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01/04/2013

The Medical Gaze

Craig M. Klugman, Ph.D.

Over the winter holidays I found myself in a coffee shop one night talking to Nelly, a nurse who works part time in her semi-retirement. She has been a nurse for 45 years, having graduated from a hospital-based nursing program in the mid-1960s and doing such jobs as labor and delivery nurse, performing insurance exams, working at planned parenthood and for the last two decades in infertility medicine. She explained to me how a national conglomerate recently bought the small medical practice she helped found. Nelly was used to getting to know her patients, to guiding them through their expensive and emotionally difficult treatments. Now she works each day at a different clinic so she does not get to know the patients names, nevermind act as their advocate and guide.

Nelly told me of her surprise when she was called into a supervisor’s office a few weeks ago. The supervisor sat her down and explained that he had been observing some of her patient interactions and that she had some behaviors that needed to be corrected. After asking what those were, the supervisor informed her that her sin was that she made eye contact with the patients. Nelly explained to me her shock as she had been taught and always practiced that looking at the patient and being compassionate were hallmarks of good nursing. The problem, she relays “was that I was looking at the patients instead of at the computer screen.” Her supervisor said that she would be more efficient if she entered information into the electronic medical record simultaneously with the conversation, instead of waiting until the patient leaves to make her notes. And without looking directly at the screen, this task would be impossible.

The observation was a warning she told me. “And if they really want to reprimand me and take the care out of nursing, then I’ll simply retire because that’s not how I want to practice.”

Now this anecdote could be dismissed as a lesson about changing from a small business model of medicine to a large corporate style more focused on the bottom line and pleasing stockholders, or about an old way of nursing versus a new way. However, just a few months ago I was speaking with a physician who works in an academic medical center. She told me that whenever she logs onto the computer in her clinic, she is given a rating as to her “efficiency.” Such efficiency is based on how much of the electronic medical record she completes while speaking to the patient rather than after the clinical encounter. The more data entry she does in front of the patient, the higher her efficiency score. The irony is that this physician teaches compassion, empathy and connecting with patients to medical students, exactly the things that she is being criticized for doing in the clinic.

Medical school and nursing school classes on ethics and professionalism often teach communication skills such as looking at the patient and engaging in conversation. That such professional behaviors are now being reprimanded in the world of medicine as business means that either what we teach is quaint and outdated, or that something is very wrong when health care is treated as a profit center. These corporatized models of medicine draw on notions of Taylorism and the factory— trying to make the manufacture of a product faster and thus hopefully cheaper (and more profitable). But the clinic is not an assembly line. Patients do not come in as parts that need to be assembled into a finished good. They are human beings with history, pain, vulnerability, and hope that needs to be respected, acknowledged and honored. Medicine as business wants health care to be delivered faster, to more people, and for less money. That sounds fine in theory, but in reality the saved time often comes from the connections physicians and nurses make with their patients. One cannot speed up the amount of time needed to take blood pressure or a pulse. So where does the time savings come from? Talking. Making eye contact. Making the patient feel like a person who matters. Instead, patients are customers purchasing a product to be pushed out the door as quickly as possible so the next cog can be served.

Nelly told me that she felt too old and set in her ways to change her practice. She also felt it didn’t matter because most likely her home clinic that she helped build would be closed anyway. When I asked her why, she replied. “We’re too good at what we do. We have the highest rate for helping infertile couples get pregnant in the company. And a successfully pregnant couple does not come back to buy another round and another round of $10,000 treatments. It seems like the company wants the treatment to fail so that the patients come back and spend more and more money.” If the company fails to provide successful medical care, they make more money because a vulnerable couple comes back to try again. The company makes more money if the treatment fails.

None of this can make the patient feel supported or nurtured. But then again, who would notice since everyone’s eyes are gazing at a computer screen.

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  • bioethicsstudent13

    I have change doctors due that I have the impression that I don’t get the feedback needed when I present my case to some doctors. I feel that their schedule is to busy that they have to rush from one room to another and that they wont give you the time and day to sit and discuss any issues you may have. I personally think that people that pay in cash or have Medicaid has the most attention as patients, due that doctors can say that a certain patient in Medicaid is been seen for another reason rather than what the patient is being seen for and more $ goes into their pockets its a government issue healthcare. But for some of us with a private insurance, they have to verify if approved and do more work before it is ok. No wonder most of the doctor offices have a large client of Medicaid patients than private ones.