Portal de Periódicos da CAPES

Patient Versus Customer, Technology Versus Touch: Where Has Humanism Gone?

2008; Elsevier BV; Volume: 85; Issue: 5 Linguagem: Inglês

10.1016/j.athoracsur.2008.02.053

1552-6259

Carolyn E. Reed,

Pharmaceutical industry and healthcare

We practice medicine today in an environment of amazing and ever changing technology, in a sea of pharmaceuticals, and in a system that is money and customer driven. Computerized databases and sophisticated images dominate our practices and allow us to make decisions from remote locations. It is difficult to fathom how we would function in a medical world devoid of the tools, “toys,” and treatments of today. Yet, prior to the 20th century, the physician's most powerful and oldest “instrument” was the laying on of hands. Often little else could be done except this simple act of compassion. In fact, the laying on of the hand developed into a scientific skill and became an important diagnostic tool. Feeling the pulse, palpating the abdomen, and percussing the chest were skills honed over time. They not only helped in the formulation of a diagnosis, the patient and the doctor were connected by touch. How could humanism become separated from medicine? Webster's dictionary defines humanism as “a doctrine, attitude, or way of life centered on human interests and values” [1Merriman-Webster's dictionary. 11th ed. Merriman-Webster, Inc, Springfield, MA2005: 605Google Scholar]. Is not medicine centered on the patient, a human being who is ill? Unfortunately, there are forces that conspire against humanism. Many of these forces are not physician driven, but we have succumbed to them, and by our acquiescence we shape the next generation of doctors. In the book, “Money-Driven Medicine,” author Maggie Mahar [2Mahar M. Money-driven medicine. Harper Collins, New York, NY2006Google Scholar] details the road to corporate medicine that results in increasing costs, less efficient and unnecessary or inferior health care, which intensifies the rivalry between doctors, hospitals, insurers, drug makers, and device makers. This book is worthy of your consideration. In the corporate model of health care, the patient is a customer and the physician is a retailer. The doctor can not be the patient's advocate and may almost become an adversary. He or she must see a certain number of patients in set time slots, brush off questions that will be too time consuming, and keep an eye on the bottom profit line. Corporate medicine fosters the 9-to-5 job mentality. In a Time magazine feature story, “What Doctors Hate About Hospitals,” several physicians tell revealing and scary stories about themselves or family members becoming the patient [3Gibbs N. Bower A. Q: what scares doctors? A: being the patient.Time. 2006; (May 1): 42-52PubMed Google Scholar]. Their stories highlight fragmented care, lack of communication, and the frequency of mistakes. In a heart-rending story about his wife, one doctor in a Time magazine article reported how data were misread, tests were unnecessarily repeated, and information was misplaced because of lack of communication and continuity [3Gibbs N. Bower A. Q: what scares doctors? A: being the patient.Time. 2006; (May 1): 42-52PubMed Google Scholar]. Everyday mistakes, although most not life-threatening, were common. In addition, this was in a premier medical institution! Personally, when a patient's family member now asks me if it would be advantageous for him or her to stay with the patient postoperatively, I say “yes.” The 80-hour workweek is an example of a laudable concern regarding resident stress, fatigue-related error, and decreased morale. It certainly addresses a major concern of surgical residents today desiring an alternative lifestyle. In a recent survey of surgical residents, two-thirds of the respondents wished to work 60 hours or less per week as attending surgeons [4Breen E. Irani J. Mello M.M. Whang E.E. Zinner M.J. Ashley S.W. The future of surgery: today's residents speak.Curr Surg. 2005; 62: 543-546Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. However, a consequence of the 80-hour workweek is a decrease in continuity of care and an inevitable rise in shift mentality. In a survey conducted in 2004, 70% of surgical residents perceived decrements in continuity of care, and 43% felt that quality of care had deteriorated [5Irani J. Mello M.M. Ashley S.W. Whang E.E. Zinner M.J. Breen E. Surgical residents perceptions of the effects of the ACGME duty hour requirements 1 year after implementation.Surgery. 2005; 138: 246-253Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar]. In a closed claim study conducted by the American College of Surgeons, 20% of claims were filed largely, if not entirely, because of failure of communication [6Griffen E.D. Critical failures to communicate.Bull Am Coll Surg. 2007; 92: 11-16PubMed Google Scholar]. We must become better internal and external communicators. If we do not teach our residents how to listen, we have not taught them how to communicate. In the corporate medicine model, the health care shopper “Googles” the web, checks the score cards, chooses his expert, and even elects his procedure. Yet, the problem is that the customer is not well suited to be his own physician. Consumer-driven medicine overlooks the uncertainty of our profession; it overlooks the art. Even the very best of doctors are practicing an infant science in what Dr Casell [7Cassell E.J. The changing concept of the ideal physician.Daedalus. 