Relationship.” [Do not bother to click on the link unless you have a WSJ account.] Wachter writes well and the first sentence grabs any one who has ever struggled with the computer in the care of the patient:
The physician’s note has become an unlikely battleground for the soul of medicine. Once a narrative of the patient’s clinical symptoms, the note has been transformed into a bloodless and bureaucratic box-checking exercise whose goal is often to maximize reimbursement and provide a highly flawed window into “quality of care.”
Above the article is a very colorful picture drawn by a seven year old. It depicts a visit to the doctor. They say a picture is worth a thousand words but Wachter gets key points of the message in many fewer words:
This picture, drawn by a 7-year old after a visit to her pediatrician (and later published in the Journal of the American Medical Association), beautifully captures today’s predicament. The doctor, his back to the patient, is tapping away on the keyboard, while the patient, her mother and her sister are left to wonder whether the doctor is even aware that they are in the room. The picture is extraordinarily accurate but for one little detail: the smile on the doctor’s face. Studies have shown skyrocketing rates of physician burnout, and doctors place much of the blame on their computers.
[You can see the picture if you click on the JAMA link.]
Wachter estimates that the average physician spends 45% of his or her time just inputting information. I frequently write about innovation. Wachter holds out the idea that technology created the problem and that technology may produce the innovations that solve the problem. I hope that he is right, but I think there is a more fundamental questions that we are not facing that will be even more important to consider. What do we really want our doctors and nurses doing? What is the value added that a physician who has spent four years in medical school and anywhere from four to six years in subsequent training brings to a medical encounter? I do not think it is to efficiently generate a bill that a third party will pay.
I wish that one of my Dad’s providers had spent the time with him that was necessary to help him understand what was really wrong, what could be done, and what his choices were. By his algorithm that responsibility lies with “the explainer.” His assumption is correct. It’s not that we are not smart enough to inform our patients, it is that we have not been smart enough to structure our work flows and teams in a fashion that carves out or creates the time to do our job the way our patients imagine that we can.
I am not railing against computers. I love computers. I did finally learn to type. I type thousands of words. The problem that I was trying to solve in the last decade of my professional life was the creation of a work environment that supported the practice in a way that properly supported the best aspects of practice. It was that concept that made me an advocate of looking at practice from a systems perspective. It was that concept that made me an advocate for team based care and value based financial systems. It was that concept that caused me to embrace effective innovation. It was that concept that makes me so excited about the possibilities of AI and other technical innovations. I believe in the Triple Aim. I am also a realist. The care people want and the care people want to provide cannot be delivered with our backs to the patient while we vigorously document an L4 visit.
I think that in time innovation and systems engineering will deliver new workflows and processes of care that will benefit patients, families, and the providers who are working hard to help them. In the interim I know that many clinicians will be stressed and exhausted in ways that will “burnout” some of them even as their patients have unanswered questions. Not every patient has a famaily member who was once a caregiver and can answer their questions.
