I’ve been taking care of a particular patient for more than 20 years. She first came to see me after suffering a stroke, which severely weakened her right side. She has always arrived in my office in her wheelchair. She has diabetes, which I manage, as well as a heart condition. I’ve treated her through several urinary and skin infections. I also manage her blood pressure, but mostly I hold her hand and smile and look into her eyes. We talk about our families. She has many grown children, and she has always maintained an active interest in my growing children and remembers their birthdays.
Recently, as she has gotten older and sicker—she is now approaching 90—she has required more frequent hospitalizations and her medical problems have grown more complex. Her family expects me to be responsive to their concerns for every decline in her health. Unfortunately, her decline is taking place at a time when much of health care is delivered semi-automatically without a human face attached. The new technology may even keep her alive longer, but her family is not used to the change. They say it was the frequent face-to-face interactions and instructive phone calls with me that always gave her the confidence to follow my recommendations.
But these days my time is so consumed with computer management that I find I have less time for direct patient care. Patient expectations haven’t changed, but there is less time available now to seek the undercurrent of illness rather than focusing on the “chief complaint” that rides the surface.
The sea change in how health care is delivered is being implemented at the very beginning of a doctor’s training. A 2013 study published in the Journal of General Internal Medicine showed that interns spend 40 percent of their time at the computer and only 12 percent involved in direct patient care.
Another elderly patient of mine has developed widespread lung cancer. I continue to call him often, learning the lesson provided by my wheelchair patient. I cling to the art of medicine and the personal closeness I feel to this patient, who is also a long-term friend. But despite the closeness that reassures both of us, he tells me that his life has become a string of doctor’s visits, tests and treatments. He praises the quality and exact precision of the testing and treatment, but laments the loss of the more humane, less pressured doctor-patient interaction of an earlier time. There was less to offer then, but we had a better way to offer it.
It has always been true that the older and the sicker a patient becomes the more crucial the doctor-patient relationship and the more important the communication with family members. Unfortunately, the increasing fragmentation and growing red tape of health care is getting in the way of this basic communication.
With Medicare on the verge of approving payment to doctors for end-of-life discussions, I can’t help but wonder exactly when and where these discussions will take place. Don’t get me wrong, it is as crucial as ever for a doctor to know under exactly what circumstances a patient wants to be placed on a respirator or have someone pound on their chest or shock them with electricity if their heart stops. But it is harder and harder to find the time for such a dedicated conversation. The wheels of health are turning ever forward, in constant step with technical progress and the implementation of exciting new discoveries.
Medicare is moored in the nostalgic past, in a time when an ineffable rapport with our patients was the most important thing we had. We need to find a better way to preserve that relationship. Simply asserting its importance isn’t enough.
Dr. Marc Siegel is a professor of medicine and medical director of Doctor Radio at NYU Langone Medical Center. He is a Fox News medical correspondent.