Harpham, Wendy S. MD
WENDY S. HARPHAM, MD
Time savers are the name of the game—whether an office renovation that improves patient flow or a patient handout that replaces talk. With essential tasks gobbling up clinicians' time more than ever before, every minute counts.
Just look at how the explosion of tests and treatment options has transformed brief end-of-visit “R & R”—review and recommend—into lengthy patient discussions. And remember the days of jotting notes and orders in hospital charts before dashing off to your office? Today you have to type your way through drop-down boxes—and then wait with crossed fingers until the data go through. Meanwhile, billing and insurance forms await you.
Like the skull housing a swelling brain, the 24-hour day exerts constant pressure on clinicians' bulging to-do lists, threatening the viability of time-honored tasks that represent the art of medicine: eliciting a complete history; tailoring explanations and advice; fostering trust through personal relationships; and just “being there” with patients—especially when medicines fail.
The practical problems of time are exacerbated by an evolving culture of hurried medicine, as illustrated by two scenarios:
In the first, a highly respected pediatrician admits a teen with abdominal pain and vomiting for IV hydration and analgesia. After consulting a gastroenterologist, the white-haired physician reassures the trusting parents about the value of supportive care and tincture of time for what appears to be a viral syndrome—a working diagnosis supported by blood and ultrasound findings.
But as the teen's overnight observation stretches into a week of minimal improvement, family members push the parents to request further evaluation, insisting, “They don't have a diagnosis after a whole week? You need another doctor.”
“A whole week?” The boy is medically stable and reasonably comfortable on IVs—facts confirmed by bedside exams. Why subject him to repeated scans? Endoscopy? Are the potential benefits to the patient worth the mega-bills that would soon arrive at the home of his working-class parents?
The second scenario involves a long-term survivor who develops a late effect, likely exacerbated by a drug she's been taking for years. After carefully weighing options, her oncologist tapers her off the old medication, hoping to help the new problem. And it does. But not before the patient's usually restorative sleep becomes an ordeal of insomnia and nightmares.
The oncologist explains: “Your brain cells can take months to adjust after discontinuing a chronic medication. We can resume the old medicine at a lower dose, begin a sleep medication, or wait.” The patient requests they give her body more time.
The best response to some clinical situations is captured in the perennial pearl for house staff: “Hurry up and do nothing.” But a course of inaction is increasingly challenged in a culture that seems to have lost tolerance for uncertainty and waiting.
How did this happen? A short list of culprits might include:
- a reimbursement structure that values high-tech interventions and short hospital stays;
- a third-party insurance system that makes it easier for families to demand (and doctors to order) more tests;
- social media that invites medical opinions of friends and family, as well as strangers—some with their own agendas; and
- a federal government increasingly involved in the details of patient care, with policies shaped mostly by non-physicians.
Here and there, physicians and patients express nostalgia for a bygone era when medicine was simpler and clinicians had more time. Not me. The science and technology transforming modern medicine saved my life and spawned a survivor community over 13-million strong.
As I see it, our hope for tomorrow is tied to making changes that help clinicians with the demands on their time, as well as influencing the culture to value the time it takes for clinicians to optimize the use of science and technology in the care of each patient. Does this sound naïve? Is today's tide of change too powerful for clinicians to make a difference?
No. History is replete with stories of visionary clinicians fighting culture, superstition, politicians, and colleagues who have strayed from their noble calling. Sadly, many dedicated clinicians died before seeing the triumph of their ideas and efforts. But progress in patient care prevailed. Looking to the future, progress in patient care will—and must—prevail.
I envision future medical historians writing of how the heroes—today's clinicians—tackled the tyranny of technology and reshaped the culture of modern medicine. They'll relate how your ingenuity improved EMR and other communication aids among colleagues. How you engaged smart-phone apps, video teaching aids, and physician extenders to facilitate the history-taking and patient education that precedes shared decision-making. How you embraced every opportunity to educate physicians-in-training, policymakers, and the public about the time required to take a proper history and discuss options—measures that avoid futile tests and treatments.
And how you made it common knowledge that in some cases subclinical disease needs time to declare itself, side effects need time to abate, medicines need time to kick in, and the body simply needs time to heal.
Tomorrow's historians will highlight not only the personal stories of today's clinicians' relentless efforts, but also seminal research studies that led to one incontrovertible conclusion: Effective communication and clinical judgment based on clinicians' personal knowledge of individual patients lead to cost-efficient care.
A subtext throughout these narratives will be that the preservation of meaningful clinician-patient relationships preserved compassionate care—a benefit you can't put a price on. I even envision a book title: The Time Savers: How 21st Century Clinicians Preserved the Art of Medicine.
Dramatic medical advances and an evolving culture of medicine are putting the squeeze on clinicians' time. By finding creative time savers for clinicians and promoting a culture that values the time needed for high-quality care, we can continue to help patients benefit from both the miracles of modern medicine and the art—the heart—of medicine.