Discipline is no longer simply an art of distributing bodies, of extracting time from them and accumulating it, but of composing forces in order to obtain an efficient machine.
– Foucault, Discipline and Punish
This past Friday, I sat in a room of twenty physicians arranged in rows, each with a TV-sized computer monitor in front of him. We gathered on a Friday to learn the new computer system. We arrived begrudgingly, and in a similar ritual, complained in whispers about our very attendance. Much has been written recently about the “digital revolution” in healthcare. On the one side, icons like Eric Topol, author of “The Patient Will See you Now,” are technology apologists. He will not be surprised if in twenty years we all carry our genome on a flip drive, and in fact, will be thrilled he predicted it. On the other side are the cynics; the countless physicians concerned about the intrusion of the “ipatient” and its’ resulting erosion of the doctor-patient relationship. This Friday, I couldn’t help but wonder if something more existential was at stake. What type of person does modern healthcare seek to create?
I looked around the room again, and noticed twenty of the most highly educated Americans staring blankly at a computer screen, in unison typing out a fake message to a fake patient. In the course of the three-hour training, not one physician asked a question, smiled, or interacted with her peers. The language of the training was not about improving patient care, or patients’ lives, but around “meaningful use” and “quality metrics.” The teacher, a bushy-eyed tech savvy 22 year-old, informed us that we “will learn how to do problem-oriented charting” and then gave a mini-lecture to a group of physicians telling them that they have been documenting wrong all along. What type of person emerges from this training – one compelled to use technology for the good of patients, or a pacified subject? Physicians seem to be becoming docile bodies, whom, in the words of Foucault are “ones that may be subjected, used, transformed, and improved, and that this docile body can only be achieved through strict regiment of disciplinary acts.”
What is the use of calling physicians “docile bodies?” I would argue that at the minimum, it changes the dominant narrative of increased technology in medicine as both progress and inevitable. Indeed, EMR (electronic medical records) have led to increased patient safety in terms of fewer medication errors and streamlined lab processing. At the same time, reliance on EMR has in places increased physician burnout, and led to decreased time with patients, which may in the long-term reduce patient adherence and lead to drastic health consequences.
The rhetoric used to promote EMR technology describes the physician as anything but docile. To do this, it relies on three very simple myths. The first myth is that through personalizing their computers, physicians can express themselves. As an example, here is the computer trainer, touting the benefits of the choice: “you can arrange settings based on your personal preferences… whatever works for your own personal style.” The second myth is that maximizing electronic communication is always desirable. As an example, in order for a physician to update patient information, they have to type in the new patient information, search for how to send it to the front desk, and personalize a message to the desk staff. A few years back, a physician may have stopped by the desk to say, “Just a heads up, I updated the patient contact.” This may appear to be a trivial example, but the reality is that hundreds of interactions will be made more cumbersome, less personal, and more specialized. Note in the prior example that it is not possible for a physician to update patient information on her own. The third myth is quite simply the faith that the benefits of technology in healthcare will drown out its unintended consequences.
There are surely immense benefits from powerful technology: the ability to get up to date population health data, to view records from other providers, and to give patients access to their medical records. But there are also real dangers, both technical and existential. The existential danger is that physicians are beginning to internalize an identity as documenters and processors of data, over an identity as caregivers. This danger goes all the way from the top to the bottom. Just the other day, I worked with a pair of medical students, who from 1-4pm dutifully typed patient progress notes, which I skimmed in 2 minutes. One note was on an alcoholic who was interested in detox programs. I asked the student to go talk to the patient, for however long necessary, to figure out what the patient needed. The student was confused – did I want him to do a brief motivational interviewing session, a full physical exam, or both? The student came back 15 minutes later with a completed checklist of items. We stood outside the exam room and talked, about the patients’ family, his prior detox attempts, and whether he felt he had enough support at home. I could tell the student felt uncomfortable; some of the information was on the computer, and he wanted to get back to the chart.
The physician in modern US healthcare is becoming a full-fledged “docile body” tending and tidying the electronic world. I think the sacrificial instinct of physicians is to unconsciously accept this as the burden necessary for the privilege of being a caregiver. It is similar to the compulsion to work a 100-hour week – it is the least we can do in comparison to the suffering of our patients. We will silently sit through computer trainings, collect a paycheck, and bemoan the new system in professionally acceptable ways. After all, our patients need us. The missing piece is the existential question “What type of people do our patients need us to be?” This is not a question we can answer with checklists, algorithms, or lectures on professionalism. If I’m forced to choose between talking with my patient for an hour, or to maximize the hospital revenue based on his admission, I will err on the side of conversation. And if this isn’t medical professionalism, I don’t know what is.
Image courtesy of Wikimedia Commons.