“Pardon Me, Doctor, But Can You Spare a Few Minutes?”
Lansing C. Hoskins, M.D.
Lansing Hoskins was born in Geneva, NY, and received his undergraduate education at Princeton University. Following internship and a year of fellowship in Endocrinology at King County Hospital and the University of Washington in Seattle, a tour of duty as a U.S. Naval Medical Officer at the Oakland Naval Hospital kindled his interest in Gastroenterology. After further training in Internal Medicine and Gastroenterology in Boston at the Peter Bent Brigham and Boston City Hospitals, he joined the faculty at Western Reserve University School of Medicine and the medical staff of the Cleveland Veterans Affairs Medical Center in Cleveland, Ohio, where he was Chief of the Gastroenterology Section before retiring from the full-time staff in 1998. As Professor of Medicine at Case Western Reserve University, he continues to practice part-time outpatient care at the VA medical center, maintains a small research program there, and until 2004 headed the course teaching gastrointestinal pathophysiology at the School of Medicine.
Scene: Noon hour in the noisy cafeteria at the local VA Medical Center. "Doc," sitting alone at a small table, is finishing his customary lunch of two homemade sandwiches and a can of fruit punch when a smartly dressed, attractive young woman "AYW" approaches him with a smile and a clipboard.
AYW: "Pardon me, doctor, but can you spare a few minutes? I have a few questions to ask for a survey of the medical profession we are making.”
Doc: (Swallowing the last of his peanut butter and jelly sandwich) "Ulp…please sit down. What do you want to ask?"
AYW: "I'm making a survey on behalf of the Feelwell Foundation. Have you heard of us?"
Doc: "Uh, no.”
AYW: "Oh. Well, the goal of the Feelwell Foundation is to promote holistic wellness among the people of our country. We have been at the cutting edge of the surging advances in health care in this country over the past twenty years. Right now we are conducting an in-depth survey about how these changes have affected the relationships between doctors and their patients.”
Doc: "Sounds interesting. But why me?"
AYW: "Because you are one of the old fa--- oops, pardon me - senior physicians - who are still practicing medicine 50 years out of medical school. We selected the Class of 1954 because surely you have witnessed revolutionary changes in medical practice and we would particularly like your opinion on how these changes affected the relationships you have had with your patients.”
Doc: “Well, OK. What questions do you have?"
AYW: "The first is, What do you think is the single greatest advance in the past fifty years that has affected medical practice and the patient-doctor relationship?"
AYW: "Computers? Would you explain that, please?"
Doc: "Sure. There's a saying: ‘Every advance in science is an advance in method.’ The same applies to Medicine. The computer revolution over the past forty years has resulted in such powerful, noninvasive, diagnostic innovations as real-time echocardiography, Doppler ultrasound imaging, computerized tomography, nuclear magnetic resonance imaging, and positron emission tomography. Before these diagnostic advances we did a lot of beard stroking at the bedside, counting on experience and physical signs to arrive at the correct diagnosis. In those days, exploratory surgery was our ultimate diagnostic tool, and we subjected our patients to invasive, often painful, diagnostic procedures that are no longer necessary. And we missed diagnoses more often than we do today.”
Not only have computers facilitated appointment scheduling and financial accounting but they have also enabled us to compile and store lots of medical information and transmit it to one another anywhere in the world. If I want to know more about a patient's illness and its currently recommended management, I can access the National Library of Medicine's PubMed website on my desktop computer and scan the world's medical literature on that particular subject back to 1950. If I want to get in touch with the author of a key paper I can communicate with him by email, even if he lives in New Zealand or Timbuktu. Furthermore, in the VA system, all of our patients' complete medical records are now available as personal files in the VA network. If a patient goes to another VA facility, his medical record is readily available there. And the notes in the record are always legible."
AYW: "The computerized record sounds too good to be true. There must be a downside.”
