Tuesday, June 01, 2010

The Risks of Remote-Controlled Medicine

"It is more important to know what sort of person has a disease than to know what sort of disease a person has."
- Hippocrates
Increasingly our Western world culture assumes that most things in medicine can be reduced in to a linear, data-driven, algorithmic processes. One only needs to witness the now-famously heralded article on ICU check-lists to understand the unwavering trust we have in this model. ICU medicine's complexity reinforces our trust in this approach because patients are usually too sick to contribute to their care. While there, intensivists resort to their Fourier transform of all things living, parsing our patient's life into the various frequency spectra of their organ systems. With careful tuning of these harmonics, more often than not the patient survives. And we deem this good. So good, in fact, that the notion of a predictability to medicine has spawned the development of remote controlled ICU's and even robots to replace doctors.

Yet when we consider medicine nothing more than a rational, scientific, transactional exchange between the doctor and patient we become limited. Such interactions miss medicine's sacred, intimate and intensely human, non-linear aspects. After all, people do not travel long distances to see a specialist who merely reads algorithms. Instead, they travel long distances to see highly experienced doctor who takes huge, intuitive, and often illogical leaps. The level of presence required to hear a patient on this level of broad critical thinking is not supported by quotas, checklists, little sleep, and multiple back-to-back seven-minute appointments.

Doctors and their patients are clearly sensing this shift to the omnibus, bean-counter, centralized approach to medicine. For a myriad of seemingly well-intentioned reasons, concern for the patient has shifted to concern for documentation. We see independent thought giving way to guidelines and treatment protocols. Whether these protocols really reduce errors remains to be seen, but we already see the consequences of these processes as patients say privately, "doctors don't care anymore." We should ask ourselves when they say this, are they talking about a lack of their doctor's social graces or a potentially life-threatening disconnection? In fact, if medicine is such a formulaic service-delivery model, then the natural consequence of this rote health care model implies that all doctor shift changes are risk-free and doctors are simply replaceable, rotatable and expendable.

Yet doctors offer little to correct this shifting perception. We console ourselves that centralized certification bodies will assure the maintenance of core health care delivery competencies, but do so at the expense maintaining a yearning for excellence. The results are telling. In the march toward the mirage of error-free adequacy, doctors are being worn down by the emotional withdrawal from their patients. Burnout is common. The loss of emotional connection is not what our most altruistic, bright medical students sign up for when they enter medical school. Will it be okay if our young doctors no longer see the intangible, emotional contact with patients as a necessary prerequisite for providing health care?

Humans are a study in contradictions. We yearn for the thousand points of light only to find, more often than not, they leave us in the dark. We crave the impersonal, the predictable, and the controllable. We cling to the magical thinking that if we just do what we're supposed to, eat right, exercise, and walk the proper line we'll be fine even though each of us acknowledges, eventually, our own mortality. We want the government to provide our health care, yet realize they will never return our calls. We love the glitz, the shiney, the whizbang, but first, we want to talk to the doctor.

Both doctors and patients still want and need these intangibles in medicine. Yet more and more forces threaten to dissolve them. With each new mandate, each new checklist, each new certificate, each new order set, each new performance measure, each new computer screen, we risk chipping away at this critical cornerstone of medicine. Worse, we risk losing our best and brightest in medicine in favor of nothing more than our best remote-controlled, linear, and logical promises.



Bryan Vartabedian said...

Wes, you are describing the marginalization of the MD. A process facilitated by medical technology, health 2.0 and the institutionalization/centralization of health care. Nice post.

Keith said...


You are so right! There is something to actually seeing patients face to face that in itself may be therapeutic; seeing someone who has been raised to an elevation in society by virtue of their degree and training that gives people hope. It is on the level of seeing the witch doctor or medicine man of the village where many of the treatments may or may not have validity, but it somehow make people feel better. Often it may be nothing more than relieving the anxiety that the patient is fearful of some horrible medical condition, but this human interaction is being slowly degraded by a reimbursement system that has put prime emphasis on the technology. It is why patients think doctors don't care for them or about them. Too often I see doctors who feel their job is done when the procedure or test is completed. They may have solved the patients problem in all circumstances and returned them to good health, but they need to move on to the next procedure like it is part of an assembly line. This is what I think is often lost to doctors in specialty medicine where they do not have the ongoing attachement to the patient that grows over time (nor does the patient to the doctor). And of course it is the fields of medicine that do not require this ongoing responsibility that seem to be most desireable to our new physicians; they want the 8 hour shift where they can go home and not be bothered at the end of the day. But you and I know this is not medicine. This is more of a technician who does his one procedure or test and is done for the day.

If physicians are burning out, it is because they no longer have these relationships with their patients to sustain them through the long hours. They need to get back to practicing medicine and not just performing some procedure or test on a patient they will likely never see again. Even in th eprimary care fields, it will be necessary to extend the time we spend with patients to truley get to know and understand their problems. Otherwise, we cannot do the task justice and our patient s will realize (they probably already do) that we are simply moving meat through our busy offices.

Anonymous said...

These faceless bodies, these bringers of new checklists, mandates certifications, technology and all of which seek to drive a wedge between the patient are so removed from the "bedside" (using it as a general term)that they have forgotten the basic human interaction that drives medicine. Nurses get wrapped up into this spiral as well, meds, checklists,. charting, technical tasky stuff that we don't take the time to interact on a human level. I've learned so much from my patients that other nurses have missed, things that could make a difference to their treatment because of this. We get so wrapped up in the tasky technical side of medicine that we forget why we're there. It's bad when the docs can't do this, but when it trickles to the nurses it's just sad.

#1 Dinosaur said...

This was really beautiful. Thanks for writing it.

DrJohnM said...

"That's what I'm talking about." Blogging 401. Bravo!!

This is exactly how masters of the obvious feel when non-masters insert themselves into the delivery of medical care.


Phil said...

Try Verghese on TED for another angle....