A Hazard of Impatient Medicine
The doctors' productivity report card was titled, “Cancer Follow Up – Routine,” not “Psychiatric Consultation – Emergency.”
There is growing concern that physicians are spending less time with patients. One study at Johns Hopkins earlier this year documented that physicians in training are now spending about eight minutes per day with each of their hospitalized patients. The reasons are complex: Things that used to be done by doctors, such as drawing blood, are now done by non-physicians; restrictions on duty hours limit the amount of time trainees can spend in the hospital; and managing the electronic health record now consumes a great deal more physician time.
While the reductions in time for patient contact have been apparent for many years, some of their consequences are still just emerging. It is becoming increasing apparent that when speed is of the essence, patience, curiosity, and compassion can cease to be virtues. Instead they often become expensive liabilities that must be weeded out in the name of increased efficiency. What will medicine look like in the future? As products of this system, will today’s young physicians come to resemble customer care providers at the health care counter of the local department store?
The patient – call him Mr. Jones – was a middle aged man, successfully treated for cancer, which was now in remission. He returned for a routine follow up visit and was being seen by a fourth-year medical student, Joe. Joe’s mission was to perform a focused history and physical examination and review Mr. Jones’ laboratory and radiology results. After consulting with his attending physician, Dr. Smith, he would reassure Mr. Jones that everything was going well. The whole visit should not have taken more than 15 or 20 minutes.
Dr. Smith, who was busy seeing other patients, noticed that Joe was taking an unusually long time with Mr. Jones. What could he be doing? It was not uncommon for medical students to require more time than seasoned physicians – in fact, it is the norm. But in this case, the visit was dragging on far longer than expected, and it was beginning to push the clinic behind schedule. So Dr. Smith stopped by the exam room and poked his head in. At a glance, he could tell that Joe and Mr. Jones were engaged in a deep conversation. In fact, Mr. Jones had tears in his eyes.
Dr. Smith asked Joe if he could speak with him privately for a moment. “What is happening with Mr. Jones? Is there a problem?” Joe reported that toward the end of their session, Mr. Jones had posed what seemed to be an innocent question. “Tell me doctor, these medicines you prescribe – do they sometimes stop working?” Joe knew that for a variety of reasons medications could lose their effectiveness, and he said as much to Mr. Jones, thinking that would be the end of it. But then he began to wonder, why had Mr. Jones posed such a question?
His curiosity piqued, Joe posed a follow up question. “Do you have some particular medication in mind?” After some hesitation, Mr. Jones admitted that he did. The medication he was referring to was an antidepressant. This led to further questions, and Joe soon realized that Mr. Jones was depressed and contemplating suicide. In fact, he had even made plans to threaten a police officer, so that he would die without the stigma of taking his own life. Just a month before, he had attempted to kill himself by overdosing with another medication.
It turned out that Mr. Jones needed a radically different form of care than Joe and Dr. Smith initially supposed. As they delved further into the situation, they confirmed that Mr. Jones would require hospitalization. Arranging an emergency psychiatric consultation, hospital admission, and tending to their patient’s distressed state of mind ended up requiring several hours of dedicated attention. Fortunately, the other clinic patients were accustomed to delays from unexpected issues with other patients and waited without complaint.
From the point of view of efficiency, Mr. Jones’ case represented a glaring failure. A routine cancer follow up visit that should have required less than 20 minutes ended up consuming hours. Other patients were inconvenienced, and their customer satisfaction survey results probably reflected poorly on both Dr. Smith and the hospital. Had Dr. Smith been able to tell them what happened, they probably would have understood, but protecting Mr. Jones’ privacy dictated that he could only apologize for the delay and offer no details.
In a highly efficient medical practice, there might be no opportunity for such an interaction. The physician would be in too much of a hurry to address Mr. Jones’ medication question. Instead he would simply congratulate him on his normal laboratory results and CT scan, pat him on the back, and send him on his way. He would complete all the required sections of the electronic visit record, maintaining his high quality and patient throughput metrics.
Had mandates concerning efficiency and productivity been foremost in the minds of Joe and Dr. Smith, Mr. Jones might well have died. Not that such a death would have counted against the medical team. Their productivity report card was titled, “Cancer Follow Up – Routine,” not “Psychiatric Consultation – Emergency.” So as long as they checked off all the boxes on the electronic cancer follow up form and got the patient in and out of the examination room in a sufficiently short period of time, they would be judged winners and rewarded accordingly.
If physicians hurry too much they will lack time even to get to know their patients’ best interests, let alone base decision making on them. Listening to the patient, communicating well and taking time to answer questions, genuinely caring about the patient as something more than a number – these will become relics of a bygone era. When physicians begin to think more about efficiency than patients, quality of a sort that we cannot even measure is inevitably compromised. They end up buffing electronic medical records rather than caring for human beings. We need doctors who know the difference.
Mr. Jones, who is now doing quite well, knows this. He never completed any customer satisfaction survey. Nor did he write a letter to Dr. Smith, his medical practice, or the hospital recounting what happened or offering his thanks. But he knows. He knows the vital importance of having a physician whose primary concern is not a checklist. He knows that the patience, curiosity, and compassion of a medical student made all the difference. Every time he sees Dr. Smith for another routine follow up visit, he asks about the "great young doctor."