We live in an era of industrialized and impersonal medicine, where time spent with our doctors is kept to a minimum, almost as a science.
But it wasn't always this way. At my grandfather's funeral, in 2005, hundreds of his patients came to say goodbye. He was a cardiologist in the Chicago area, the son of a doctor -- my great-grandfather -- and the father of two doctors.
I recently asked one of his sons, my uncle Dr. James Hines -- a physician in Phoenix who graduated from Harvard College and Northwestern Medical School, is triple board-certified in internal medicine, cardiology, and interventional cardiology, and is recognized as one of Phoenix's best doctors -- to talk about his experience in his 35 years as a doctor, and specifically how his interactions with his patients differ from his father's and his grandfather's.
What are the major differences between how your grandfather and father practiced medicine vs. how you practice medicine today?
One obvious difference is that my father and grandfather could afford to spend more time with their patients. Though they had much less to offer their patients in terms of testing and treatments, my father had the time to make house calls -- I'm sure that I went on a house call or two with him.
Today, while that nugget of human interaction and the human element is still there, we've got so much else to deal with that is extraneous to our core work as doctors. We have to work harder to have a good relationship with a patient. This includes a lot more paperwork and a lot more data to review.
Has the way the community views doctors changed as a result?
I think so. This is a more subtle difference between my dad's generation and mine. I have memories of going to the hospital with my dad on the weekends. He would park me at the nurses' station. He was a real professional, very well-respected -- I saw the notes that he would take. He didn't cut corners. It was pretty much a universal respect without many questions, without many reservations or judgments.
Today, if you do a good job, your patients still do respect you and they appreciate what you do. Every once in a while, you have a patient come in and say, "I saw what Medicaid paid you and how underpaid you are." But in the community, apart from your patients, you're just another guy making a nice living. Are you any different from the guy selling real estate or a successful banker? I don't think so. The mystique has gone away.
You first began practicing in 1980. How has the patient-provider relationship changed in these last 35 years?
The mandates of government and insurance companies to collect and record a multitude of data pieces, whether or not they're relevant to the patient's problem and situation, has taken much time and effort away from individualized evaluation and treatment. Significant cuts in reimbursement for all services has required me and just about all other physicians I know to see more patients but spend less time with each one.
Bureaucracies are forcing doctors to spend large amounts of time filling out data fields. It takes lots of time away from personal interaction. On average, I'm spending about 15 minutes per patient per appointment, and then charting everything afterward. I'm booked every 15 minutes. I think I spend about 20 to 25 hours per week on paperwork, on top of what my assistant already does.
Doctors used to take beautiful notes. They would describe a patient's history. They would talk about the tests that they were going to run.
Bureaucracies have no interest in the narrative form. There are no more essays in medicine. They only want structured data. If you can't put it in a field, they're not interested. There are no more novels, no more short stories.
Does care feel different from a patient's perspective?
Certainly. What they used to do when someone had stomach pain and they didn't understand why they had stomach pain: They put them in a hospital on a Monday. On Tuesday they would have an Upper GI exam. On Wednesday they would have a Lower GI exam. By Friday, the main doctor would come in and tell you what was happening. So my dad would see them over a period of four to five days. He would see them five times on one investigation.
Now, it's out of the hospital. If the patient is admitted, the hospital is on the clock by the insurance company. So insurance companies are doing everything they can to minimize the interaction between the hospital and a patient.
Once this move was made to commoditize what a provider does -- well, then we want a product that we can measure and sell. So much of what is good in a doctor/patient relationship is immeasurable.
Do you think Obamacare has changed the patient-provider relationship?
Not much yet, but it will. Obamacare will almost certainly mandate more data collection/paperwork and will result in further cuts in payment. You will see more physicians leaving third-party payor medicine and providing services to patients who can afford to pay cash for good service.
It's not just Obamacare. It's the same people doing the same kind of thinking. There are industries that exist to decide what information doctors and hospitals collect and how to analyze that information. They're hoping this will make the system better.
But here's a major problem with structured data: If you implement something in 2010 and look at the results in 2014 and you say to yourself, "Life expectancy is now three months greater, so we must be doing something right" -- well, there are 100 other things that could be affecting that. It's enormously difficult to measure.
How frequently do you interact with patients by email, video calls, or social media?
I don't want that. I can't bill for it, and their communications would often be very extraneous to true medical issues. Also, the U.S. Justice Department is all too eager to find a doctor-patient communication that occurs outside a secure form of electronic communication. This is a HIPAA violation. For instance, two heart surgeons in Phoenix were threatened with a $1 million fine for using email to communicate with patients. They settled for $100,000.
Do you think there's an expanded role for nurses or other non-doctors to play in improving patients' understanding of their own health, given the constraints on the amount of time doctors can spend with them?
I work with a nurse, and I'm constantly amazed by how good she is, how patient she is. We're a great team. There are certain medical decisions that she's not comfortable making. But she's far more patient than I am and it's absolutely necessary in this system for nurses to play a big part in communication. The most important thing, for every health care provider, is that quality must be extremely high. And if they're a very caring person, that goes a long way.
Katherine Ryder is the founder and CEO of Maven, a digital health company that connects women instantly with healthcare providers via video.