THE BLOG

Paper-Centered Care

03/28/2014 12:32 pm ET | Updated May 28, 2014

Recently, I had a first-hand experience with health care from a patient and family perspective. My teenage daughter needed to go to the emergency room when she began wheezing in the cold weather and didn't improve with her inhaler. She has mild asthma, and it was only her second time in an ER, so we were both anxious.

As a physician, I had an idea of what to expect, and could figure out some of what was happening without an explanation; yet it was still disconcerting when different medical staff came into the room at different times and did not introduce themselves or give their title. A nurse came in with medicine and handed the pills to my daughter with no explanation. "Take this," was all she said. I had to specifically ask to find out what the medicine was. At one point, the physician's assistant and nurse had a disagreement about how many breathing treatments my daughter had gotten, because the nurse hadn't told the physician's assistant that the first treatment had been a double dose. When we were ready to go, we were handed a prescription. No other instructions. The prescription said, "In Spanish Please." We don't speak Spanish.

The experience left me angry, but if I were not a physician with a general idea of what was happening, I would probably have been terrified for much of the time.

During the two hours we spent in the ER, staff walked in and out of the room. They worked at the nurse's station, intent on their jobs, looking busy, filling out paperwork, or typing on the computer. But the interaction with my daughter and with me was minimal. When and how did health care become so impersonal, so detached?

That recent ER experience with my daughter reminded me of something that happened during my first year as a young physician in training. It was the early 1990s. I was admitting a patient to the medical ward. I marveled at my own skill and efficiency as I wrote a set of orders for a patient I knew was coming to the floor from the emergency room, but who had not yet arrived. Admission orders serve as directions for the nurses in how to care for the patient. They include the medications, diet and what kind of IV fluids to give. I joked to my colleague, Jeff, that I had become so good at writing admission orders that I could do it by simply reading the patient's referral papers. I would be done with the orders without even seeing the patient!

Jeff, also an intern, replied, "Oh, that's nothing. I once did the orders, admission note, everything, on a patient without seeing her. I was busy all night with patients on the floor having emergencies and I never got to her."

"Amazing!" I said admiringly.

"Yeah, amazing," Jeff said wryly. "When we went to see her on rounds the next morning, we walked in to her room and found her gasping for breath. The senior doctor -- the attending -- asked me, 'Was she like this last night?' and I said, 'No, I think this is pretty new.'"

Jeff blushed and winced a little at the memory. He had run around frantically ordering tests on the woman that morning, hiding the shame he felt at not having tended to her personally the night before. She had come through the episode okay, to his great relief.

Medical internship is a frantically busy time. For this first year of residency, the training that occurs after a doctor earns an "M.D." but before going out to practice independently, doctors work long hours on the general medicine or surgery floors of the hospital. Interns are the front line in the care of patients hospitalized in a teaching hospital. They order and check on numerous tests, write orders for medication, put in intravenous lines and draw blood from patients. When the patient has an emergency in the middle of the night, interns are the first physicians to respond and make an assessment.

The massive crush of work, long hours, and extreme fatigue make it very tempting to cut corners wherever possible. And "wherever possible" may mean spending time with the patient. The intern can go home when all the tests are ordered and checked, all the blood drawn, all the orders written. No one checks on whether they have spoken to their patients.

Jeff learned something from his scare with the patient he never examined. Many doctors don't. Even indirectly through Jeff's experience, the smugness I had felt at being able to write orders on a patient I hadn't met or examined still sticks with me more than 20 years later. The memory returns when I am tempted to treat a patient by paperwork, reminding me that I am neglecting the most important part of my job as a physician.

And those temptations are common. In today's complex and fragmented medical system, the pace and demand often do not lessen for a doctor once she is out of training. Workload demands are high for nurses and other medical staff as well, and "work" continues to be defined and measured as completing medical tests and notes. These are the metrics insurance companies, oversight bodies, and hospital administrators tend to use. Not surprisingly, the act of talking and listening to the patient continues to be marginalized in this system.

There has been an acknowledgment that fragmentation and heavy workload on medical professionals can lead to cutting corners and making errors, such as giving the wrong medicine or operating on the wrong arm. The solution to this is to standardize procedures through routines and checklists, which improves quality and uniformity. Yet one danger of checklists is that they can potentially exacerbate the problem of health care professionals being overwhelmed by paperwork, removing them even further from the person in front of them.

In the case of my daughter's visit to the ER, poor communication led to several errors or potential errors. These included confusion over how many breathing treatments my daughter had received, a request for the prescription bottle to be printed in Spanish, and no clear instructions for what we were to do after going home. All of these could have been avoided not with sophisticated tests, but by the medical staff talking briefly to each other and to us.

There is a lot of talk in health care today about "patient-centered" care. Sadly, my recent experience with the health care system seems to show that we are more of a paper-centered system of care right now.