Both patients and doctors have expressed dismay at the way health care currently is delivered in this country, driven by market forces. The essence of healthcare has traditionally hinged on the personal relationship between a patient and a doctor, freely chosen by the patient to provide needed medical services. It’s easy to sit and lament that the days of the home-visiting, hand-holding, kindly doctor carrying his black bag are gone.

There was something comforting about seeing the physician arrive; he (it usually was a man) seemed like a living antidote against the fears of illness. Kindness, concern, and hand holding were some of his most powerful tools. The black bag hardly carried any drugs that could cure illness. Early in the twentieth century, Supreme Court Justice Oliver Wendell Holmes is said to have remarked that “if the whole of the materia medica, as used now, could be sunk to the bottom of the seas, it would be the better for mankind-and all the worse for the fishes.”

So be careful in wishing for the “good old days” of health care. The care might have been kinder and gentler, but the ability to diagnose and treat was primitive compared with today’s remarkably sophisticated methods. The striking extension of the average length of life for both men and women is evidence of the success. Medicine has become increasingly “high tech” in terms of the tests to find out what is wrong. Hearing the patient’s main complaint, the story of the illness, and doing a physical examination form the cornerstone of making a diagnosis, but they are far from sufficient today. Blood tests, scans, and X rays all sharpen the accuracy of the diagnosis. But all these “smart tools” have had the effect of distancing the doctor from the patient, and placing less importance on their interacting with each other. Increasing evidence suggests, surprisingly, that computers may be able to take diverse clinical information, process it, and come up with a more reliable diagnosis than the physician who is relying on clinical judgment alone.

In a medical equivalent of the Deep Blue versus Gary Kasparov chess contest, Lars Edenbrandt, an artificial intelligence expert at the University of Lund in Sweden, pitted a computer against a physician. Edenbrandt, programmed the computer to “read” electrocardiograms (EKGs). He trained the computer by feeding it more than ten thousand EKGs, telling it which were from patients who had heart attacks. He then asked Dr. Hans Ohlen, an expert, to read several thousand EKGs and indicate which ones represented heart attacks. The computer rated the same EKGs-and won, with 20 percent greater accuracy.

What seems like a “bad news” story for the doctor-patient relationship may in fact have a silver lining. We can get greater accuracy and fewer errors in diagnosing diseases using technology, but there may be additional benefits. In a recent NEW YORKER article, describing this new computer capability with the potential to replace the fallible human being, Atul Gawande pointed out that in a new era “

[physicians] will be freed to do what only they can do…talk to their patients. It’s because medical care is about our life and death that we need doctors who can address our fears, hopes, and ignorance. Doctors who can help give meaning to what we’re going through.”

It’s not only high-tech diagnosis but also high-tech treatment that is changing medicine. The more high-tech the treatment a patient must go through, such as bone marrow transplantation or repeated cycles of high-dose chemotherapy, the greater the need for the “human touch,” since the emotional and human needs are greater. Fortunately, we have many ways to help patients cope with treatment today, including many things that might be called “high touch”. In addition to the technological changes in medicine, health care in the United States has been turned on its ear in the past decade by managed care. The effect has been to batter the old-fashioned doctor-patient relationship. Health maintenance organizations (HMOs) and other managed-care plans, reimburse physicians at such low rates per visit that doctors schedule shorter and shorter office visits in order to see more patients. Both patients and doctors decry the new order that speaks of vendors, customers, and products. Health care is something that was valued as somehow set apart from, (and above) the world of business and the marketplace. Clearly, if patients and physicians banded together to protest, they could be more effective than either group could be alone. There is a need for new partnerships, between patients and physicians at a societal level.


These current problems point out even more emphatically how important the bond is between a doctor and a patient with cancer. The mind is the only organ that is involved in every patient with cancer. Meaning the human dimension is the only aspect of cancer care that is involved in every encounter, with every patient, at every visit, no matter what the cancer diagnosis is or whether the treatment is surgery, radiation, or chemotherapy. You would think this fact would have gotten more attention in medical schools, especially regarding cancer, but it has been slow to be recognized. Medical schools are now beginning to provide doctors with training in how to give bad news. More effort is being made to teach the importance of communication and how to do it better. Patients and their families repeatedly stress the importance of the way the diagnosis is presented and how helpful it can be when it is told in a sensitive and kind manner.

Joan a thirty-nine-year-old journalist, had her annual mammogram. The results were sent to her gynecologist, who called her and said, “I have the results of your mammogram, and I need to see you. We’ll likely need to get a biopsy.” Following the biopsy, she went back to her doctor, but this time Joan asked her husband to go with her because she had become increasingly anxious and worried, and she was not thinking as clearly as she usually did. The doctor sitting with them said, “The biopsy confirms what I thought it might be. The spot on your mammogram (remember you saw it, too?) is an early form of breast cancer. I know you must feel shaken, but we caught it early, and actually this type of cancer is highly curable. What we have to do is remove the lump first. Then we’ll give some radiation to the breast, and after that, we may want to add chemotherapy.” Joan began to cry. “How can I deal with this now? I have my mother’s illness and the children need me. Are you sure?” H