Close Observer of U.S. Health System Gets (an Uncomfortably) Closer Look — Physician’s First Watch

Medical News |
January 23, 2014

Close Observer of U.S. Health System Gets (an Uncomfortably) Closer Look

By Joe Elia

Arnold Relman, a long-time commentator on U.S. health policy, got unexpectedly immersed in the healthcare system last summer when he broke his neck in a fall. He recounts the experience in The New York Review of Books.

His narrative gives a patient's-eye view of his ordeal and subsequent recovery. He also offers this observation: "New technologies and electronic record-keeping affect how doctors do their work. Attention to the masses of data generated by laboratory and imaging studies has shifted their focus away from the patient. Doctors now spend more time with their computers than at the bedside."

And this: "What personal care hospitalized patients now get is mostly from nurses."

We should note that Dr. Relman served as editor-in-chief (and this writer's boss) at the New England Journal of Medicine. We assure you that, should other medical editors have similar misfortunes and live to write about them so engagingly, we will cover them.

Reader Comments (7)

Victor Elinoff' MD Physician, Family Medicine/General Practice, Endwell Family Physicians

Right on! We meaning everyone involved in health care planning administration and delivery are creators of the environment Dr R. described . The older PCP family docs are moving away from hospital care financial and other concerns make rounding on your own patient increasingly more complex and time consuming. The complexity of meeting metrix including data and avoiding state and federal sanctions makes nursing more attentive to computer than pt as well. Is it too late to change the path we are on? The computer is running our lives in the office as well. Is humanity gone from health care ? Dr R survived and that is what shows up in the metrix.

LOUIS COLASANTI Other, Epidemiology/Statistics, Vermont State Colleges

The number of comments that focus on EHR, Medicare and 'government intrusion' issues avoid the central problem, which is the model of care. Health insurance -- private as well as public -- had fueled the adoption of computerized systems long before the intrusion of any EHR mandate. Furthermore, accurate and aggregated EHRs {omitting, of course, any personally identifying information} have the potential to provide invaluable insights into the efficacy of treatments. The problem is not computers, nor is it 'government intrusion', which has been no more intrusive than private insurers. The problem is with the model of care, and that model of care had nurses providing most of the personal care to in-hospital patients long before computers and long before Medicare.

This is not the time, nor is there the space, to go into sufficient detail here. Suffice it to say, then, that a closer look at the spectrum of our model of care, starting with medical schools, is in order. With respect to medical school education, one can begin with the conspicuously absent pieces of the puzzle in the curriculum about the importance of direct patient care, but then proceed to the unnecessary limits on admissions. Next, one can pay some attention to re-thinking and extending the roles of PAs, nurse practitioners and other providers. All this could go a very long way, indeed, toward maintaining closer patient contact and providing improved care, whether in the hospital, the clinic, or the office.

Bruce Bodner Physician, Surgery, General, Taunton, MA

Great article by Dr Relman, shows how sharp a guy he is. I think the computerized record is a result of governmental intrusion and virtual takeover of medicine. The lawyers, and the court system in particular demand "documentation" . The politicians discovered that telling docs and hospitals to make an electronic medical record would do all sorts of great things, so without anyone really testing that hypothesis, we have been forced to embrace it. The government embodies bureaucracy, paperwork, forms and process, so there should be no surprise that inviting it into our profession, as ironically Dr Relman has done for many years, will result in those aspects gaining ascendency over quaint concerns like "caring".


I'm surprised he didn't recognize this prior to his own personal event. This is been going on for years.P

Janet Chene MD Physician, Family Medicine/General Practice, Solo Practice

I noticed this since 1995 when Medicare implemented more complex and convoluted documentation requirements. In order not to be severely fined by Medicare, the hospitals spent tremendous funds to train the nurses for this system and bought all new computer systems to handle the documentation. As a result since this the nurses (and now doctors) are all around the nurses stations tending to the charts rather than at the bedside. Suddenly, the call lights were almost all on down the hallways and the patient could not even find someone to change a bed pan in a timely manner.

David Foster, MD Physician, Family Medicine/General Practice, Oregon

When I was a medical student, the admitting H&P was a five page "check the box" form with little space for text. Quality was defined by how many boxes were checked. Now, many systems mandate an electronic version of the same form(s). Quality (and payment) is defined by how many boxes are checked. Forms flow back and forth - the drug the patient has been stable on for ten years now becomes a hazard they day they turn sixty five, the test or procedure now is declared unnecessary the same day.

Care of patients is now relegated to PAs or FNPs (or even office staff with minimal formal training) because the doctor is busy with charting (the simple UTI can generate a five-page chart entry - with a needle of useful info buried in a haystack of irrelevance). The "nurses" you see providing your care are more likely nurse aides (the nurses have to spend more/most of their time completing forms and reports). Why? Because information CAN be collected, the collection is now mandatory, reviewed by protocols and standards that have not been verified for significance or applicability,

The inmates are running the asylum.

Fred E. Pittman, BA,MD,Ph.D and DTM&H(Lond) Physician, Gastroenterology, Medical University of SC (Retired)

My training was at Yale, Columbia P&S, Cornell New York Hospital and at teaching centers in the UK and Paris. Early on I learned the importance of the patient's history. One mentor put it this way: "If you will listen the patient will tell you what the diagnosis is." Though probably not quite that simple,the medical history and the physical examination remain critical to excellent patient care.

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