I pull up in line and edge toward the recessed microphone at the base of the huge bill-o-fare. “Welcome to McDonald's; may I take your order?” a feminine voice rings out over the loudspeaker.
“Large coffee with cream,” I say, straining my throat to deliver the message.
“Will that complete your order? Yes? Pay at the first window, please.”
I ease the car forward and coast to a stop, fumbling with the exact change in my hand. The window slides back, a palm pops out to accept my payment, recoils, then returns with a receipt. I glance up through the narrow opening at the eyes of a former patient of mine, but there's no acknowledgment; she's already speaking into the headset, focused on taking the order of the next customer in line.
I advance to the second window. A masculine arm extends with my cup of coffee. The boy smiles, carefully enunciating the words: “Have a nice day!” I recognize his face as well. At one time I treated him for acne vulgaris. But today there is no indication that he recognizes me.
Periodically, I experience such chance encounters with former patients since I left my previous place of employment, where I practiced general pediatrics for 20 years. I still work in the same community, but in a different venue at an acute care walk-in center. I still practice medicine, but the emphasis has changed: address only the problem at hand, prescribe treatment, offer a feel-good farewell, and move on to the next patient. Although my clinical acumen remains relatively sharp, I wonder about the overall quality of care I now deliver.
These days I encounter patients through brief windows of time. Some days the line seems endless. My supervising physician telephones at the end of every evening—to speak not to me but to the office assistant, asking only for that most important statistic: a daily headcount of patients seen.
“Life is maintained by the respiration of oxygen and of sentiments,” said physician Oliver Wendell Holmes, Sr., a century and a half ago. Despite the passage of decades, they still speak to me.
I logged Gladwell's 10,000 hours toward clinical competence 30 years ago. I easily recognize the child who presents in respiratory distress. I know what she needs: life-sustaining oxygen, bronchodilators, a burst of steroids, and close follow-up.
And although I recognize the need for sentiments—in both the patient and myself—many times I no longer have the luxury of time necessary to provide them.
The McDonaldization of modern medical practice allows only one order at a time—with payment expected at the first window and receipt of goods at the second—before taking your leave and moving on.