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It's on You

by Emily Friedman

First published in Hospitals & Health Networks OnLine, 5 April 2005

The health care aspects of this increasingly do-it-yourself society raise questions about quality, safety and priorities for patient and provider alike.

The idea came to me after a busy but not unusual day. I went to the grocery, where once upon a time the clerk at the photo section would hand me my pictures. Now the clerk is gone, replaced by a rack of packages of processed photos (that anyone can steal, I might add) from which one chooses one's own, if one can find them amidst a jumble that has reduced the alphabet to a series of random letters.

Then I got my groceries and stood in line with all the others who were waiting for service from the two checkout stations that actually had live people doing the checking out. There were, of course, many self-checkout stations, but I have avoided them ever since I put my purse down at one of them to get out my credit card and the machine started yelling at me that there was "an unchecked item" threatening the sanctity of the entire system.

I then went over to the bank that is conveniently located in the grocery, which is a good thing, because while this bank normally has nothing but self-serve locations, the grocery store ones are staffed, though by a few overworked and undertrained young people. The line was quite long, so I ended up using the ATM, of course.

I then went to fill up the car with gasoline, but the card reader at the pump was broken (although it was not labeled as such), so after several tries I had to go into the office and wait in line and take the abuse of the clerk who insisted that I should have charged the gas at the pump. The one with the broken card reader.

And then I went back to the office and spent the usual two hours plowing through e-mails, many of which were responses to sent messages that were responses to sent messages that were responses to sent messages. I estimate that at least 30 percent of the e-mails I receive represent 10 to 20 exchanges; in most cases, the issue at hand could be settled by a three-minute phone call. Most of the rest of the e-mails were reports, press releases and research that I, of course, have to download and print out, because in most cases, mailed print versions are no longer available.

The next day I went to the airport, where the line to speak to a human being was out the door. They want you to use the self-check-in kiosk, but I have not yet been able to master this particular technology, owing to the fact that it requires information that I never seem to have and to which I do not believe I have access. It is also useless if there are any special circumstances, and if you fly the airline I use, there are almost always special circumstances. And besides, half the time the thing is broken.

I do not share these gripes with you because they are anything special with me; indeed, these are the parameters of contemporary life. And none of them, by itself, is any big deal. The problem is that there are so many of them, each one developed by somebody who thinks, "Well, it's just a little bit more work for the customer." And the cumulative effect is that it's a lot more work.

These thoughts led me to consider the implications of all this for the health care system, the people who work in it and its patients.

A Growing Burden

The first implication of the increasing reliance on technology that replaces people is that in many areas of our lives, we have to spend more time doing things that other people used to do for us. The technology certainly is cheaper than having human beings do the work; the problem is that, to a large degree, human beings are still doing the work. It's just the customers who are doing it.

(One must also wonder about the consequences of shifting work from someone who was paid for it to someone who is not. In other words, who is really benefiting from this economic "recovery," most of which seems to be represented by layoffs and outsourcing that are rewarded by the market?)

Health care, by its nature, is labor-intensive. And people who work in health care are becoming more and more burdened by all this "labor-saving" technology. Nurses, in particular, have been raising the alarm for years about the amount of time they must spend on work that is not direct patient care. In some instances, they have resorted to extreme measures, such as the California Nurses' Association's successful ballot referendum requiring higher nurse-to-patient ratios in hospitals. The hard-fought battle to reduce the hours worked by medical residents is another example. The unions seeking to organize health care workers have found a fertile issue in mandatory overtime. Efforts by health care organizations to reduce staffing levels in the face of high personnel expenses and labor shortages (and, sadly, in many cases, the desire to increase profits) have created quite a backlash.

There is reason to be concerned about nurses and techs and physicians who are bombarded constantly by demands for higher productivity and requirements that they learn this or that new technology. Given that they, too, have to deal with ATMs and do-it-yourself checkout and airline kiosks and broken card readers, they're just as tired and overworked as everyone else. This can, and does, lead to their being distracted, resentful and more prone to error. And as support staff are replaced by yet more machines, there are fewer places to turn for relief.

A Steep Learning Curve

A second consideration is that many of these technologies have a very steep learning curve, and often training is incomplete, rough-and-ready or nonexistent. In the early 1980s, my then-employer implemented a word processing system. We all went to school for three or four full days to learn how to use it. We even had a real, live teacher! These days, you are lucky if you are vouchsafed one two-hour class. Much of the time, the training consists of a CD, or, even worse, instructions to "Ask Charlie" or "Call IT if you have any problems."

And we always have problems. Both the hardware and the software are hard to learn even when they are working properly, which can be a rare event. Much of the programming is counter-intuitive or even downright weird in terms of its own twisted internal logic. And that's leaving aside the joys of viruses, hackers, bugs, glitches and crashes. (And, for women, the irritating tendency of IT techs to assume that if you are female, you must be a technological dunderhead.)

