Inside Story

Quo vadis, doctor?

Is technology endangering the doctor–patient relationship?

Jacinta Halloran 21 October 2022 2669 words

The last of a dying breed? One of Richard Baker’s images in A Fortunate Woman.

During my medical training I worked for a year as a resident doctor in a regional Victorian hospital. Conditions were less regulated in those days, so I was expected to work a solid nine-hour day in the wards and operating theatres while being on call — overnight and weekends, day in, day out — for births and other obstetric emergencies. Are babies often born at night? Yes, they are, or at least they were back then, when interventions made in the daylight hours — elective Caesarean sections and inductions — were much less prevalent.

Those were the days before mobile phones, when doctors still carried pagers that beeped whenever they were needed. Sleep-deprived and stressed by the onerous workload, my heart rate soared every time my pager sounded, its insistent beeping a reminder that I was, in essence, in servitude to the hospital’s consultant medical staff, nurses and patients. My time was never my own.

One weekend, in an effort to provide me with a much-needed afternoon nap, my visiting boyfriend wrapped my beeper in aluminium foil and placed it in a metal tin to prevent it from receiving a signal. It would have been much simpler to turn the awful thing off but I, in my befuddled state, had refused to do so.

In The Doctor Who Wasn’t There, a history of technological innovations in medicine, Jeremy Greene, medical historian and practising physician, devotes a chapter to the development of the medical pager, which he aptly labels The Electronic Leash. The pager was made possible by FM radio technology and marketed by Motorola and similar corporations in the 1960s as a modern tool to streamline a doctor’s professional life.

Just like the telephone before it, the pager proved a double-edged sword: greater connectivity meant more flexibility — a doctor could be out at a barbecue and still contactable if a patient took a turn for the worse — but also more accountability. If a doctor could be contacted then he or she should be contacted.

This is one of Greene’s recurring themes: the greatest enthusiasm for novel medical technologies was often on the side of those who stood to gain financially from their widespread adoption. Doctors, among the supposed beneficiaries, were usually more gimlet-eyed, not only about the extra demands this new technology might place on them, but also about how it might interfere with the doctor–patient relationship. “The medium of care is always contested by different parties with very real professional, political, and financial stakes at play,” Greene writes:

The source of contention has always been an exchange about technology and power. In the name of empowering the consumer of healthcare, technologists present their new platforms as essential passage points for the future of medicine. In the name of defending the humanity of the patient, physicians assert that no technology should displace the doctor from the bedside.

Again and again, Greene tells us, this tension played out with new technologies. Both entrepreneur and doctor viewed each innovation as having subversive potential. Those who stood to gain financially from the widespread adoption of whatever they were spruiking — the pager, wireless monitors, closed-circuit television clinics, the electronic medical record — saw only the benefits of this subversion: better access to information for health professionals, better quality care for patients.

One of the towering mid-twentieth-century figures in this debate was Vladimir Zworykin, vice-president for research at the Radio Corporation of America and, later, founder of the Center for Medical Electronics at the Rockefeller Institute. Zworykin championed a number of innovations, among them the mainframe computer. As well as seeing the computer’s potential to store all manner of medical data, he envisaged a day when the computer would become integral to the doctor’s interaction with patients.

“Zworykin insisted that the fundamental relationship between doctor and patient would only be enhanced, never degraded, by the presence of the computer in the clinic,” writes Greene:

In 1962, he asked an audience of physicians to imagine a typical medical clinic fifty years in the future, in which physicians were freed of asking the same questions, conducting the same physical exam over and over again, since a standard history and physical would be automatically performed by a human–machine interface. In the year 2012, he predicted, any “Mr Jones” stopping by Middletown Clinic for his annual check-up would see the computer before he would see his doctor.

But doctors were conflicted, and sometimes their concerns were motivated by self-interest. “Physicians believed that telephone, radio, television, and computer all enabled an extension of their professional authority,” writes Greene, “but worried they could also lead to loss of control of the conditions of their own labour, or, worse yet, might open up the private spaces of the profession for new forms of public critique.”

It wasn’t only the medicos who saw the potential downsides of an increasingly wired-up clinic. Much of the development in the field took place during the cold war, when concerns about tracking and surveillance were rife. Fast-forward to 2022, when, as Greene writes:

One out of every five US employers that offered health insurance in 2018 collected wireless physiological information from the wearable devices of their employees… Many firms now use Fitbits and Amazon Halos and other wearable sensors not just to monitor the health of their workers but also to optimise their daily work routines — and dock their pay for bathroom breaks.