1986; 115: 185-208PubMed Google Scholar] calls a “sea of doubt and uncertainty.” Cassel [7Cassell E.J. The changing concept of the ideal physician.Daedalus. 1986; 115: 185-208PubMed Google Scholar] stated, “Judgment must inevitably be made on the doctor's personal experience of past cases, the comparison of the present size, sound, or feeling of something with what is remembered, and on what a clinician believes to be the problem, based sometimes on very scanty evidence.” Dr Gawande [8Gawande A. Complications. Picador, New York, NY2002Google Scholar] echoes that the predicament of medicine is uncertainty. Gawande [8Gawande A. Complications. Picador, New York, NY2002Google Scholar] stated, “As a doctor, you come to find that the struggle of medicine is more often with what you do not know than what you do. Medicine's ground state is uncertainty. And wisdom—for patients and doctors—is defined by how one copes with it.” It actually surprised me to reach the end of Mahar's [2Mahar M. Money-driven medicine. Harper Collins, New York, NY2006Google Scholar] book and read her words about the need to empower the physician. I have been concerned about physician's ceding their power to the medical corporate CEOs and executive nurses. What Mahar [2Mahar M. Money-driven medicine. Harper Collins, New York, NY2006Google Scholar] says on page 343 is that the consumer movement seems to ignore that “before patients can reclaim their rightful place as the center—and indeed the raison d'être—of our health care system, we must again empower doctors. Physicians must be free to practice patient-centered medicine—based not on corporate imperatives, doctor's druthers, or even patients' demand, but on what scientific evidence” and experience suggest would be in the best interests of the patients. In other words, society needs to recognize doctors as professionals.” Medical care is not a commodity. Kenneth Arrow [9Arrow K. Reflections on the reflections.in: Hammer P.J. Haas-Wilson D. Peterson M.A. Sage W.M. Kenneth Arrow and the Changing Economics of Health Care. Duke University Press, Durham, NC2003Google Scholar], the father of health care economics, said everything comes back to trust. The physician's power lies with what Arrow [9Arrow K. Reflections on the reflections.in: Hammer P.J. Haas-Wilson D. Peterson M.A. Sage W.M. Kenneth Arrow and the Changing Economics of Health Care. Duke University Press, Durham, NC2003Google Scholar] calls his “moral authority—authority grounded in the belief that, as a professional, he will put his patients' interests first.” The corporatization of medicine, sophisticated technology, and the rise of specialization have all added to looking at the patient as a disease or a fragmented body part. Gone is the remarkable diagnostician who by taking a careful history and using his or her hands can tell you what is wrong with a patient 75% to 80% of the time. More diagnoses are missed by not listening and looking than not knowing. In this age of doing more, and in less time, apportioning care in fixed units and tracking efficiency, the interaction with the patient is often the first to suffer. Observers have noted that on average, physicians interrupt patients within 18 seconds of when they begin telling their story [10Goodman J. How doctors think. Houghton Mifflin, Boston, MA2007Google Scholar]. Surgeons may be the worst offenders. We all know that feeling of frustration as a patient in a 15-minute time slot begins to ramble about what seems to you is extraneous, or worse, pulls out a sheet of paper with 20 typed questions. Yet, how we initially ask questions, respond to a patient's emotions, whether we allow him or her to freely participate in a dialogue, will often result in the provision of vital information and help us in future interactions. I tell my residents that the time spent up front with the patient and the family will pay huge dividends later when perhaps the operation does not go well, when complications occur, or when we really do have to cut a visit short because there is an urgent need to be elsewhere. The fact that you have established an initial rapport, a connection, a two-way dialogue that shows the patient you are an individual who cares about another individual allows much leeway as the patient's treatment unfolds. Americans are enamored with technology, and medicine is no exception. There is that belief that the most sophisticated instruments will make an earlier diagnosis leading to a cure, that the latest drug or device will short circuit the disease process, and that better technology equals certainty. Surely, a sharper image or a more comprehensive battery of laboratory tests is better than a confusing and rambling patient history; in fact, this may be true a good deal of the time, but reliance on technology has made us forget the simple things. Technology has supplanted listening and talking with a patient for a growing number