When Efficiency Meets Anxiety

There are few among us who has not had the sinking feeling that something is awry in the body, perhaps something serious. Such a problem is always anxiety producing. Never mind that the body has worked without a whimper for years; when symptoms not easily explained pop up there are three ways to handle it. 

First, ignore it.  That is not an option that should be utilized for any length of time, and never if the symptom(s) are severe.  Second, decide what the trouble is and try to treat it yourself.  I once heard that a physician who treats himself has a fool for a doctor and a fool for a patient; that is even truer if one has no medical expertise. The third choice is to see a medical professional.

In olden days that meant an MD but that is no longer true.  There are nurse practitioners, physician’s assistants, osteopaths who are all competent.  There are chiropractors, homeopathic practitioners, alternative medicine gurus, and a host of other possibilities.

Those with the benefit of an MD or DO behind their names are well aware that some of these options are worthwhile, but many are not the best source for significant medical problems.  The patient is not always able to make wise decisions about who is going to be the best person to sort out the disturbing new problem.

The day of the solo practitioner in medicine is in a major state of major decline if not over.  Nearly all are allied with a group of like-minded physicians banded together in a group practice or, even more common, with a clinic structure what encompasses multiple specialties.  On the surface there are many advantages of such an arrangement.

There are economies of scale where administrative procedures can be standardized, where equipment and supplies can be purchased in large quantities, where physicians can have consultations more easily if everyone is working under the same roof, where call schedules can be shared with a large number of other doctors. 

There are downsides to this efficiency, particularly in the hospital setting.  Many physicians, particularly internists, pediatricians, and family practitioners do not see patients in the hospital.  This care is delivered by hospital-based specialists who, while highly qualified, do not have the continuity of care that often is needed.  Hospitalists are pejoratively called “shift doctors.”  They work stated hours, for a stated number of days, and then pass the care of the inpatient to the next hospitalist. 

The latest incarnation is the “nocturnist,” a physician who works only at night. Many move from hospital to hospital on a contract basis that may be as short as a few weeks. Very complicated cases may take a long time to understand and while the fundamentals of the problem may be passed on to the next team, the nuance of care cannot be transferred so readily.

The efficiency of this system can be remarkable, particularly in the case of the electronic medical record.  It places the physician at the bedside with a computer which can call up all pertinent information instantly.  It has a major disadvantage for the anxious patient and family when the visit is completed but he feels like a bed-ridden player as the game swirls around the room.

I encountered a patient who was asked by the doctor, “Are you depressed?”  He replied, “Of course I’m depressed!  You’re been here 15 minutes and haven’t taken your eyes off the computer.”

I often ask patients after discharge, “Who was your doctor?”  The answer is almost invariably, “I have no idea.  They changed every day or so.”  The physician whom they have been seeing as an outpatient for years is out of the loop and can have a difficult time understanding from the electronic medical record what transpired under the care of a half dozen physicians who never saw the patient before and will never seem him/her again.

If this sounds like another rant of “It was never like that when I was in practice,” it is more than that.  Undoubtedly, there are efficiencies that we never imagined but there have been losses, too.

I am neither a technophobe nor a technophile but I do believe that technology has replaced touching.  There will never be a substitute for sitting by the patient’s bed with a hand on the shoulder and assuring them that the physician who has known them for years will be there, no matter what.  That can relieve a lot of anxiety that a system built on efficiency can never replace.     

J. Hayden Hollingsworth, MD, FACC

 

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