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Emergency physician Drew Remignanti discusses his KevinMD article, “High tech should not replace high talk and high touch in health care.” In this episode, Drew examines the limitations of artificial intelligence and high-tech solutions in addressing the complexities of the U.S. health care system. He emphasizes the irreplaceable value of compassionate, personal interactions between patients and physicians, highlighting how technology can supplement but never substitute the human touch essential for effective patient care. Drew also critiques the profit-driven consumer-provider model, explores the disparities in health care access, and offers actionable strategies for restoring meaningful patient-physician relationships to improve health outcomes and reduce costs.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome back Drew Remignanti. He’s an emergency physician, and today’s KevinMD article is “High tech should not replace high talk and high touch in health care.” Drew, welcome back to the show.
Drew Remignanti: Hey, thanks a lot for having me again, Kevin. I appreciate it.
Kevin Pho: All right. So tell us what this latest article is all about.
Drew Remignanti: Well, I think what we’re losing a clear grasp of is the importance of the interpersonal interaction between a patient and their physician. That’s being devalued and rapidly replaced by this new model—the consumer-provider model—which is both more expensive and less effective than a true one-on-one connection with a physician who knows you and who you feel known by.
Kevin Pho: Now, what are some examples that you see that make you say that?
Drew Remignanti: Throughout my career—I worked for 40 years as a board-certified emergency physician—progressively more and more pressure was placed upon me and my colleagues to see patients faster, keep them more satisfied, and, oh by the way, not make any mistakes along the way. In emergency medicine, and really for physicians everywhere, you learn when to speed up and when to slow down with a patient, but there was intense pressure to become more and more “productive.” We never received a direct threat of firing, but it was implied, like, “If you want to keep your job, you have to become more productive.”
There are no “products” in health care. There’s information, there are interventions that may or may not be useful or appropriate for the patient, but there are no “products.” And certainly as patients, we don’t feel like consumers—or I never did.
Kevin Pho: Now, you said that when you worked as an emergency physician, there was more pressure on you and your colleagues to see more patients. Was that pressure explicit? Did administrators literally come up to you or write to you and say, “You have to see more patients?”
Drew Remignanti: Very much so. They kept data on how many patients you saw per hour, and in emergency medicine that’s kind of the metric—how many patients per hour you can see. That might also be used in primary care or other specialties. They would literally tell you, “You need to see more patients.” My response was, politely, “When I’m with a patient, it’s you’re not there—it’s me and the patient. I need to decide how much time we need to have this communication.” Obviously, in the ED, sometimes there are other people who need attention, so you juggle who can wait and who can’t. But from an administrative standpoint, you were definitely getting bonuses based on productivity, and then you’d get told, “You’re not productive enough. You’ve got to improve that.”
It got progressively more offensive as I was 35-plus years into my career, and this was coming from people with far less experience than me—though still clinically experienced physicians. When you’re not in the room, how can you decide that I need to spend less time with a patient? So you need to be pretty firm and say, “That’s for me to decide.”
Kevin Pho: What were some of the repercussions if you weren’t as productive as they’d like? Did you see that your colleagues would lose their jobs because they didn’t see enough patients? Was that constant pressure there?
Drew Remignanti: I had a progressive concern toward the end of my career. I’d decided I was going to try working full-time until 2020, since I graduated medical school in 1980. I thought, “I’d hate to get fired at the very end of my career because I wasn’t ‘productive’ enough,” but it was more important to me to spend the amount of time needed with each patient. In my book, I describe several cases where I came close to making a life-threatening decision based on missing something because of going too quickly. So yes, it was a constant pressure.
Kevin Pho: Your article talks about the infiltration of technology into the doctor-patient relationship. Overall, do you think that technology has helped or harmed that relationship over the years?
Drew Remignanti: I think it’s helped us come to more accurate decisions and treatment plans with our patients. I wouldn’t trade the high tech at all. But it doesn’t necessarily promote the patient-physician relationship. It’s just a tool that can be used effectively. It doesn’t replace the interpersonal connection.
Kevin Pho: What are some examples of high tech in the emergency department that had the biggest impact over the decades you’ve been practicing?
