By Rod Moser, PA, PhD
Marcus Welby, where are you? Growing up in the 1950’s in rural Pennsylvania, our little town and the surrounding farming community had three part-time doctors. The nearest hospital was only six or seven miles away. We had no ambulance service, other than a few guys who had a big station wagon. Our doctors knew us, and we knew our doctors. House calls were common, and personal and fast service was the standard. Office visits: .00. House calls: .00. Medicines and x-rays were extra, of course. America in the 1950’s was a time when neighbors helped neighbors, we shared party-line telephones, and we knew everyone, including the vehicle they drove.
Four decades later, I am no longer a barefoot little boy, but a clinician in a busy, suburban medical practice in California. The practice of medicine has changed in so many ways, but I have tried to keep my small-town friendliness in patient care. No longer do I pick up a thick, manila folder with patient files falling out of them. I miss seeing my own handwriting, including my “margin notes” to jog my memory. When someone told me about a new puppy, I wrote it in the margin of the previous visit. If they were going to Disneyland, or they their grandmother was visiting, I jotted this down as well. When I casually mentioned these at the next visit, people were amazed at my memory, but I usually confessed that I wrote it down. Events that are important to your patients are events that should be remembered (even with a little help from the margins).
Our staff recognized our regular patients and called them by name. The friendly people on the phone even recognized voices, made family connections, and added another dimension of personalization. People liked it. The front desk staff knew the providers’ likes and dislikes. They know that I need extra time blocked off for a teenager coming in for depression, or a child with abdominal pain. Scheduling mistakes would happen, but a friendly phone call would quickly rectify it and it rarely happened a second time. Over the years, I discovered that if you are nice (very nice) to the people who book your appointments, patients known to be time-consumers (taking up considerably more time than their appointment slot), the perpetually late, and the ones with challenging personalities do not appear on your schedule just before lunch.
Ten years ago, those charts started to disappear. One by one, they were scanned into a huge mainframe computer system in preparation for EMRs – Electronic Medical Records. In place of our wooden desks in the exam rooms, a computer and keyboard was mounted on the wall with a big moveable arm. It was mounted high enough for us to use, but not high enough to keep little kids from pounding on the keyboard. Recently, the smaller 15-inch flat screens were replaced with 24-inch screens so that we will not be able to see the patient, if we decide to type our notes during the visit. Patients became MRNs – Medical Record Numbers.
And, now the final blow toward depersonalized care. Our group has decided to outsource our friendly and personal phone crew (Patient Service Representatives) to another state! I guess I should be glad that it isn’t Bangladesh or Mumbai. Soon, when our patients call, a different (hopefully, friendly) voice will answer to book their appointment or address their needs. They will not be able to causally discuss the weather, since they will not even be in the same state.
Why use humans at all? Now, our patients can book appointments online, or send us an e-mail with their questions or requests. I can no longer customize my schedule, putting the quick and easy appointments, like rechecks or freezing warts near the end of my work day. My last appointment could be a complicated abdominal issue needing lab work or an orthopedic injury needing an x-ray. By the time they are in the exam room, the lab and x-ray may be closed for the day. The patients grab at these end-of-the-day appointments so they don’t have to miss work, but apparently, it is okay for me to extend my long day into the evenings.
I guess I don’t mind the e-mails as much as someone knocking on my door saying that I have an important phone call; maybe an emergency. Most of the time, a person who feels their problem is an emergency may be greatly exaggerating. I suspect the next thing that will happen is those patients will no longer be sending me an e-mail with little or no helpful information, but including pictures as well, or even worse, live video.
Where will this lead in five years? Ten years? Will medical providers even need to leave their homes? Will we have advanced medical robots to do the hands-on component of our exams?
I have always been a gadget nut. I love technology. I love computers.
I can’t say that I like the progressive depersonalization of medical care, though.
Humans need human touch. All of the advances in science are not going to replace a gentle, healing hand or a warm smile.