Greene has meticulously researched his subject: his bibliography runs to more than forty pages. What’s more, he’s succeeded in creating a fascinating narrative from what might have been a very dry history of wires and batteries. I suspect he might himself be a gadget enthusiast, much like one of the book’s principal personages, Norman Jeff Holter, the cardiologist inventor of the Holter heart monitor, which is still widely used today. Holter’s electronics laboratory had its origin above the family grocery store, and I can imagine Professor Greene holed away in his backyard shed on weekends, happily tinkering with circuits.

I’m not a Luddite but neither can I claim to be particularly tech-savvy; still, my interest was piqued by such things as the incredibly useful spin-offs of the humble telephone: the miniature telephone, which eventually became the hearing aid, and the telephone-probe, distant cousin of our contemporary diagnostic ultrasound.

The Doctor Who Wasn’t There was partly written during the pandemic, when telehealth was the top-of-mind medical technology for healthcare workers. While the telehealth industry was already attracting substantial corporate investment in the United States before Covid-19 came along, it was still in the early stages of implementation. The sudden onset of widespread lockdowns in 2020 saw the health workforces of the United States and many other countries — those that were digitally resourced — rapidly pivot to this mode of service delivery.

Inequities quickly emerged. Reflecting on his own experiences of working in a community clinic in East Baltimore, Greene writes:

In my first full month as a telepractitioner, not a single African American or Latino patient was able to successfully access the full telemedical suite in my clinic sessions… Similar challenges of equity in access to telemedicine were reported in community health centres and other primary care practices in Philadelphia, New York, and Boston. Video visits were repeatedly found to be less common in telemedical encounters among Black and Latino patients, and in households earning less than $50,000 per year.

This pattern of inequitable access to novel technologies is another strong theme of Greene’s history. In 1971, for example, a physician in Boston built a microwave link connecting a remote urgent care clinic to the emergency room of Massachusetts General Hospital, and federally funded demonstration projects for similar technology were set up in Harlem in New York, on the West Side of Chicago, in rural Vermont and New Hampshire, and on Native American reservations in Arizona. In the end, though, these technological experiments in disadvantaged communities fizzled and died when interest turned to some other emerging technology.

I was working at a metropolitan Headspace centre during the pandemic and found my young patients to be very comfortable with video consultations so long as they had a private space in which to talk. One of the common healthcare barriers for young people is physical distance and lack of good transport options: with the click of a mouse, telehealth removed this obstacle. But my experience was not the norm in Australia. As a recent nationwide survey of telehealth services during the pandemic found, people with disability, people on low incomes, people with limited education and employment, older people, Aboriginal and Torres Strait Islanders and people in rural areas were most affected by the digital divide.

At first blush, writer and documentary maker Polly Morland’s A Fortunate Woman is the antithesis of Greene’s book. In lyrical, reflective prose, Morland charts the daily life of a female GP who works in a picturesque rural English setting. Medical technology is barely mentioned; instead the focus is squarely on the doctor–patient relationship. This relationship is precious, Morland argues, and also under threat.

Morland’s book is charged with great admiration for her doctor-subject and an anxiety that the way this doctor works may not be sustainable. Of general practitioners in Britain as a whole, she writes:

Workloads have increased. Practices and their teams have got larger. The role of technology has expanded. Part-time working has become the norm [as it] is often the only way to endure the pressures of the job. All the while, the wholesale management of risk according to standardised guidelines trumps the judgement of individual doctors… As patient numbers have risen, access to a doctor, any doctor, has become the overriding priority, and individual relationships find themselves pushed to the margins.

Morland reports “a rising sense” among GPs that these pressures constitute “nothing less than an existential emergency.” Concerns that something vital is being lost have fuelled “an intensifying research effort to understand, articulate and quantify the value of the human relationships within medical care, before it’s too late.”

What will become of the doctor at the bedside? Richard Baker

This is not a uniquely British phenomenon. Pandemic imperatives and stresses aside, many Australian GPs are struggling with the pressures of running a small business in addition to their medical work, which is intellectually demanding and time-consuming enough. Medical graduates, meanwhile, are turning their backs on general practice as a career. Recent Western Australian research shows that the number of medical graduates working as GPs more than halved among those who graduated between 1985–87 and 2004–07, dropping from about 40 per cent of graduates to about 15 per cent.