Put this into a health care setting, and the dangers are significant. As we become more dependent on machines, our ability to operate them properly and interpret their outputs correctly becomes ever more critical. Looming on the very near horizon (or already here) are electronic health records, communitywide health care databases, massive amounts of information on provider performance, and public release of quality data. It would be comforting to think that the people involved in these efforts are properly trained in the technology and can handle the responsibility. Instead, they may be folks in another country whose English-language skills are poor and whose computer skills aren't that much better. Even sophisticated U.S. techies can have lapses; the recent, very public, massive overestimation of the impact of obesity by analysts at the Centers for Disease Control and Prevention is one of many examples. The gross underestimate of the true costs of the new Medicare law is another, although there is strong evidence that this was done intentionally.

And, of course, at the patient bedside, the technologies continue to proliferate; we can only hope that the people using them know what they are doing. History tells us that this is not always the case.

Asking Too Much of Patients?

On the patient side of the equation, there is also an increasing workload, some of it quite demanding. As part of my annual physical, I was asked to provide a specimen for analysis. The prep requires, among other things, a greatly modified diet for a week; a prohibition on eating a wide variety of foods that I happen to like a lot, including broccoli (yes, I like broccoli) and cantaloupe; and a ban on taking vitamins and painkillers. Furthermore, the instructions for actually collecting the specimen were so complicated as to be hilarious.

Halfway through the week of prep, I pulled a muscle in my rib cage. I carried on for two more days, in great pain, avoiding painkillers, but I did get rather tired of not being able to sleep. Then I realized I had already blown it because there were some pieces of broccoli hidden in a salad I had eaten in a restaurant. I had to start all over.

It seems to me that the technological Powers That Be might be able to come up with a test that does not require patients to completely disrupt their lives in order to produce a specimen. But then, if the Powers That Be were subject to the same things they put patients through, we wouldn't still be doing mammograms.

The point is that as more and more work is shoved onto patients, it simply adds to the burden created by all the other things people are now forced to do for themselves. And I fear that they will simply avoid doing some of these things, which does not bode well for preventive health. This system should be making it easier for people to live healthy lives and to recognize early warning signs and engage in effective prevention of disease; instead, we are making it harder for them. I have several college-educated, intelligent friends who have simply refused to get some of the tests they should have because of the inconvenience, stress, pain or all of the above that is involved. And they have decent insurance; for those of us who do not and are thus underinsured, on top of all the other fun, we get to pay for the pleasure!

Too Much of a Good Thing

And this is only the beginning. With defined-contribution health plans, malpractice-shy physicians and pharmaceutical firms with products to sell all seeking to ensure that patients are highly "informed," the amount of information (and misinformation) that is starting to pour forth would confuse anyone.

Just look at the arthritis drug situation. First Vioxx was pulled off the market, then warnings were issued about Celebrex, then Bextra came into question, and soon all COX-2 inhibitors were associated with much higher rates of heart disease. Makers of over-the-counter painkillers started advertising that their drugs are safer, unless you have stomach problems or liver trouble or any of a half-dozen other complaints. One manufacturer started running an ad that urged patients to use its product, but added, "If you aren't going to take our product properly, we'd rather you didn't take it at all." The snake-oil crowd on the Internet also has products to push.

Then an FDA panel, many of whose members have close and lucrative financial ties to the pharmaceutical industry, decided that maybe COX-2 inhibitors aren't such a bad thing, as long as they are used in low doses, in which case they won't work very well. But this way, if the patient takes too much and has a coronary, it's on the patient, not the FDA or the drug makers.

And the 84-year-old patient with severe arthritis pain can only ask, "What on earth am I supposed to do? What's the truth? Who can I trust?" I don't know that we have an answer for her.

This happens every day in every way as lay people try to figure out what insurance to buy, what drugs to take, which physician to choose, which treatment option to select. Drowning them in conflicting, sometimes intentionally misleading information does not create an informed patient; it creates a confused and often angry patient. Equally important, it creates a patient who cannot or will not do what is expected, even demanded, of him or her.

No Blast from the Past

None of this should be seen as a plea to return to the good ol' days of paternalism in health care, when the physician was all-powerful and the meek little patient did what she was told. I firmly believe that the enormous advances we have made in patients' rights--from the ability to refuse treatment to the choice of hospice to self-care at home to the growing availability of information on provider quality--have made both the system and the care better. Likewise, many of the new technologies are going to make health care safer, more effective and, one hopes, less painful and disruptive.

But at the same time, we need to be sensitive to the fact that lack of time, difficult technologies and information overload can run counter to the goals of the health care system and the wishes of patients and providers. It is a question of keeping our priorities straight.

Note to our readers: In my last column, I had a brain-free moment and identified Sen. Evan Bayh of Indiana as a Republican. He is, of course, a Democrat. Please forgive the error.

First published in Hospitals & Health Networks OnLine, 5 April 2005

Emily Friedman 2005

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