The evolution of the “doctor visit”

Years and years ago, I wrote a novel called The House of God, based largely on my experiences as an intern at what was then known as Beth Israel Hospital in Boston. At its core, the book was about the injustice in medical training.

A lot has changed in medicine in the ensuing 40-plus years, not all of it for the good. In fact, all of us — doctors, nurses, patients, hospitals — are in the mess called American Health Care. As Roy Basch, the narrator of Man’s 4th Best Ho$pital, the just-published sequel to The House of God, says, “I am called to write this about a time when medicine can go one of two ways, either toward more humane care, or toward money and screens — which is money and money.”

Toward the end of the new book, I sum up what I’ve learned about the way medicine has changed.

In the past, way back before the screens, what was a good patient visit?

Your doctor greeted you, sat and talked with you — chief complaint, history — then asked you to undress behind a curtain for the physical. During this, he or she wrote up what was learned so far. Then the physical. While you were dressing, he did what is now strange: he paused. He sat there and did nothing, as much nothing as possible — except he: Considered. Mused. Sensed. Intuited. Put it all together. Came to a vision of what was wrong and how he might right it, and if not, how he can be with you in caring for you in your illness, no matter what. He integrated. When you returned he faced you and said, “Let’s go over what I found, and see what we can do about it.”

Computer screens prevent us doing that. Machines never pause. Never have cause, to pause.

Screens iterate. Doctors integrate.

Now, your visit to your doctor has become satire.

You walk in—lucky if you get eye-contact—and sit across the desk. Your doctor is trapped, hunched behind a computer screen, back or shoulder to you. The doc asks a question, you answer, the keyboard goes ‘click-click’-de-‘CLICK!’ faster and faster. On and on it goes, and you find yourself in The Patient’s Dilemma: Do I keep talking, or wait for a break in the action—usually the next question. Is he or she still listening, or not? The new definition of “A good doctor?” One who can contort his or her body to touch-type while still making eye-contact.

As you keep waiting, two questions may enter your mind:

What is your doctor doing?

What you don’t know is that your doctor is sitting there in front of that screen seething, because she is forced to sit in front of a screen seething, instead of what she wants to do, to talk and listen and be your doctor. She spends 60 percent of every workday — at least six hours — in front of that screen, more time than with patients. Family doctors spend an additional three hours at night at home during “pajama time,” digging out from under the pile-up in the screen. This is The Doctor’s Dilemma.

Why is he or she doing this?

You might think she’s doing this because it will be better for your health care. It may not. It may be worse. Worse for your care and — for sure — worse for the care of your doctor. It is only better for the money, the health care industry. The screens weren’t primarily designed for care, but for billing. To make as much money as possible. Doctors are caught in this mess. We’re not treating the patient; we’re treating the screen.

It’s not that your doctor wants to turn his or her back on you.

It’s the health care industry that has turned its back, on both you and your doctor.

How can we put the human back into the everyday doctor visit?

There is a frenzy of trying to use technology to re-establish the healing human connection in the doctor-patient interaction. These efforts range from advanced transcription of voice-to-record, scribes who do the data recording during a patient encounter, and so on. The IT department at NYU Grossman Medical School, where I teach, worked with the dominant and much-loathed electronic medical record to create a patient-focused dashboard for each doctor. The dashboard both improved quality of outcomes and reduced costs.

These attempts are useful, but they don’t address the root cause of this inhuman encounter: billing, the link of patient data to cash. In each of these tech improvements, the doctor is still forced by the money-people to massage the bill for the highest private insurance payments. There is a war across the screen — and like all wars, it’s about money. On one side, doctors are forced by the accountants to bill the most. On the other side, insurance people are striving to pay the least. No “program” or “bot” could do this job. It’s trapping doctors in the epidemic called burnout, moral injury, or just plain abuse. Forcing us to lie, to provide maximum payment. So long Hippocratic Oath.

I think the solution is obvious. Why are VA hospitals’ electronic medical record systems widely preferred to any of the other ones out there? Because they are not-for-profit billing machines. All across the U.S., each VA diagnosis and treatment has approximately the same reimbursement. No war across the screen. No Hippocratic hypocrisy.

Some kind of single-payer national health care system is inevitable. (Imagine the coordinated response against Covid-19 if it had been in place.) Private insurance — more heavily regulated — could still survive alongside, as in supplemental Medicare and in most other countries.

In Man’s 4th Best Hospital, the legendary Fat Man has brought together The House of God gang to staff a public clinic leaning up against the gigantic hospital. His goal? “To put the human back in medicine.” His solution for doing that?

“Squeeze the money out of the machines.”

Samuel Shem is the author of the House of God and Man’s 4th Best Hospital.

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