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.