Drew Remignanti: Our X-ray imaging has become much more sophisticated. When I was training, CT scans were novel, and many hospitals didn’t have a CT scanner. You had to decide if the patient was stable enough and if you should transfer them to a facility with a CT scanner. Now, every hospital has a CT scanner, many have MRI, which is even more sophisticated. I wouldn’t trade that, but I think most everyone would agree that advanced imaging is often overutilized.
You can even order your own total body MRI—head to toe—without a physician order for about $2,500, if you have the money and anxiety. But then you might find an incidental finding—something that doesn’t really matter clinically but that can lead to anxiety, further tests, and so on.
Kevin Pho: Do you find these advances in technology sometimes take the place of establishing a doctor-patient relationship? For instance, in a busy emergency department, it might be easier to send someone off to a scan rather than do a careful history and physical.
Drew Remignanti: No doubt about it. In most busy EDs I’ve worked in, the nurses are essentially deputized to send a patient for a CT scan of the brain if they think it’s necessary, which might be good sometimes, but I’ve definitely seen scans that weren’t necessary. Then they find something incidental, and I have to spend more time calling the radiologist, clarifying significance, etc. For patients, more information seems better, but we need to think carefully about whether that information really helps. It can lead to overtesting, which might not be in the patient’s best interest.
Kevin Pho: You resisted the pressure to be more “productive” and maintained that connection with patients. How did you push back?
Drew Remignanti: You have to be confident in your ability to decide what’s best for the patient. At the same time, you must keep an open mind that you could be wrong. That leads to a lot of second-guessing, especially in emergency medicine where you’re juggling multiple patients. It’s a sophisticated balance. You have to say, “No, I’m going to take the time I need with this patient,” and remain aware that there are other people in the waiting room.
I’d see colleagues just activate the trauma team, do a pan-scan, basically test everything, because it was easier. You wouldn’t miss anything, but you’d generate charges and risk picking up incidental findings that might lead to unnecessary treatments. It’s easier for the physician, but not necessarily best for the patient. I was fairly stubborn about it—important to me to do what’s best for the patient.
Kevin Pho: Reliance on technology and focus on productivity has only increased over time, especially with private equity buyouts and the commoditization of medicine. For physicians who are practicing now and for those new to the field, what advice do you have to help them push back?
Drew Remignanti: The pressure is enormous. I’m sympathetic to anyone trying to figure out when to trust their own judgment. Always listen to the patient, and consider colleagues’ points of view. But realize there is a huge spectrum—some admit everyone with chest pain, for instance, which might be safe from a liability perspective but not in the patient’s best interest.
You have to develop your own confidence while constantly questioning, “Is this the right decision?” That’s one reason why so many physicians experience burnout. In emergency medicine, we have the highest rate of burnout—63 percent—because that constant pressure to make the right decision is difficult to live with.
Kevin Pho: Where do you see us going? The trend doesn’t look promising.
Drew Remignanti: I’m an optimist despite the evidence to the contrary. In my book, I refer to health care as “going to hell in a handbasket.” But we need to rejuvenate the patient-physician relationship as the key interaction in health care. The consumer-provider model wants to declare that relationship dead, as though you don’t really need a physician. You can have a mid-level provider, and you don’t need to consider which tests to order—just order a lot of tests. That’s not what we need.
Kevin Pho: We’re talking to Drew Remignanti, he’s an emergency physician. Today’s KevinMD article is “High tech should not replace high talk and high touch in health care.” Drew, as always, let’s end with some take-home messages that you’d like to leave with the KevinMD audience.
Drew Remignanti: Well, for patients—and I’ve been a patient longer than a physician; I have a 50-plus-year history of chronic autoimmune disease—don’t think of yourself as a “consumer” of health care. You can be a consumer of health information, but find a physician whose judgment you trust, who knows you, and whom you feel known by. Study after study shows that the more informed and active you are in your care, the better you do. You and your physician can create a treatment plan, and you’ll be more adherent to it if you’re engaged and informed. That can cut your mortality risk in half.
I wrote a book based on 40 years as a physician and 50 years as a patient. I discuss raising the health care interaction to a true partnership between patients and physicians. It’s hard to explain every concept here, but the book lays things out more completely.
Kevin Pho: Drew, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.
Drew Remignanti: And Kevin, thanks again for having me.