Doc: "Oh, yes. The downside is that every doctor, nurse and other health care worker must type his notes into every one of his patients’ computerized records, and this takes longer than handwriting notes into a chart. For me, it takes about 20% longer to type them than to write them. This is extra time spent on the mechanics of patient care rather than on patient care itself. And if the computer system crashes you're out of luck. But despite these inconveniences, the advantages of the computerized record system outweigh its disadvantages.”
AYW: "I see. Now, doctor, my next question is What do you think is the second greatest advance in the past fifty years affecting medical practice and the patient-doctor relationship?"
Doc: "It's a toss-up between our mapping the human genome and the development of ‘Evidence-Based Medicine’ - that is, medical practice based upon the results of statistically sound, well-controlled clinical studies. Right now I would say that evidence-based medicine is my choice. For the first time in 2500 years of the history of medicine, this scientifically advanced form of evaluating diagnostic methods and treatments is freeing us from emotional bias and the poorly informed opinions dispensed by medical authorities.”
AYW: "Very interesting, Doctor. Now I want to ask you what you think is the single worst thing to affect the practice of medicine and the patient-doctor relationship in the past fifty years?"
AYW: "Computers! But you just said .."
Doc: "I know, I know. But methods are not ends. Computers have changed our lives for the good, but they have also dampened professional enthusiasm for practicing medicine.”
AYW: "How so?"
Doc: "The computer's ability to store vast amounts of information has turned it into a strong selective force promoting those individuals in our population who are inclined to bean counting, record keeping and monitoring others. The result is the rise of a managerial class, headed by such people, which has intruded itself into the traditional two-person relationship between patient and doctor, increasing the burden of physicians’ time spent on the mechanics of health care. Without computers this simply would never have happened.”
AYW: "But without computers we would not be able to devise models of cost-effective health care and plan intelligently to meet local, regional and national health care needs."
Doc: "True. Providing high quality, cost-effective health care certainly is a meritorious goal. But it requires massive amounts of information as well as methods to measure quality of health care and cost-effectiveness. Without computers we could not have undertaken such an ambitious goal. We've got the computers, so now what has happened? The birth and growth of an equally massive, unwieldy health care bureaucracy. For example, a few years ago I received "as a public service" a pamphlet from Pfizer, Inc. entitled Health Care Acronyms. It contained no fewer than 730 acronyms for names of health care organizations and abbreviated terminology in health care. Today if you search this title on the Internet you will find similar lists made available by a number of health care organizations to help their own people and others to find their way through the maze."
AYW: "But, don't you think that the efforts of this managerial class, as you call it, have improved medical care overall?"
Doc: "To some extent. But measuring the quality of health care is very difficult. For example, how do you measure the quality of care a doctor gives his patient when only he and the patient are present in the privacy of his office? And another problem, particularly with hospitalized patients: in the past, the doctor may have provided excellent advice to his patient about several issues pertaining to his care without documenting those details in the patient's record. But now, new rules imposed by managerial authorities in the name of quality assurance mandate that every detail perceived to be important to quality care be documented in the patient's record at each visit. Again, this is another example of the current unfortunate trend in medical practice that requires physicians to spend extra time on the MECHANICS of health care at the expense of time spent in the PRACTICE of health care. Furthermore, a clerical staff is now required in order to monitor documentation and compliance with such imposed requirements. The result? Not only increased medical care costs, but also conversion of hospital space formerly devoted to patient care into offices to house the increased clerical staff.”
AYW: "Surely, effort spent on the 'mechanics' of medical practice - in this case more complete documentation in the patient’s record - must be worth the extra time."
Doc: "Maybe, but that's only part of it. Physicians in full time hospital practice now spend additional time serving on, preparing reports for, and remaining within the practice guidelines of hospital committees set up to monitor our health care -- committees like Bed Utilization, Length-of Stay, Quality Assurance and Internal Review Boards. And that doesn't include the onerous preparation for a periodic visit from that Team of Teams, the Joint Commission on Accreditation of Healthcare Organizations (the "JCAHO"). Couple these activities with the need to see more patients in less time in order to meet fiscal requirements and you have overburdened physicians and unhappy patients".
