What Can Hidden Video Teach Us About Our Healthcare System?

Dr. Gretchen Berland, an assistant professor at the Yale University School of Medicine and former documentary filmmaker, writes in the New England Journal of Medicine of an extraordinary experiment she has conducted over the past 10 years. It involved giving videocameras to people in wheelchairs, and asking them to document their daily lives (samples of the videos can be seen here). The footage provides insight into the struggles faced by the disabled in conducting daily activities; it also provides a penetrating view of what happens during visits to the doctor, replete with considerable potential for communication breakdowns. At best, a common result is that doctors don’t get the full story of a patient’s condition; at worst, the patient can wind up receiving inadequate or improper care. Berland describes her findings as follows:

By the time Galen Buckwalter‘s physician knocked on the exam-room door, Buckwalter’s video camera had been recording for nearly 40 minutes. He had booked the appointment because his shoulders were hurting, and the camera recorded his view of the examination table, the comments he made while waiting and, eventually, a largely transactional and superficial exchange with his physician. Two weeks later, in his home, the camera would record a strikingly different take on his shoulder pain – a growing problem that, Buckwalter worried aloud, might cost him even more of his cherished independence.

As an internist, I was disturbed by the contrast between those two scenes, the second revealing the depth of Buckwalter’s concerns and fears, none of which were apparent during the conversation with his doctor. In the later tape, Buckwalter’s struggle is palpable. If such stark contrasts are common, how much do I really know about my own patients? Probably far less than I care to admit.

Berland candidly assesses a major flaw in our healthcare system, the various shortcomings of which Dubner has discussed before. Incomplete communication during visits only adds to the existing soup of unnecessary treatments, huge expenses, and potentially deficient coverage. Surely there must be ways, besides a basic “Yes/No” survey on a clipboard, to streamline the process of initial doctor visits so that patients feel comfortable giving physicians the bigger picture. Perhaps an online log that patients can fill out and doctors can review before the appointment, describing conditions and symptoms in detail, or even documenting pain levels for the few days prior to the visit? Any other ideas?

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  1. Doug says:

    Other ideas? How about more time to interact with the doctor and discuss the problems or utilizing something akin to a system of case managers to interact with the patient not only in the intake process but also to follow up regarding the course of treatment? More expensive perhaps but probably more effective too.

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  2. dd says:

    I wonder if having patients give full histories to nurses and letting the nurses convey the salient points would work. That way, someone hears the full story, but it doesn’t require as much of the doctor’s time.

    It would still be prone to human error, of course, but at least a nurse is more suited to the job than a piece of paper.

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  3. nordsieck says:

    This issue parallels quite nicely with the call center industry. The way to reduce costs is not to make interactions short, but to deal with real customer issues as quickly and efficiently as possible (on the first time). Yes, there are a lot of people out there who want comfort medicine, but there are a lot of people who keep going back to the doctor’s office.

    If efficiency was measured by per-patient-issue-resolved rather than by doctor-facetime-per-visit, a much different picture would emerge.

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  4. misterb says:

    Perhaps a big part of the problem is that we use doctors for things that nurses and med techs could handle at least as well. If doctors were able to concentrate on cases of life-threatening illness, and weren’t required to treat less serious conditions, patients could get better care in both cases.
    Reasons this won’t happen:
    1) legal exposure
    2) the patients themselves don’t want “second-class” treatment even if it’s measurably better.
    3) the drug companies would fight any non-medicinal treatments tooth and nail
    4) The AMA would fight for its monopoly

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  5. Shameem says:

    re: call center…. and on the plus side..we could outsource to india.

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  6. Ben G Thomson says:

    Agree with #2, dd that “having patients give full histories to nurses and letting the nurses convey the salient points” is a good idea. I’ve been to two doctors in the same specialty, same office, for two different problems – both had somebody take the time to get my full story before the doctor appeared.

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  7. Michael D says:

    I think the online log is a great idea, but does not remove the problem of ineffective communication. I always wondered why the diagnosis process was not more automated. Diagnostics (simply put) involves the piecing together of symptoms or variables to arrive at a conclusion. The doctor is relying on experience and/or knowledge, neither of which may be complete. Why not have a web site for your health profile? (lets forget about privacy issues for now) It would be a repository of your full medical history. Guided questions could be flow-charted based on current symptoms and past medical history. The time spent with the doctor would more focused, since the data is now standardized and summarized before the visit. The appropriate actions would then take place (further testing, medications,etc) based on the output of the web site. Progess could then be tracked online and appropriate next steps recommended.

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  8. Brian Burke says:

    I read an article within the past year about how although we hold doctors to high standards, there is more to the story. Patients have to do a good job of helping the doctor during the visit. I would bet it can be frustrating to be a doctor trying to extract relevant information form a patient.

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