of doctors. It is repeated daily on morning rounds as the medical student recites the lab values, the inputs and outputs, and results of imaging while patients receive a fleeting flash of the lights before the team has moved on. Society places a much higher premium on technology than on listening or counseling. Time spent in an operating room or performing an invasive procedure is rewarded 10-fold more than conversing with patients and family. Does not a patient come to a surgeon for a procedure? However, high technology does not necessarily equate to better care. In fact, when it brings little benefit, it may actually distract health care workers from doing what they know works or at least palliates. Dr Wennberg, Director of the Center for the Evaluative Sciences at Darmouth Medical School, told author Mahar (page 159) that up to one-third of our health care dollars are squandered on ineffective, sometimes unwanted and often unproven procedures—more than $65 billion lost to over treatment. Wennberg states: “And much of that waste can be traced to a hospital culture where technology and training support a reimbursement system that favors intervention over what some call ‘thinking medicine’ (ie, talking to and listening to the patient” [2Mahar M. Money-driven medicine. Harper Collins, New York, NY2006Google Scholar].) We pride ourselves in practicing medicine in the most highly technological country in the world. We spend 40% more dollars per capita on health care than the next most expensive nation. Yet, it has not produced the best medical care or anywhere near the top health status. In a study published in 2004, quality of care was measured using 24 yardsticks of effective care developed by the Medicare Quality Improvement Organization and was compared with the annual Medicare spending per beneficiary. The study found an apparent inverse relationship between expensive care and low-tech effective care [11Baicker K. Chandra A. Medicare spending, the physician workforce, and beneficiaries' quality of care (web exclusive).Health Aff. 2004; (April 7, Available at: http://content.healthaffairs.org/webexclusives.)Google Scholar]. The notion that harm may occur from increased technology has received little attention. The concept is explored in an article published in The Journal of the American Medical Association (JAMA) in 1999 [12Fisher E.S. Welch H.G. Avoiding the unintended consequences of growth in medical care.JAMA. 1999; 281: 446-453Crossref PubMed Scopus (233) Google Scholar]. More medical care may be introduced at the level of diagnostics and treatments or at the level of adding to the system capacity. More diagnostics may lead to labeling and pseudo-disease. More treatment may lead to lower treatment thresholds. If people are treated for inconsequential disease, the risks will exceed the benefit, and if patients with a poor prognosis, regardless of therapy, undergo persistent treatment, quality of life and harm may ensue. Of course, more to do creates greater physician distraction (missing the “forest for the trees”). Nowhere does patient (not customer) orientation and touch (not technology) play a more important role than in caring for the dying individual. As a thoracic cancer surgeon, I face the fact that I “lose” more often that I “win” against the disease. But I do not lose if I can in some small way humanize death. It is a fact that approximately 80% of all Americans hope to die at home, but 75% end their lives in hospitals or nursing homes in seclusion, away from their own beds and away from their loved ones. Of these Americans, one-third die after 10 days in an intensive care unit. Medicare dispenses roughly one quarter of its dollars in the final year of a patient's life. To realize when further care or treatment is futile, when attention should be turned to the family who will be left to cope after the patient is gone, and when dignity is more important than one more insult to the failing body, is not easy; it is clearly more an art than a science. It is when touch and presence are needed. You can fail at winning the battle but still be a healer. Listen to the words of the essayist Anatole Broyard [13Broyard A. New York Times Magazine.1990Google Scholar], shortly before his death from prostate cancer: “I wouldn't demand a lot of my doctor's time. I just wish he would brood on my situation for perhaps five minutes, that he would give me his whole mind just once, be bonded with me for a brief space, survey my soul as well as my flesh to get at my illness, for each man is ill in his own way . . . Just as he orders blood tests and bone scans of my body, I'd like my doctor to scan me, to grope for my spirit as well as my prostate. Without some such recognition, I am nothing but my illness.” It is much easier to order a test, balance the blood chemistries, and add a drug than to minister to the soul. Yet the surgeon is in the unique position to do just that by restoring humanism. Nobody would want to give up the advances and benefits of technology—the 64-slice computed tomographic (CT) scanner, the positron-emission tomographic (PET) scanner, the left ventricular assist devices (LVADs), and so forth. However, advanced technology