Dr. Andrew Smolar: Medicine and humanity

Doctors have known for some time that we are falling short of our humanistic ideals. It was my turn to learn it firsthand.

I had avoided covid until February. Although I had a short course — mitigated by Paxlovid— some weird lab results surfaced after I recovered. My internist wanted me to see a few of his colleagues.

I started at LabCorps. The portal told me there was no opening locally for three weeks. I figured I’d ask the people at the closest branch, three buildings from my office. I showed up in person. The receptionist said, “Oh, forget that broken locator — just come tomorrow morning at 7.”

I arrived at 6:56. There were already five people waiting, dressed for work, looking edgy. One worker was behind the front desk drinking coffee. At 7:05, the phlebotomist arrived, and she joined her colleague drinking coffee until 7:23. By then, the five had doubled. Two employees for all these patients? How’s that been working?

Then, onto one specialist. I had tried one university network, but the experts identified by my internist didn’t have openings until August. So I went with the neighborhood guy. He’s in my “system,” so my test results must be in the “chart.” My wife says bring copies of everything — five years’ worth — just in case. “Oh no, we don’t have anything, glad you brought them.” An ultrasound and exam later, he says triumphantly, “Your bladder is fine and it’s not your prostrate.” But what about the out-of-range blood and urinalysis findings? “That’s not my department … you’ll have to see a renal person.” But isn’t the elbow connected to the shoulder? “You can look those things up … Dr. Forrest is excellent.”

Forget Main Line Health — this time I’m going to an academic center, with Dr. Herring specified by my internist. Three voice mail menus and samples of elevator music later, I’ve got the patient care coordinator. I state up front that I’d like to see Dr. Herring, with a brief description of why and reference to my internist. She takes 25 minutes of information — biographical, some clinical which of course she can’t decipher, plenty about insurance. “Dr. Herring can see you in August.” Anything sooner at another site? “Let me check — maybe — wait — now I see that Dr. Herring isn’t accepting new patients.” You mean we spent 30 minutes for you to tell me I can’t be seen? “That’s how our system works … you can take that up with our medical board.” System?

I caved. I asked my internist to make a direct call to a colleague at another university, and I was scheduled for May, later moved up to April. Even with my physician status, I couldn’t get on a specialist’s schedule easily. This impediment has grown for several reasons: patients ignored gnawing problems during the pandemic and they blossomed, senior doctors have been retiring because of strain caused by modern practice, and general practitioners are increasingly ill-equipped to handle complex problems. In psychiatry, the problem has been amplified by a mushrooming of people now declaring they need treatment — partly the result of reduced stigma and partly the result of cultural turmoil.

I’ve been thinking about this issue for some time, because when patients describe medical problems and I’ve recommended specialty consultation, they’re placed on long waiting lists. I’ve begun calling colleagues, asking them to see my patients as a personal favor. They usually oblige. One time, I did the same for a colleague, whose patient was suffering from cognitive decline. I called my colleague to discuss the case, given that the problem involved medications he was prescribing. He seemed surprised: “I thought you would handle it.” I guess he wasn’t thinking that collaboration was necessary for our patient. Maybe he thought I would correspond via the nifty electronic medical record? But we had to talk. Old-fashioned, maybe, but required.

We continue to fall in love with powerful connectors such as Facebook and portals that provide immediate test results before the doctor can explain them to the patient. These innovations are impressive but have side effects, which we are always slow to consider. Several of my patients are drawn to Mister Rogers, the Pied Piper for children. He spoke directly about feelings and addressed the vulnerability of children without shame. No obstacles obscured his aim — not a shortage of funding, not resistance to controversial subjects such as race and not technological advancement, as he conversed with his audience simply on public television.

People’s desire to be known at their core hasn’t changed. The MBAs who have designed our medical system prioritize the financial bottom line, and doctors are too often complicit. They’ve overlooked a basic fact: We are whole people, with organs that communicate, with minds that are trying to be in sync with our bodies, trying to keep up with a world that is moving too fast.

Andrew Smolar, M.D., is a clinical associate professor of psychiatry at Temple University School of Medicine.