Grapes of Medicine
“And it came about that the owners no longer worked on their farms. They
farmed on paper; and they forgot the land, the smell, the feel of it, and
remembered only that they owned it, remembered only what they gained
and lost by it. … Then such farmers really became storekeepers, and kept a store.”
At the suggestion of a friend, I recently re-read The Grapes of Wrath and I was struck by the similarities between how landowners treated their farmers, and how doctors treat their patients.
The story centers on the Joad family floating amongst a flood of migrant workers, kicked off their land by large corporations, as they make their way to California only to be met as “the other” and get treated as sub-human by landowners. What Steinbeck wrote almost 80 years ago about the industrialization of farming is replaying itself today in the form of the digitization of doctoring. It is almost too easy to read the quote above and replace “owners” with “physicians” and “farms” with “patients”. Electronic medical records (EMRs) allow physicians to detach from a lot of the hands-on aspects of doctoring and to treat healthcare more like a storefront.
When I began residency, I was told to bring a computer with me into patient’s rooms so that I could work on my note while taking a history. I distinctly remember searching through old notes to find a description of a rash until I realized that I could just look at the patient sitting in front of me. Lost in the myriad of notes from years ago, I had forgotten about the patient entirely. In his 2008 essay about the creation of the “iPatient”, Abraham Verghese lamented on this exact loss of the physical exam in the age of EMR. But the distance created by computers does more than erode our clinical skills, it also enables us to fully detach from our patients as human beings, akin to the detachment between the Californians and the migrants:
“Sure, they talk the same language, but they ain't the same.
Look how they live. Think any of us folks’d live like that? Hell, no!”
The “us versus them” mentality runs deeply through medicine, but this is not something new, and it is often necessary for physicians to dissociate from their patients. However, with EMR as an ever-expanding buffer, we’ve begun to dissociate so far as to forget about the original patient. “The Chart” has become the proxy patient. We often believe history written by an unknown third party more than the patients themselves. Instead of treating a patient with heart failure who was hoping to leave by Friday to see their grandson play baseball, we treat an anonymous 79-year-old male with a compilation of complex diseases and a set of lab derangements that need to be corrected, who is threatening to leave against-medical-advice prior to the creatinine returning to baseline.
The bleak dystopian novel that could be written about the future of medicine would include doctors who never see their patients, never get to know them, and just prescribe medications based on algorithms like the A.I. that will soon replace them.
But this is not necessarily our future.
The Grapes of Wrath ended with one of the most iconic and depressing scenes in literature, which I will not ruin for you here, but the story is just a stepping stone in history. Taken into perspective, the revolution of industrial agriculture has been a tremendous boon to society, but as often is the case, the people stuck in the transition period suffer from the radical change.
Perhaps we are now in that transition period, where the bloat of EMR is just the storm darkening before the dawn. EMR has already helped with the efficiency of medicine, reduced medical error, and improved outcomes. Albeit this has come at the cost of one of the core tenants of our profession - humanism. But EMR is constantly improving and in the future, we may see breakthroughs such as voice recognition and A.I that will maintain the efficiency of mass data but allow us to retain personal connections with patients.
But while we are in this transition period, let’s not forget the patients stuck in rooms with physicians who stare at screens and click. Next time you are in a patient’s room, try to remember that the chart is only a set of words and numbers, and it is not those words and numbers that you are treating, but the person in front of you.