The patient, self-conscious as she sits on an examination table wrapped in a paper gown, begins to describe her troubling symptoms. Which should she emphasize: the pain in disparate parts of her body is what she feels the most, but does the 3-pound weight loss have a higher priority? Or the sweating at night? Should she start with the weird rash on her legs, or perhaps mention that her grandmother died of leukemia? Does her recent trip to Laos have anything to do with this? The old doctor, who types away as he stares at a computer screen, doesn’t seem to be paying much attention anyway. While in the waiting room, the patient skimmed the Nov. 12, 2018 issue of New Yorker magazine, in which Atul Gawande (The upgrade: why doctors hate their computers) wrote: “Many fear that the advance of technology will replace us all with robots. Yet in fields like health care the more imminent prospect is that it will make us all behave like robots.”
That old but tech-savvy doctor, having reviewed the patient’s Problem List, recent labs and his previous visit note, is editing the pre-written template for the current encounter. Computers have helped in many ways, but have also added greatly to time demands. Despite running late, he tries intermittently to smile in a reassuring way, and to read the patient’s eyes and body language; he realizes that it’s not going well. Why does she keep pointing at her neck and shoulders, when the pustules on her shins give away the diagnosis? On the computer screen, the cursor flashes over Laboratory and Radiologic Tests he wants to order, click-click-click-click, then pauses over the Diagnosis section. Which ones can the doctor justify; which diagnoses will not bounce back from the Auditing Department?
Meanwhile, the clinic Administrator is reviewing a huge pile of committee reports and computer printouts on her desk. Weekly access data. Numbers of Urgent Care drop-ins vs scheduled appointments. Emergency Room visits. Subspecialty same-day access. Patient satisfaction scores. Not great, but reasonable. She turns her attention to coding errors in diagnoses, which cause the most blowback, and even accusations of fraud, from insurers and the Federal Government– and which, even now, cause her to wince with displeasure. She’ll have another firm talk with the Auditing Department. Thank God for the computers, which give her some semblance of control over a thousand clinicians; whoever complained about herding cats should try her job!
In this imaginary scenario, the Secretary of Obamacare issues two things: the first is a deep sigh of frustration. Why? Millions of previously uninsured people have gained medical coverage, including the poor and disenfranchised; those with pre-existing health conditions; women in need of contraception or maternal care; those in underserved rural areas. But all of that is now in danger of vanishing! The second thing issued by the Secretary is a nationwide announcement that the President of the United States is moving to eliminate Obamacare– against the will of the vast majority of Americans– this time through the courts, since his efforts in Congress have repeatedly failed.
It’s a huge, complicated picture with many moving parts. A pessimist reduces it to the classic scene of a small fish about to be swallowed by a big fish, which, in turn, is about to be swallowed by a bigger fish with sharp teeth. And that fish has an even bigger fish, blond hair flapping weirdly and mouth wide open, swimming up right behind it.
An optimist sees a pyramid. At its base is a federal government composed of enlightened, aisle-crossing politicians with the best interests of the populace at heart, a government which supports an efficient system of universal health coverage. Above that are the pharmaceutical companies (reined in by government) and the insurers, which are technologically advanced, innovative, not-for-profit and cooperative while still competitive and capable of adaptation. On the next level are the unified healthcare providers, including attentive, non-distracted physicians who are led to best practices by technology even while working side-by-side, rather than top-down, with their patients. And those patients, empowered by their providers, insurers and government, sit at the very peak!
Even assuming a change of Presidents and a radical return to normalcy in Congress, achieving the optimist’s view of healthcare will take major reforms in the insurance industry and advances in technology such as artificial intelligence. With so many separate moving parts generating friction and threatening to fly apart, artificial intelligence can act as both glue and lubrication, especially in adapting quickly as circumstances (political, demographic, climate etc.) change. But a progressive, widely-held understanding of subtle nuances and the “big picture” will also be needed, and unfortunately, those are not coming anytime soon– not before the next election, anyway.
As I begged in my previous post, please don’t forget to vote in 2020!