Mar 14, 2019
The Average Doctor Visit Fails Patients. Here’s How AI Can Fix That
In the fall of 1975, I entered medical school with ninety other students, most of us fresh out of college. We were an idealistic lot. Marcus Welby, M.D., about the kind family doctor with the ultimate bedside manner, was the hot medical TV show at the time, and Dr. Kildare reruns were still showing frequently. It was a simpler world of medicine—one with time to have a genuine relationship with patients. There were few medical procedures or fancy scans (beyond X-rays) or lab tests that could be ordered. Notes of a visit or hospital rounds were handwritten in the chart. A clinic appointment for a new patient was slotted for one hour minimum and return visits for thirty minutes. There was no such thing as a retail clinic. Or relative value units for a doctor’s performance. Or monthly productivity reports for each doctor. There were few hospital or clinic administrators. There was no electronic health record, of course, and its requirement of spending twice as many hours with the computer as with patients. Even typewriters in medical facilities were not to be found. The term “health system” hadn’t been coined yet. Throughout the United States, there were fewer than 4 million jobs in healthcare. We spent less than $800 per patient per year for healthcare; this accounted for less than 8 percent of the country’s GDP.
What a difference forty years make. Medicine is now a big business—the biggest business in the country. There are more than 16 million healthcare jobs in the United States (the leading source of employment in the country and in most cities, as well), and many “nonprofit” health systems have top-line revenues that tower into double-digit billions. We now spend more than $11,000 per person for healthcare and over $3.5 trillion per year, approaching 19 percent of the gross domestic product. Some medications and therapies cost more than $1 million per treatment, most new drugs for cancer start at more than $100,000 for a course, and many specialty drugs are about $2,000 per month. You can adjust the numbers for inflation and for the growth and aging of the population, and you’ll quickly see that it’s a runaway train. Health systems now have remarkable investment assets, like Kaiser Health with over $40 billion, Ascension Health with more than $17 billion, and Cleveland Clinic with over $9 billion.
Along with the explosive economic growth of healthcare, the practice of medicine has been progressively dehumanized. Amazingly, ninety years ago, Francis Peabody predicted this would happen: “Hospitals . . . are apt to deteriorate into dehumanized machines.” Rather than all the talk of “personalized” medicine, business interests have overtaken medical care. Clinicians are squeezed for maximal productivity and profits. We spend less and less time with patients, and that time is compromised without human-to-human bonding. The medical profession has long been mired in inefficiency, errors, waste, and suboptimal outcomes. In recent decades, it has lost its way from taking true care of patients. A new patient appointment averages twelve minutes, a return visit seven. Long gone are the days of Marcus Welby.
AI is going to profoundly change medicine. That doesn’t necessarily mean for the better. The applications of the technology may be narrow and specialized today, with many of its benefits still in the promissory stage, but eventually it will affect how everyone in medicine—not just pattern doctors, like radiologists, pathologists, and dermatologists, but every type of doctor, nurse, physician assistant, pharmacist, physical therapist, palliative care provider, and paramedic—does their job. We will see a marked improvement in productivity and efficiency, not just for people but for operations throughout hospitals and clinics. It will take many years for all of this to be actualized, but ultimately it should be regarded as the most extensive transformation in the history of medicine. The super-streamlined workflow that lies before us, affecting every aspect of healthcare as we know it today in one way or another, could be used in two very different, opposing ways: to make things much better or far worse. We have to get out in front of it now to be sure this goes in the right direction.
One of the most important potential outgrowths of AI in medicine is the gift of time. More than half of all doctors have burnout, a staggering proportion (more than one in four in young physicians) suffer frank depression. There are three hundred to four hundred physician suicides each year in the United States. Burnout leads to medical errors, and medical errors in turn promote burnout. Something has to give. A better work-life balance—including more time with oneself, with family, friends, and even patients—may not be the fix. But it’s certainly a start.
Time is essential to the quality of care patients receive and to their health outcomes. The National Bureau of Economic Research published a paper in 2018 by Elena Andreyeva and her colleagues at the University of Pennsylvania that studied the effect of the length of home health visits for patients who had been discharged from hospitals after treatment for acute conditions. Based on more than 60,000 visits by nurses, physical therapists, and other clinicians, they found that for every extra minute that a visit lasts, there was a reduction in risk of readmission of 8 percent. For part-time providers, the decrease in hospital readmission was 16 percent per extra minute; for nurses in particular it was a 13 percent reduction per minute. Of all the factors that the researchers found could influence the risk of hospital readmission, time was the most important.
In 1895, William Osler wrote, “A case cannot be satisfactorily examined in less than half an hour. A sick man likes to have plenty of time spent over him, and he gets no satisfaction in a hurried ten or twelve minute examination.” That’s true 120 years later. And it will always be true.
