Monday, April 13, 2015

What is the Heart?

This year, at the annual meeting of the American College of Cardiology (ACC), Dr. Abraham Verghese, the noted infectious disease specialist, author and Vice Chairman of the Department of Medicine at Stanford Medical School gave the keynote address.  He entitled his talk, “I Carry your Heart” after the ee cummings poem and spoke about what “heart” means.  When you speak to a group of cardiologists who are among them the most knowledgeable heart specialists in the world,   it is an act of courage for an infectious disease expert, and a novelist, to come and tell them what “heart” means.  But his talk was about the two types of hearts – the biological heart we study and probe and repair with surgery and with pharmacy, and the spiritual heart that connects us as individuals. 

For many years, Dr. Verghese has written eloquently about the need to retain, and even improve humanism in medicine.  He laments the fact that medical students now spend about 40% of their time on the computer instead of with the patient when they are on the clinical wards.  He worries that it takes an emergency medicine physician an average of 140 clicks of the computer mouse to admit a patient, and that the electronic medical record is losing the patient narrative as it focuses on the numbers and standard algorithms. 

In one interview, related to his speaking at the ACC meeting, Dr. Verghese says, “…Society will judge us poorly 20 years from now.  They’ll look back and say, “You were complicit.  Why did you let EPIC and all these electronic medical records rule your life?  You actually signed up to learn the new ICD codes and plug them in.  Exactly what did this do for patient care?”  And the answer is that it did nothing for patient care.”

The computer focuses on data and transaction capture for billing and review purposes, rather than the flow of the patient’s story and their journey through illness.  It monitors and directs the use of standard algorithms in a world in which patients are not standard (see my previous post).  This altered focus is changing the heart of medicine.  It is changing the spiritual nature of the doctor/nurse/patient relationship to a series of standardized tasks that can potentially be done without human intervention at all.  There are those, such as Vinod Khosla, who speculate that this is a good thing: that the computer dynamic will remove all errors from the clinical pathways that the limited knowledge of any single physician is prone to.  That view however, leaves out a critical element in helping the sick overcome their illnesses.  It leaves out the human connection we all need. 

Clearly no one, least of all Dr. Verghese, is suggesting we give up the strong potential for technology to improve care.  Rather he is saying that in addition to having the best MRI of the heart, the best computer algorithms to guide treatment, we need the human understanding of a person’s story, including their struggles, their hopes and their dreams, to truly treat the person.  He quotes Paracelsus who advises physicians, “To love the sick, each and every one of them, as if they were our own.”  It is hard to “love” the individual patient if your view of them is only gained through the data on a computer screen. 

Physicians and nurses, and all health professionals are given the privilege of knowing people in ways that few others do.  People open up their hidden vulnerabilities; they disrobe in the exam room and tell their doctors and nurses secrets that they do not even tell family and friends.  They look to their health professionals to treat those vulnerabilities and those secrets with a sacred trust that is exalted above the usual human interactions. That cannot and should not be lost to an information revolution that reinterprets everything into zeros and ones. 

Dr. Seth Bilazarian, writing about Dr. Verghese’s appearance at the ACC meeting, speaks about the lack of enthusiasm, hope and eagerness for the future of many physicians he spoke to at the meeting.  He sees sadness and a sense of resignation among those physicians.  The health care finance experts and computer experts, who are involved in the push towards computer run medicine, while well intended, don’t appear to understand or value the spiritual heart necessary in medicine.  This can create a bleak future for doctors and patients alike. 

Dr. Bilazarian sees some hope in the fact that people like Dr. Verghese are actively speaking and writing about the need to maintain the care of the spiritual heart and not only the physical heart.  I see hope in the numerous efforts to better integrate humanities into medicine, such as the  Business Innovation Factory and Robert Wood Johnson Foundation “Narrative Play Book” effort and in efforts such as ours at Accolade to develop operational systems that focus on patients as complex, unique, autonomous people.   

The challenge is that EPIC and other computer systems do not encourage the building of trust that comes with a patient narrative and that is central to the art of medicine.  We don’t find a measure of the spiritual connection in a claims database.  As health professionals, we lose the human touch if our focus is on the computer algorithm, the clicks we must make, and the strict adherence to guidelines.  We must, instead fight to keep our focus on learning who the patient is and not only what their disease is; what their concerns and values are, and what their social support is like.  It is imperative now, for everyone, not only health professionals, to demand that the human aspect of care be maintained and elevated in order to create the best care for all.