As we advance our medicine some are forgetting humanity. Healthcare systems that have embraced relationship-based medicine have shown better patient outcomes. Something as simple as relationship based medicine leads to decreased hospitalization, less physician burnout, and less infections in hospitals. The proof can be seen from the recent winners of the Malcolm Baldrige Awards.
Electronic Medical Records
The day Maryvale Hospital (now closed) adopted a new electronic medical record system operating room nurses were suddenly glued to the computer screen. No longer were they keeping a roving eye on the room, watching the surgeon, anesthesiologist, the patient, the ebb and flow of the operating room. A good operating room nurse is ever vigilant to anticipate urgent needs of the ongoing surgery. Now the nurses are servicing a computer, which has increased billing for the hospital. Has this improved patient care?
Go to any nurses station in most American hospital floors and you will see banks of computer screens with nurses in front of them. The patient’s are in their rooms – the nurses are servicing a computer that documents something that makes a bill available for the hospital, who has people in some rooms. Has that made the care of patients in the hospital improved?
For those not familiar with electronic medical records, they are the most backward of all adaptations of computer science one can imagine. And yet these systems, mandated for our use, have enriched their makers. They were suppose to make care better for patients, but have they enriched the lives of patients?
The medical records from one hospital won’t talk to another hospital’s system – so what do they do to get your records? They fax them (that 1980’s technology).
Electronic Medical Records are the second most “hacked” files on the internet. Your information is not yours, but belongs to a hospital(or a clinic or a doctor) that often has inferior internet firewall protection. Your most personal information, easily available to a hacker- and almost impossibly available to another doctor who needs to take care of you.
Call up your primary care’s office and ask to get records – see how long it takes. Then read the pages and pages of information that comes across when you do get it – and see how much of it is important to your health.
Martha Singer, an attending orthopedic surgeon: ” Yes, on the wards as well, everyone is huddled around the screen and not the patient. The hospitals like them because of billing and compliance, but they are not for patient care. Except the antique system we use at the VA, which has more patient focus but is still a huge huge time suck. I think there are 26 clicks and several text boxes to order an MRI. Ward clerks were kind of a good thing, a human check and balance.Cut and paste allows a follow up physical therapy visit to last for 14 pages…arg arg arg. None of us picked this career for the unreimbursed mandate of learning a hospital’s choice of how they would like something documented….I think a huge source of physician burnout. there, end rant.”
Checklists and Impersonalization
“The Checklist Manifesto” written by the surgeon, Atul Gawande, goes into great lengths about how checklists before surgery decreased problems in the operating room, and forged a bond between the operating room team. Checklists are now mandated and used in order to avoid operating on the wrong side (left vs right) or wrong operation for the patient. But what this says is often we really don’t know the patient. If the patient was a friend of yours then you would know that they have been having problems with their right knee, and if they tried to get you to operate on the other one you would stop and say “wait a second.”
The checklist is a manifestation of our loss of the personal relationship with the patient. They are now relegated to a checklist. Nothing wrong with a checklist, by the way – and it is good medicine. What disturbs me is when a surgeon is operating on a patient and they don’t know them. When a patient is just “a case,” or “a gallbladder,” then you not respecting the person who putting their life in your hands.
Relationship Based Medicine Is Better
So before sounding like Clint Eastwood saying “get off my lawn” and “the good old days” lets go back to a few simple principles that have been proven to work (Malcom Baldrige Approved):
First is getting back relationships in medicine. This has been proven to work in our primary care system in Alaska, SouthCentral Foundation’s NUKA system of care. Their primary care doctors have decreased hospitalizations, improved customer satisfaction, and decreased physician and nursing burnout.
If the nurse gets to know the patient in room 201 as “Mary who just had her colon taken out, and her son Fred is here who is the nicest guy” instead of “The patient in 201” then the nurse will have less burnout, and more invested than looking at a computer screen. Don’t think it can be done? Ask our fellow Malcom Baldrige award winner, Adventist Health Castle (AHC) on the windward side of the Hawaiian island of O’ahu. Every nurse knows every patient – their personal care has led to decrease of infections, falls, with an increase in benchmarks. Why? Because relationships matter (they will tell you that “love matters.”).
If you put the patient at the center of the relationship, and not a machine, you, as a doctor, will have less burn-out and enjoy them.
If the surgeon has the relationship with Mrs. Jones than rather a checklist, it is an encounter with a patient who is depending on you, and you smile when you think about her. And know that you will be doing your best for her.
If Aliens Came To Earth
Imagine aliens coming to earth to determine what people of earth value. Now imagine them coming to the operating room of a major hospital.
What they would see are people who change into special clothes (we call them scrubs). They would observe that some people do a ritual washing of their hands. They would see another person (the patient) who is prepared and given something to go off to have visions, and then their body is washed and prepared and special clothes made for them.
They would hear a person(the nurse usually) go through a ritual check list.
During the operation they would see that all are paying homage to electronics:
The anesthesiologist is looking after a machine, and checking a “communications device,”- maybe checking Facebook on the Iphone.
The nurse is looking at a computer screen and entering in data.
The surgeon is looking at a monitor above the patient, and the technician is handing instruments to service the monitor.
If aliens came they would be convinced that we are servicing machines, not people.
We need to improve technology – but we must not forget our humanity.
One final thought: do you remember when you were going out with some friends? Did you get dressed, make certain you were wearing nice clothes? Would you think of going out with your friends wearing an old pair of scrubs? Nothing wrong with clean, pressed scrubs and a nice laboratory coat. But it does irk me when I see doctors wearing old scrubs to the hospital. When medicine is relationship-based you respect the “customer” and you dress for it. Respect the patient, they are your customer, and respect yourself. It is a relationship that you build with the patient (customer-owner).