Why so? Commentators point to the negative press general practice often receives during student training and the failure of Medicare rebates to adequately reflect the cost of providing good-quality care. Yet, as Morland observes, general practice is the speciality that provides the bulk of continuity of care and disease prevention. This counts for a lot: in fact, Morland claims, there’s evidence that continuity of care is linked to lower death rates. “An existential emergency” may not be an overstatement.

Morland came to write her book soon after reading writer and critic John Berger’s A Fortunate Man, first published in 1967 and reissued by Canongate books in 2015. By all accounts this slim volume has a minor cult following in the British medical world. It takes as its subject a male GP Berger met through a mutual friend; Berger gives him the pseudonym of Dr John Sassall. Berger portrays a highly admirable GP, knowledgeable, capable and completely dedicated to his patients’ physical and psychological wellbeing. He was also mentally unwell at times. A sufferer of what was thought to be untreated bipolar depression, he suicided a year after the death of his wife.

The title of Berger’s book, then, carries a chilling irony. As Gavin Francis, a British GP and writer who contributed the introduction to the new edition, wrote in the Guardian, “A careful reading of A Fortunate Man reveals its title to be a paradox; fitting for a study of a man whose very openness to experience — his gift to the world — was also his undoing.”

Further impetus for Morland’s book came from a twofold discovery: that the bucolic valley in which A Fortunate Man was set was the same valley in which she now lived; and that the current female GP in the valley had decided on her career path after reading Berger’s book as a seventeen-year-old. A Fortunate Woman is both tribute and palimpsest. It reverentially references the text that inspired it while replacing John Sassall with his contemporary female counterpart, his style with hers.

This female GP, known throughout Morland’s book only as “the doctor,” is of a different generation, and much has changed since Sassall’s time: general practice is more regulated and bureaucratic; patient numbers have increased, as has the complexity of care; and the GP workforce in Britain is now 69 per cent female. (In Australia that figure is just over 50 per cent.) All this has implications, for both the nature of the work and how the GP responds to its demands.

Like its predecessor, A Fortunate Woman can be viewed as an extended photo essay. Berger’s book contained black-and-white photos by Jean Mohr, some showing Sassall examining and treating patients with both doctor and patients clearly identifiable. Mohr also photographed the landscape in which Sassall worked.

Richard Baker’s photos in A Fortunate Woman are in the same mould, except they were taken during the pandemic, and the doctor’s face is largely obscured by a mask, protective eyewear and visor. Patients, too, are masked, so the anonymity of all concerned is largely preserved. These images serve as a historical record of a time when some aspects of the doctor–patient relationship we took for granted — the sharing of a close physical space, the touch of a caring hand — were not always possible.

Morland’s style is beautifully measured, its tone empathic and warm. She writes perceptively and tenderly about both the doctor’s daily interactions with patients and the external environment from which she, the GP, derives much of her equilibrium. She rides her electric bike from her cottage to the clinic, then afterwards to home visits, traversing the narrow, walled roads and winding lanes of the valley, visiting breathless elderly women, stoic farmers, even a dying child. She finds solace in a quiet evening walk with her dogs. The external environment can work against the doctor, too: the winding lanes and lack of street names make home visits a navigational challenge, and a snowstorm threatens to halt proceedings on the very first day of the Covid-19 vaccination clinic.

Morland’s GP is a country doctor archetype — a wise and caring diagnostician with unbounded energy, a good sense of humour and the patience of a saint. The last of a dying breed, perhaps. The constraints of working in such a way — economic, geographic, workforce, psychological — are continuing to tighten. Can technology save the day? Will some form of AI — the “electronic brain” envisaged by Vladimir Zworykin and his contemporaries — become our standard medium of medical care? What, then, will become of the doctor at the bedside?

The stethoscope of the early nineteenth century, Greene tells us, was a new technology of the time, with its champions and detractors. Now older physicians lament the fact that their younger counterparts don’t use the stethoscope like they do, relying instead on newer modes of listening. The future of medical practice will look different from its past: this is inevitable. Both of the books under review here are concerned with this process. Morland asks that we strive to preserve the humanity of the doctor–patient relationship. Greene urges us to stay awake to the errors of the past. •

The Doctor Who Wasn’t There: Technology, History, and the Limits of Telehealth
By Jeremy A. Greene | University of Chicago Press | US$29 | 336 pages

A Fortunate Woman: A Country Doctor’s Story
By Polly Morland | Picador | $34.95 | 256 pages