A Fax from the Past

I am, heaven help me, a historian of what we academics liked to call “graphic narrative,” and so I tend to see all other history in relation to my beloved comics. So it is that I happen to know that sequential comics as we know them in their modern form were born simultaneously with the birth of medical imaging, which we trace to Röntgen’s discovery of the X-ray in the late 19th century. After WWII, new advances in imaging technology came with increasing frequency: nuclear magnetic resonance spectroscopy in 1946, ultrasound in the 1960s, the CT scan in the 1970s, the first full body MRIs at the end of the decade. 

When my own relationship with the medical establishment was renewed a little more than a decade ago, we were on the tail end of the most dramatic rise in the use of medical imaging technologies in history. Between 1997 and 2006 the use of CT scans doubled and MRIs tripled. And as the number of images proliferated and their resolution (and costs) increased logarithmically, the weight accorded to those images inevitably grew accordingly. Each of these technologies of course required specialists in “reading rooms” —deliberately isolated from contaminating patient’s narratives—to read them and translate their findings back to the ordering doctor. 

Since then, of course, other barriers have emerged between patient and doctor, most notably the computer screen. When I was sent to the Mayo in 2006 it was not so much because of the vaunted diagnostic skills of that institution’s practitioners. I was a patient at one of the largest research hospitals in the country, after all, and they were justly proud of their own skills. Instead what dazzled my doctors was the speed with which the Mayo could conduct tests and, most importantly, share data between various specialists—even within hours of a particular test or procedure. What made the Mayo a magical place in 2006 was their computer system. 

Today, of course, electronic records are increasingly ubiquitous, especially in larger networks and hospitals. When my adult medical drama began in 2004, less than 10% of practices used electronic medical records. Following the Great Recession of 2008, President Obama’s stimulus efforts included incentives for hospitals and doctors to adopt electronic medical records. Just seven years later, today over 80% of hospitals and over 50% of doctors have translated their records to electronic systems. 

In many ways, Obama’s efforts in this area have had a more seismic effect on American medicine than even the Affordable Care Act. While the ACA might yet prove victim to political or judicial interventions, electronic records are here to stay. And, they have transformed, for better or worse, every aspect of the ways in which patients and doctors interact. 

I’ll have numerous occasions to meditate on the good and the bad in the weeks ahead, no doubt. But one recent experience really brought home for me the change just a few years have made for both patients and doctors.

A couple of months ago, as my symptoms started to multiply, my primary care physician sent in a referral for a neurologist appointment. As it happens, Ohio State had not long ago lost a substantial chunk of their neurology department in some contract or policy dispute. The details are opaque from where I sit, but the whole thing was ugly enough that some version of the story even made the local papers. The end result is that the neurology department at my particular hospital is desperately understaffed and outside help is needed.

So it was that my neurology referral had me sent not to one of the doctors working at my hospital, but instead to a newly “associated” practice. 

As it turned out, the association in this case was very new—so much so that the practice was not yet hooked up to the Ohio State network and could not access my medical records—images, test results, etc. In fact, hardly a computer was to be seen anywhere. In the backroom I heard a fax machine going and something that sounded an awful lot like a 2400 baud modem (I probably hallucinated that last part, overtaken by the 1980s ambiance of the place).

Now the doctor I saw seemed like a splendid neurologist. Smart, thoughtful, and attentive. But he was also visibly frustrated with his situation, frustration that my visit had clearly exacerbated. It seems my primary care provider’s staff had faxed over reams of papers, but most of them turned out to be billing records with little to no information related to my particular case. 

I ended up pulling up what I could from my phone via the app that accesses a redacted version of my records available on the patient end. At least this way I could give a proper accounting of my medicines and recent blood test results. But the EMG and MRI images remained out of both our reach. 

“Here,” he said, handing me a card. “Have them fax over reports and mail a CD with the images.” 

“What are these ‘fax’ and ‘CD’ you speak of?” I responded. Making it worse, I used those annoying air quotes and, for some reason, a phony French accent. He was not amused.

In truth, I was pretty frustrated myself. The clinic to which I had been sent was well outside the city and was not, shall we say, appointed so as to instill confidence in such amenities as “hygiene” or “21st century.” I was tired, in pain, and had just learned precisely nothing for my troubles. Now I was being told that if I hoped to move my diagnostic process forward, I would have to make recourse to technologies that were obsolete as far as any self-respecting technophile was concerned. What if someone saw me? (“Burning a CD? Hey, 2004 called…”)

How quickly we forget. Somewhere in my basement is the massive folder of paper records from my first tour of duty a decade ago: faxes and xerox or actual typed pages—even handwritten notes. I’m pretty sure there might have even been a page or two of dot-matrix paper and even a mimeograph. Indeed, looking at those pages not too long ago (in one of my occasional forays into the chaos that is my basement) I was struck by how many doctors’ annotations and handwritten conversations were to be found in the margins of those records. 

In 2005 reading through a patient’s records meant flipping through pages in a folder. A decade later it means scrolling through a screen, punching up specific tests for comparison data, zeroing in quickly on relevant data and narrative through a series of filters and keywords built into the system. No more time spent reading irrelevant tests and observations from attending physicians. 

But of course, in the messiness that is our human condition, it is sometimes from those seemingly irrelevant or digressive observations that sparks are kindled. Maybe more than sometimes. In my half-century as a patient I have seen it more than once. I see it rarely today. Today’s electronic medical records highlight objective data: numbers, diagnoses, dates, and more numbers. Space is afforded for narrative, of course, but such notes are largely understood to be of interest only to the authoring doctor. What gets communicated from physician to physician are numbers: “objective data.” And when a case gets complicated, drawn out, the amount of numbers becomes overwhelming—and time consuming. 

Leaving my neurological appointment in the strip-malled hinterlands, I found myself feeling surprisingly guilty, wishing I could take it back that crack about their anachronous technology. My words had hurt—briefly but visibly. And I knew that because, it now occurred to me, I had seen it in his eyes

So many appointments involve not only little to no physical contact, but often no eye contact beyond the initial greeting. There are just too many screens, and too many numbers. This neurologist might not have had access to my images or my data, but he was the first doctor who had actually seen my not-so-new tattoo—taking the time to actually look at my body since he didn’t have any numbers or any screens to look at. When I made my wisecrack, he was looking me in the eye, and so it was I saw its effect.

Of course, part of why it hit him hard was because he wanted that connection to Ohio State, those screens, that network, that data. And it was coming, he assured me. They were going to hook him up soon, put him and his staff through the training with managing the database, communicating across the network, entering objective data. And as the numbers grew and the records took on weight and heft, there would inevitably be less time for skin- or eye-contact. Or storytelling. 

Oh well, I thought, at least then I can go back to making my wisecracks with impunity. And no one would ask me to {shudder} ‘fax’ a document or burn a ‘CD’ again. I occupied myself on the long ride home by composing in my mind various witty tweets about the experience.