AYW: "But haven't you noticed that these activities have improved medical care at this hospital?"
Doc: “I really don't think so. We are a university-affiliated Veterans Affairs Medical Center with well-trained faculty and well-supervised house staff so that we already have quality assurance. For us the mandated monitoring activities have had a surreal, make-work quality. For example, I once chaired a Quality Assurance Committee that was required by administrative guidelines to compile data from patients' hospital records in order to assess the quality of certain elements of the medical care they received. We met weekly for chart reviews and evaluations, and after several months we submitted our recommendations in a report to the hospital administration. After one year we were to reexamine patients' records to determine if patient care improved as a result of our recommendations. Then we discovered that our original reports and recommendations had been lost and therefore were neither reviewed nor acted upon. As a busy doc I perceived this experience as like the fruitless tasks assigned to Sisyphus and others residing in an upper level of Dante's Inferno. Although C.S. Lewis defined Hell as ‘the kingdom of eternal noise’, I do believe that on earth it is assignment to membership on committees whose reports are read by few or none, and whose preparation erodes our time, energy and creative spirit."
AYW: "Have there been any improvements in patient-doctor relationships in this VA Medical Center during your 40-year career here?"
Doc: “Yes. Both the VA and I have evolved over these years in ways that have affected our relationships with our patients. I've observed that this VA Medical Center has developed a more ‘patient-friendly’ atmosphere in recent years.”
AYW: "How did this come about?"
Doc: "Since the 1950s the Department of Veterans Affairs, like other federal agencies, pioneered equal employment opportunities, particularly for minority citizens. In our hospital, this meant hiring persons who were often less qualified to do their assigned jobs. Furthermore, their previous backgrounds tended to emphasize looking out for themselves rather than serving patients and the public. The result was a weak supporting staff of marginal competence who were frequently more intent on holding onto their job under Civil Service protection rather than on making the extra effort so often needed in dealing directly with patients. The attitude: ‘That's not in my job description!’ was often palpable and overtly expressed. This made practicing medicine here more difficult than it should have been. However, it's been very satisfying to observe that, with time and job stability under Civil Service protection, many of our supporting staff grasped the concept of service to others. These became reliable and effective members of the health care team, more courteous to patients as well as to doctors and nurses. Now a new generation – in many instances their college-educated children - are filling the clerical ranks, to the marked improvement in attitude, performance and professionalism. I give the VA credit for making this possible.”
AYW: "And you said that you had evolved, too.”
Doc: "I came to this VA Medical Center because it offered an academic career in patient care, medical research and teaching. As an ambitious 35 year-old entering his first academic position, my goals and attitudes towards patients were different from what they are now. Then I was intent on discovering the causes and mechanisms of disease. I tended to view patients as people who happened to have the diseases I wished to study and discuss on teaching rounds with house staff and medical students. Now, as an outpatient physician I have become more actively involved in the direct, personal, one-on-one care of my patients. Now I view my physician’s role as one who, traveling along life’s journey with my patients, strives to help them along the way by being an attentive listener and knowledgeable healer. I believe many physicians evolve like this over the years from student days to retirement.”
AYW: "What are your thoughts about the patient-doctor relationship in today's medical environment?"
Doc: "We should keep two goals in sight. The first is to ensure that all our citizens have access to affordable health care. The second is to preserve sufficient time during each appointment of patient with doctor to allow for that unhurried interaction that results in the doctor's better understanding of his patient and the patient's acquisition of trust and confidence in his doctor. That is the essence of the patient-doctor relationship. Anything less than that, especially in this time of medical regimentation and highly technical specialization, will lead to doctors’ becoming nothing more than highly skilled health technicians.”
AYW: "If you had it to do all over again, would you enter the medical profession again?"
Doc: "Yes, indeed.”
AYW: "Thank you, Doctor.”