The Patient, Not the Data

By Julian Fisher, MD

Health news cascades over us with innovative tests and treatments, new technologies and the need for electronic health records, yes, all of it good, beneficial we hope, but lost in this forest of information is the patient.  How refreshing to read in The New York Times today an eloquent appeal from humanist, writer and physician Abraham Verghese, MD his plea to "Treat the Patient, Not the CT Scan."

His argument is so simple and credible.  All humanistic-physicians agree with him.  How can we, though, run against the tide of history?  Here is what we face.  There is a documented shortage of primary care physicians in this country, with only token efforts to respond meaningfully.  The rewards for being a hard-working primary care physician are far less than for being a specialist or a specialist with a device (an endoscope) or a specialist with a device that beautifies (a laser).  We as physicians are effectively reimbursed for 20-minute new-patient visits and eight-minute follow-up visits.  Twenty and eight, you ask, how can that be?  That is how, in effect, insurance companies calculate their payments -- mind you, they are not rationing care, but they are rationing care and have been for a long time, national debates aside.

It is a challenge for any primary care physician to take a complete history from a patient with complex complaints, examine the patient, formulate a plan, and record it (oh yes, it should be in electronic form now) in 20 minutes...and let's make sure the patient undressing and dressing time is not counted in that time.  For the 8-minute sprint, we may only have time for one complaint, not all three that need to be dealt with.  Begin to see the dilemma of primary care?  It is almost as if primary care is a marathon race, with runners (patients) zipping by the finish-line referees (primary care providers) with but moments to evaluate their performance, grade them (treat them) and move on to the next.

In such a scenario, Dr. Verghese's plea for better examination and more attention to the patient rather than the tests becomes ever more eloquent.  One of my most revered neurology teachers / professors, Robert Joynt, MD, used to say that over 90% of diagnoses in neurology were made as the patient walked into the room.  That holds for so many areas of medicine, and in the rush to mechanize and computerize, we have lost those invaluable observational skills or have not been willing to pay for their being taught and deployed.  What a shame for health care, for patients, and for society.

How can we correct that?

Julian Fisher, MD is a Boston-based neurologist and medical information entrepreneur.

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James Fallows is a national correspondent for The Atlantic and has written for the magazine since the late 1970s. He has reported extensively from outside the United States and once worked as President Carter's chief speechwriter. His latest book is China Airborne. More

James Fallows is based in Washington as a national correspondent for The Atlantic. He has worked for the magazine for nearly 30 years and in that time has also lived in Seattle, Berkeley, Austin, Tokyo, Kuala Lumpur, Shanghai, and Beijing. He was raised in Redlands, California, received his undergraduate degree in American history and literature from Harvard, and received a graduate degree in economics from Oxford as a Rhodes scholar. In addition to working for The Atlantic, he has spent two years as chief White House speechwriter for Jimmy Carter, two years as the editor of US News & World Report, and six months as a program designer at Microsoft. He is an instrument-rated private pilot. He is also now the chair in U.S. media at the U.S. Studies Centre at the University of Sydney, in Australia.

Fallows has been a finalist for the National Magazine Award five times and has won once; he has also won the American Book Award for nonfiction and a N.Y. Emmy award for the documentary series Doing Business in China. He was the founding chairman of the New America Foundation. His recent books Blind Into Baghdad (2006) and Postcards From Tomorrow Square (2009) are based on his writings for The Atlantic. His latest book is China Airborne. He is married to Deborah Fallows, author of the recent book Dreaming in Chinese. They have two married sons.

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