Tuesday, November 16, 2010

The "but" is not the message

Two telling patient encounters still stand out in my memory, one from before medical school and one from my practice. The first one was at a clinic that I visited as a mentee to a clinician, where a young woman came in for a routine physical. After the talking and the physical were done, as she was standing by the door about to turn the handle, she looked at my mentor and, with tears in her eyes proclaimed: "I am worried that I may be pregnant!" The second event that I recall was when I was seeing a relatively new asthma patient, an upper-middle-class woman in her 30s with a husband and two kids. When we were ostensibly done with her medical issues, and as she was getting up off the examining table to leave, she suddenly broke down and revealed her concern for her husband's health.

Both of these encounters stuck with me as an illustration of how the human psyche drags after us into the office where one complaint per appointment is the rule of the day. And this is where studies like the one discussed by Jane Brody in yesterday's edition of the New York Times have a certain, shall we say, "duh" factor. The patient wants to feel good, really? Is this really news to any clinician? And yes, different patients will have different utilities for what their diseases or treatments are doing for them. And yes, some people are more resilient than others. And yes, some people will rely in the doctor's expertise, while others are more willing to be empowered. But in the end, is it really necessary to spend dollars on studies that confirm all of these observations?

But here is what really got me, this one small paragraph in this 600-word or so essay:
Of course, everyone knows that a doctor’s time these days is limited. But for medical care to be delivered efficiently and economically, assessing health-related quality of life is an essential element that can help doctors identify therapy that is counterproductive or ineffective or needs to be modified.
Note especially the leading sentence, "Of course, everyone knows that a doctor's time these days is limited". Let's stop here. As we sit and ponder it in silence, we just know that there is a big gigantic "but" that is about to hit us on the head. And sure enough, it does -- how predictable. But it is this sentence alone that should be printed in bold letters and stand alone, so that everyone -- researchers, patients, administrators, government bureaucrats and other pertinent parties -- stop and really think about the ever-growing crevasse between what is good for the patient, what is good for the doctor and what is good for the society and the reality of our widget-producing healthcare system.

To introduce the "but" is to deny the gravity of what is happening. The "but" diminishes any chances of a meaningful conversation about the real barriers to what we all know is good patient care. The "but" assumes a petulant contempt for the obvious on the part of the physician willfully avoiding the messiness of anything that is not lucrative. The "but" dilutes the important message: WE NEED MORE TIME!!! That is the message, not that we need to pit groups against each other with the "but"!

Now, the problem is huge and is likely to get worse. But... sitting on our hands and getting angry at the evil medical establishment for not taking the time to deal with our quality of life in the shrinking appointments will not change the system. People are people, and our psyche, no matter how hard we work at leaving it in the waiting room, will invariably follow us into the exam room. And all important emotional stuff comes out at the end, when the time has already run out, when the patient or the doctor is about to turn the door handle.

So, while the problem is clear, the solution is not. Nevertheless, the "but" is a way to evade having to find the real solutions. Let us keep the "but" out of the conversation and focus on what really needs to change.        


  1. Beautifully written piece, as always, Marya. You are indeed correct when you indicate that the problem is clear and the solution is evasive. You are also correct in your assessment that we (implicitly and explicitly) minimize the need to deal with quality of life issues when we *presume* that the widget-making aspects of providing care are primary and all other issues must fall into place.

    Obviously this is not the way things should be. And it certainly is NOT what most of us envisioned as what would be most important before we became doctors.

    Your two examples at the beginning of this post reminded me of so many similar occasions in my professional career when focus on pathology or process was exactly not what the patient wanted from me.

    I certainly don't have a solution, but I've definitely been thinking about ways to (personally) strengthen my "social contract" with patients in every encounter. I truly feel that this would be the key to providing a much better service to my patients.

    Now. If only the over-arching structures that I have to deal with had the same perspective....

    More work to do.


  2. Thanks, Chuk, for your thoughtful comment. We seem to think that the "but" can solve the problem of time, when there are so many directions a doctor is pulled at all times. Not the least of which is the need to produce widgets.

  3. In our primary care practice (Maine) we talk about the snowstorm epiphany. It occurs with fair regularity on days where a heavy snow causes multiple cancellations and our pace slows. Inevitably, one of us tells the group later in the week that the opportunity for an unhurried and deeper conversation with a patient has led to a solution to a problem that had resisted all previous attempts - often despite much testing. Sometimes it is a diagnostic breakthrough, sometimes therapeutic, and sometimes 'just' a deeper insight into and/or acceptance of an issue. But it is always truly rewarding for both the provider and the patient, and enough different from the routine that we are driven to tell all our partners.

  4. Pheski, I am fascinated by your comment! Would love to hear from other clinicians whether they have anecdotally observed a similar phenomenon.