David Meltzer, an internist at the University of Chicago, has studied the relationship of time with doctors to key related factors like continuity of care, where the doctor who sees you at the clinic also sees you if you need care in a hospital. He reports that spending more time with patients reduced hospitalizations by 20 percent, saving millions of dollars as well as helping to avoid the risks of nosocomial infections and other hospital mishaps. That magnitude of benefit has subsequently been replicated by Kaiser Permanente and Vanderbilt University.
These studies demonstrate the pivotal importance of the time a clinician spends with a patient. Not only does a longer visit enhance communication and build trust, it is linked with improved outcomes and can reduce subsequent costs. It’s like an up-front investment that pays big dividends. That is completely counter to the productivity push in healthcare, where clinicians are squeezed to see more patients in less time. Of course, saving that money takes the doctor’s time. One study, called the Healthy Work Place, of 168 clinicians in thirty-four clinics, demonstrated that pace of work was one of the most important determinants of job satisfaction. A fascinating 2017 paper by psychologist Ashley Whillans and her colleagues, titled “Buying Time Promotes Happiness,” showed that time saving resulted in greater life satisfaction. The people studied were diverse, drawn from representative populations of the United States, Canada, Denmark, and the Netherlands, as well as a separate group of more than eight hundred Dutch millionaires. The increased happiness derived from purchasing time was across the board, independent of income or socioeconomic status, defying the old adage that money can’t buy happiness. The ongoing Time Bank project at Stanford University’s medical school shows how this works. The Time Bank is set up to reward doctors for their time spent on underappreciated work like mentoring, serving on committees, and covering for colleagues. In return, doctors get vouchers for time-saving services like house cleaning or meal delivery, leading to better job satisfaction, work-life balance, and retention rates.
Like my classmates back in 1975, most people who have gone into the medical profession are motivated by, and feel privileged to have, the ability to care for patients. To a large degree, the rampant disenchantment is the result of not being able to execute our charge in a humanistic way. David Rosenthal and Abraham Verghese summed it up so well:
In short, the majority of what we define as “work” takes place away from the patient, in workrooms and on computers. Our attention is so frequently diverted from the lives, bodies, and souls of the people entrusted to our care that the doctor focused on the screen rather than the patient has become a cultural cliché. As technology has allowed us to care for patients at a distance from the bedside and the nursing staff, we’ve distanced ourselves from the person- hood, the embodied identity, of patients, as well as from our colleagues, to do our work on the computer.
AI can help achieve the gift of time with patients. In 2018, the Institute for Public Policy Research published an extensive report on the impact of AI and technology titled “Better Health and Care for All,” projecting the potential time freed up for care of patients will average more than 25 percent across various types of clinicians. One of the most important effects will come from unshackling clinicians from electronic health records. At the University of Colorado, taking the computer out of the exam room and supporting doctors with human medical assistants led to a striking reduction in physician burnout, from 53 percent to 13 percent. There’s no reason to think that using natural-language processing during patient encounters couldn’t have the same effect. But the tech solution per se won’t work unless there is recognition that medicine is not an assembly line. As Ronald Epstein and Michael Privitera wrote in the Lancet, “Physicians, disillusioned by the productivity orientation of administrators and absence of affirmation for the values and relationships that sustain their sense of purpose, need enlightened leaders who recognize that medicine is a human endeavor and not an assembly line.” They’ve got it mostly right: we need everyone on board, not just leaders. If the heightened efficiency is just used by administrators as a means to rev up productivity, so doctors see more patients, read more scans or slides, and maximize throughput, there will be no gift of time. It’s entirely possible that this will happen: it was, after all, doctors themselves who allowed the invasion of grossly inadequate electronic health records into the clinic, never standing up to companies like Epic, which has, in its contracts with hospitals and doctors, a gag clause that prohibits them from disparaging electronic health records or even publishing EHR screenshots. This time it will be vital for doctors to take on the role of activists.
Unfortunately, doctors’ activism is unlikely to be supported by professional medical organizations, at least not in the United States. For one thing, there is no singular representation for doctors: the American Medical Association membership is not even one-third of practicing physicians. Worse, even that representation is hardly real: professional medical groups function predominantly as trade guilds to protect reimbursement for their constituents. There is a lot of capital available for potential influence, however. Of the top seven US government lobbyists in 2017, four were healthcare entities: Pharma Research and Manufacturers ($25.8 million), Blue Cross Blue Shield ($24.3 million), American Hospital Association ($22.1 million), and the American Medical Association ($21.5 million). These days, unfortunately, it’s used to protect financial interests, not the interests of patients or clinicians.
But even as tech gives doctors more time, that will not be enough. It is, however, the root of several necessary changes to how physicians are able to think about, and interact with, their patients that must be achieved if medicine will ever truly be deep.
This is an excerpt from Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again.