In a recent issue of the Annals of Internal Medicine, Terwiesch and colleagues propose “reimagining provider visits as the new tertiary care.” Initially, their arguments seem sound, even reasonable. Then, they conclude with this:
The conceptual change is to see every engagement with a clinician not as something to be celebrated but as a kind of failure—an inability to accommodate patient needs by any of the less expensive technology-enabled levels of support. In this vision, provider visits, including those of primary care practitioners, become the new tertiary care.
With technology both facilitating and encroaching on our practices, should we now view the patient visit as a failure of the medical system? What’s missing from the authors’ new vision is the human factor in medicine, the personal relationship between doctor and patient that is the basis of medical care. The soul.
As an internist with thirty-five years of practice experience, I would suggest that an “engagement with a clinician” that leaves the patient feeling heard, understood, respected and cared for is indeed “something to be celebrated.”
The authors of the Annals article are all distinguished academicians at the University of Pennsylvania’s Wharton School of business and Perelman School of Medicine with impeccable, impressive credentials in healthcare management, behavioral economics, and operations management. The whole article is about efficiency, technology, and human resource management. Nowhere does it address how patients might feel about less contact with their physicians.
Some of what Terwiesch et al. propound makes good sense. Using a watch or phone app to continually monitor a patient’s blood pressure or glucose level or even movement status in Parkinson’s disease gives a provider a day-by-day, cumulative view of one aspect of the patient’s health, not just what the patient reports or blood tests show in office visits every few months. The authors suggest that future automation should be able to provide “ongoing interpretation of incoming data streams.” Simple problems that arise could be addressed by technicians or care extenders.
So far, so good. As the authors point out, reliance on non-physician staff for patient communication is already part of many practices, with medical assistants or nurses providing answers to uncomplicated patient questions. This should allow physicians more face-to-face time with their patients. But that is not the goal of this new vision of healthcare. Rather, it is for the physician to spend less time with patients. As they put it, “the enduring solution must come from achieving good outcomes while each patient spends less, rather than more, time with health providers.”
To me, this sounds great for “systems management” and lousy for patient care. I am all in favor about having more information about my patients’ lives and health outside the office, but more information is not the same as better information. I need to know so much more than the data can tell me, knowledge I derive from the history the patient gives me, from the tone of his voice, from her facial expressions and body language. Data doesn’t replace communication. Data doesn’t replace personal interaction. Data doesn’t replace the warm smile, the gentle touch on the arm.
Medical practice is, by its very nature resistant to automation. In July 2016, consultants at McKinsey published the results of their study of the suitability of many jobs and professions for future automation. (https://www.mckinsey.com/business-functions/digital-mckinsey/our-insights/Where-machines-could-replace-humans-and-where-they-cant-yet) The two professions least susceptible to automation were healthcare and teaching because they involve managing and developing people as well as application of expertise to decision making, areas where—at least for now—computers are inferior to humans.
Even more important, I would add, is that computers don’t have “theory of mind”: the ability to recognize mental states in ourselves and others and to understand that others’ feelings and beliefs are different from ours. Only humans have theory of mind, and we get better at it over the course of our lifetimes. As physicians, we depend on theory of mind to create relations with and understand our patients.
It is this ability that helps make the provider visit crucial to providing good healthcare. It is the personal interaction, when provider and patient sit down together to talk, that is at the core of medical practice. It’s where the magic of medicine takes place.
We need more of it, not less.