Did Medicine Lose The Narrative?

Gene Beresin MD, Harvard Medical School faculty, wants to bring back the narrative to medical education. He made the point yesterday that coherent narratives help both patients understand themselves, and medical trainees understand their field. Narratives, he argued, creates attachment, and attachment creates security and comfort-crucial elements of a healing process. I am sorry, Dr. Beresin, as much as I fully support your mission, I am afraid that despite all of the advantages of electronic medical records, the major downside is the loss of the narrative. The stories are becoming much less important, replaced by symptom checklists and automated responses. I am not saying that medical care will get worse without the narrative, but I am saying that without the narrative, the practice of medicine changes its lure. Some folks,  like myself, are drawn to narratives. We love stories, be that in our patients, in books, in film or in theatre. The stories create a richness of life’s experiences which deepen one’s sense of oneself, as one begins to see a wider perspective of the world. So, maybe if I were coming of age today, I would be drawn to Eastern medicine, where the narrative still matters. Dr. Beresin, a man, I would guess, in his sixties, holds the old torch, making me nostalgic. He volunteered that he is also a musician, a man of the arts. That’s cool. Yet, despite his Ivy League credentials, I am afraid no mover or shaker in our health care system is going to listen. The value of the narrative is slipping away from the health sciences. It is too bad, but it is our future.

Doctor, Patient and Pharmacies: An Oedipal Triangle

 

For years, pharmacies call me “demanding” a refill for a patient. Sometimes I have never heard of the patient. Other times, I just saw the patient and handed them a prescription. Still, other times, I have not seen the patient in quite some time. Without knowing the circumstances, pharmacists leave messages like “this is our third call,” as if, I have been a “bad girl” and not responded, as if I need to respond to a message that does not make sense. Today’s LA Times, exposes a practice that I have long suspected. Pharmacies call for refills, even when the patient does not ask for a refill, so that they can bill the insurance company. “That is why I don’t call back pharmacies unless the patient tells me ahead of time that I will get a call,” I want to scream to all who will hear. As I see it, the pharmacy represents an intrusion into my relationship with my patient. I work to help my patients, not the pharmacy. The pharmacy enters into my relationship with “demands” which I find out of place. One of the many advantages I have, by not having a staff, is that I am on the front lines with all of the administrative details of practice. My ship is small, but it sails. No intrusions allowed.

 

http://www.latimes.com/business/la-fi-cvs-caremark-20121024,0,6138463.story

Electronic Medical Records: Do You Want Fries With That?

  The Affordable Care Act, the digitization of our world, and the changing delivery of health care all comes together to roll out electronic medical records, now active at Kaiser, and soon to be active in almost every primary care setting, certainly by 2014. To be clear, I think that this will be a net positive for patient care. Medical information will be helpful to emergency room visits, doing health maintenance, and tracking prescriptions. I am optimistic about the benefits for the vast majority of patients who now have fragmented care, or no care at all. My concern is how will electronic medical records change the joy in the practice of medicine. Will taking care of patients retain the fun, if a menu comes down for every patient, reminding the provider to remind the patient to wear his seatbelt when he drives in his car? Again, I think it is a good idea, and it will help, for the computer to prompt the physician to remember preventive medicine questions, as preventing accidents, for example, is a very important part of health care. Now, though, that conversation, stems from a general concern for the patient, usually discussed, at a visit where critical medical issues have already been addressed. Yes, of course, the computer eliminates the human error, inherent in trying to remember too many things, especially when the provider has too many patients. At the same time, the fun in patient care, at least for me (and I am not a primary care doctor, I understand that) is the spontaneity of conversation, which is based on a deep training of important questions which are well-timed to the moment of most open communication. For example, there is a big difference if you tell a patient to stop smoking in a rote fashion, as opposed to telling them to stop smoking after they just told you that their uncle died from lung cancer. I fear that this art of persuasion will be lost with the advent of electronic medical records. In so doing, I fear the fun of patient care will diminish considerably. Sure, there is an upside. Efficiency is going to make the doctors feel better, as inefficiency, in the current system is degrading and demoralizing to physicians. Balancing it out though, I still fear that this roll out will be a net gain for patients and a net loss for providers. As with so many of my grim predictions, I really hope I am wrong.