Like It or Not, Doctor: “You Have Mail”

I can recall the first time I faced a computer and asked it a question. I was an intern and I was asked to try a new system for collecting the results of morning blood tests for the twenty or so patients under the care of my team. It was in the fall of the Year of Our Lord, nineteen hundred and seventy-four. Thirty years plus a few days ago medicine and I entered the computer age. Since that time the role of the computer in medicine has expanded in ways that seemed unimaginable to me at the time. To be honest, at the time it was almost unimaginable that I had to take care of twenty sick people. I can recall quite clearly sitting at the computer while my group of students, fellow interns, and residents stood behind me and fired questions. One asked, “What’s Mrs. Tyson’s hemoglobin today?” Another asked, “Has Mr. Amare’s potassium level come up?” I took those two questions first. I typed in the names, the lab test, and the date. Presto! There on the black screen the white numbers of the results appeared in several seconds. I could hear the response of the group. “Fantastic” was the summary phrase. It was not because Mrs. Tyson had finally stopped bleeding or that Mr. Amare’s potassium level was finally up to a level that would support a heartbeat. No, it was because it was now clear that we would not have to start rounds in the hematology lab, then march to the chemistry lab under the cover of dark, followed by a trek to the radiology film library and finally crawl to the bacteriology lab to find out just what was growing in Mr. Thompson’s blood before we started rounds promptly at 7:00 AM. I could type and I could read. In a circle of summa cum everything with medical awards I was the guy who could get data and get it in a hurry. My days of medical training changed that morning. It changed for all of us on that clear, cool, fall afternoon in 1974.

It is 2004. I go to my office every morning and the very first thing I do (after getting a cup of coffee, of course) is turn on the computer and scan the e-mail. Ten new messages have arrived in the past twelve hours. Let’s see just what the e has for me. One is a Viagra sale in Canada. (delete). One is a sad story from a deposed prince from an African country who wants me to invest in gold “riches such as the world has never seen.” This prince is down on his luck. His own sister had him deposed. He had sent a mass e-mail six months ago and things in the family still seem tense. (delete) In another, a reader has taken issue with my, shall we say, journalistic talent. I sent him a cordial reply thanking him for reading my column. Three others were deleted without being opened as they were from our old friend, #!#$%%^&**(Who the heck is that guy. He writes everybody.) Finally, four e-mails were from patients. Two were college students giving me scheduled updates on their symptoms and asking for directions regarding medication changes. Another was to request a refill on a medication. I forwarded that to my nurse who will call in the prescription. I answered the patient with “done, have a nice day.” The final e-mail was from a patient who had had a CAT scan done two days earlier and wanted the results. He was out of town on business and was worried. This was a tough way to start the day. I had been called in the late hours of the previous day by the radiologist and was told that the patient had advanced cancer of the pancreas. I had seen the patient on only one occasion for an evaluation of mild upper abdominal pain and some weight loss. His wife had come with him, as there was a sense of trouble by the time he was referred. I did not answer for about an hour. Then I sent the message that his scan “showed some abnormality” in the pancreas and that I would discuss it with him in the office upon his return to the city.

For the remainder of the day, I felt very uneasy. I still feel uneasy. Just as thirty years ago, I knew that medicine would never be the same again. Because of the computer age and the speed of information transfer, I had told a patient by e-mail (if he concluded what I knew) that he had a terminal illness and that he might be dead in six months. In the age of information technology, there are times when the extreme desire to have data in a hurry joins forces with the power to provide it and the results are contrary to the basic principles of medical care. Doctors wish to assure patient confidentiality, and yet many, including myself, encourage patients to contact the office by e-mail. Patients agree that there is a risk of privacy invasion, but they are more concerned about their health issues than about privacy. Doctors try to be personal and humanistic, but at the same time may send a death notice by e-mail. Beyond the privacy issue and possibly dehumanizing aspects of the computer age in medicine, there are other practical matters to attend to. Unlike thirty years ago when I had twenty patients under my care as an intern, practicing physicians have several thousand patients seeking quick answers in a way that avoids “telephone tag” or an office visit.

Last week, one patient thanked me for some advice regarding her medications and concluded the e-mail by asking me to cancel her next office visit since her concerns were resolved. Some doctors are concerned that patients would flood them with e-mails and that answering them would be essentially practicing medicine for free as there is no reimbursement for a medical reply. I think the e-mail system of patient communication saves me time in that it does reduce phone calls for simple matters. At the present time, most of the e-mails are answered in a matter of minutes and fee-for - service has not been a significant issue. In other parts of the country, the matter has risen to the level of insurance coverage for such communications. That is a good thing and it will likely be a covered service nationally in several years. Most patients are very willing to pay for electronic medical care, but there is as yet no standard by which to apply a charge. In the broad scheme of things, we can expect that in the near future patients will have direct access to their own electronic medical record and that they may directly obtain lab and x-ray results without asking the physician.

It remains to be seen if the masters of information technology can find a way of telling a husband and father of three children that he has six months to live and do so in a way that bears any resemblance to the way that doctors and patient truly wish to communicate with each other. I doubt it.

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