does not equal certainty. As with all advanced diagnostic tools, critical information can be missed, the data can be misinterpreted. False positives become more frequent. It is the very uncertainty of medicine that keeps “one on his toes.” That uncertainty can often be gut-wrenching and intimidating, yet stimulating. I tell residents that just as you begin to feel a bit complacent, a patient or procedure is waiting around the corner to humble you. As Dr Lown [14Lown B. The Lost Art of Healing.in: Random House, New York, NY1999: 119-120Google Scholar] in “The Lost Art of Healing” states, “Effective patient management requires appreciation of the art of healing, in which one is guided by experience, by the recall of a similar case, and by the exercise of common sense. A sense of humility, too, is an asset, for any prescription or advice has a substantial measure of conjecture . . . A doctor confronts a single, singular individual. There is never any certainty as to where the individual fits in the normal statistical distribution curve. Statistics may present probabilistic truth, but they shroud souls and obscure individuality” [14Lown B. The Lost Art of Healing.in: Random House, New York, NY1999: 119-120Google Scholar]. How can we make sure that humanism is not lost? I think we can do a number of things. We can start by cultivating in ourselves and in our residents the art of listening and touching, fundamental elements in the doctor–patient relationship, which is critical to the integrity of the health care system. Patients crave somebody who will listen. This skill is best cultivated by exposing our residents to the clinic where the patient has a story to tell; where inattentiveness or worse, indifference, will be quickly discerned by the patient and the doctor will be shut out. We must involve the residents in end-of-life situations. We must teach them that sometimes it is alright to let go. Dignity in dying may be our greatest gift to the patient. Humanism incorporates the notion of error. We will make mistakes. We must admit them, study them, learn from them, and not let error paralyze us. I believe too often we hide our emotion. I have promised myself that the day I no longer walk out of the hospital with tears in my eyes after the loss of a patient will be the day I quit medicine. I would suggest that the residents and young surgeons in the audience build a “shoebox” as I have done. Over the years, I have added notes sent to me by patients and families to this box. At times of discouragement or fatigue, I only have to open the box, reach for some notes, and quickly discover that I have touched lives in a way no other profession can. Let me share a few notes from my shoebox with you: From the wife of a patient who underwent an esophagectomy:“Thanks for saving Jimmy's life on March 28th, 2005. We will never forget that date or the ensuing two-year journey. He survived the operation because of your skill as a surgeon. He lived because you never gave up!”From a relative of a patient with an unresectable cancer:“Thank you so much for reviewing and seeing my father-in-law. He really appreciated you taking the time to review his case with him. No other physician had taken the time to sit and explain everything to him. Watching you talk with him made me realize what a true gift you have for dealing with people with cancer. Your compassion and honesty showed through . . .”From a patient who survived one cancer only to later succumb to a second:“I will always be grateful to you for your kindness and being an excellent surgeon. I will always value your friendship. May you always have good health, happiness, and joy always.” We must provide better continuity of care. This is clearly more difficult with the 80-hour work week and a myriad of physician extenders. But safety is threatened by lack of communication and seeing the patient as a body part or a single disease. There is no easy fix for this problem of fragmentation. A universal electronic record will help by keeping all encounters in one accessible place, avoiding repeat tests and procedures, and decreasing medication errors. However, I fear that reducing the history and physical to checked boxes and drop-down screens will depersonalize the patient. The secret to continuity of care will be more communication and a true team approach. Continuity of care will also be increased if our residents do not think of the patient as an operation. The surgical procedure is only one event, although often highly an important one, in the continuum of their disease management. We should be pilots of cardiothoracic disease, not mechanics. We have to realize when technology is a hindrance, not a help. Tests, machines, and procedures can not supplant listening, experience, and intuitiveness. Patient versus customer, technology versus touch, organ versus soul: where has humanism gone? It has not gone. Humanism is why we chose medicine and why young people enter medical school. We can not let the light flicker, but must keep the beacon bright. If each one of us keeps the individual patient as the primary focus, and if we remember that medicine will always be an art as well as a science, humanism can never be lost.