Wednesday, November 30, 2011

The List

Most appointments with physicians are either followups or relate to new concerns and, generally, run fifteen minutes.  

At the end of a session for, say, indigestion, the patient and doctor decide on a course of action.  Thinking the visit is over, the doctor moves towards the door, at which point the patient, with some panache and the dexterity of a Las Vegas black jack dealer, draws "The List," from their pocket along with an announcement that they have more questions.   

Already running late,  with many scheduled encounters ahead,  the physician suddenly experiences  a nascent desire for a career change, perhaps  lion taming. 

"The List" varies in style and form but aficionados have apparently agreed upon a number of, until now, unwritten rules.

1- There can be no fewer than five questions on any list.
2- Pencils are the writing tool of choice and the smaller the piece of paper the better.
3- The list must not be revealed at the beginning of the appointment.
4- Issues raised on the list must have been present for no less than five years.
5- It is required that the patient's major worry is placed last on the list.

The doctor who decides to extend the appointment to address the list faces the distinct possibility of mayhem in the waiting room from patients, who correctly believe their time is as important as the physicians,  protesting loudly.

What to do?  The key is to commandeer the list as quickly as possible to make sure there are no alarming elements that need immediate attention. 

Then, the practitioner needs to discern just how concerned the patient is about any of the listings. 

The first step, in my experience,  is to tell the patient that their appointment time is up.  This is hard to say but fair given that their stated reason for coming to the office was addressed in the scheduled time.  Additionally, it is unfair to delay subsequent patients short of an emergency or pressing contingency with the current patient.

Then, most tellingly, the patient is asked if they wished to make a special appointment to focus on the list.  If they said yes, then I knew the issues needed my undivided attention.  If no, they were probably mostly curious,  wanting to economize and get as much out of the appointment as possible.

Over many years,  very few of my patients accepted the invitation to set up a special visit to address the list.

With soaring health care costs and co-pays, it is a small wonder that some individuals might try to get as much into an appointment as possible.  However, in doing so, they do themselves a disservice.  A bloated agenda, conducted by a doctor now on the run,  will invariably not lend itself to thorough and responsive care.

Mission essentially accomplished.  With the element of surprise contained and a galloping list corralled, clinical balance is restored and a sensible and reasoned approach to the list emerges. 

Indeed, this problem can be headed off by a "List" savvy doctor asking at the beginning of an appointment if there will be other questions, some possibly more immediate than the declared reason for the visit.  

So, while "The List" presents a formidable challenge for the practitioner, it can be managed with candor and understanding.  Lion taming still remains a possibility but, for the foreseeable future, the notion can be stored away in a vault for safe-keeping and possible future deployment.


Tuesday, November 15, 2011

Let's Dance

Over the years of practicing medicine, patients taught me many lessons.

On one occasion, the lesson came from a couple whom I had never seen before. They were quite elderly and each looked frail, layered in ordinariness, dressed in non-descript clothes of a  distant era.

In contrast to their appearance was the husband's courtliness, helping his wife off with her coat and then getting her comfortably seated.  Their affection for each other was palpable and they unquestionably were still very much in love.

sensed they had an interesting story to tell and was eager to discover it.

A fifteen minute appointment leaves you little time to really get to know your patients,  so  I utilized a favorite technique for connecting with patients when time is short.

Early in my practice I had discovered that even the most taciturn would open up and talk enthusiastically and appreciatively about their lives, revealing much in a very short time, when asked one of two questions: How did you and your spouse meet, or, where did you grow up and what was it like growing up there?

With this couple, there seemed most to be learned by asking how they had met.

They met in the early 1950s at the Eagle Ball Room where singles came to dance to big band music and perhaps even find romance.

He spotted her and asked her for the first dance of the evening.  After the music stopped, he asked her to marry him.  She accepted right on the spot.

Sixty-four years latter it was obviously a brilliant, if impulsive, decision.  "But how did you know that she was the one," I asked?

"Because we danced well together."  

Go figure.

So what did they teach me?  First, that the good life is not always governed by reason.  Second, that sometimes the heart is better than the head in navigating ones destiny.

Sunday, November 6, 2011

Getting To Know You

The big prize for the primary care practitioner is regarded by many as the opportunity to know their patients well in sharp contrast to the generally fleeting relationship of sub-specialists and their patients.

This was certainly true when doctors regularly made house calls where there was much to learn: Hemingway dominating the book shelves; the lawn overgrown; a chessboard with a prominent place in the living room; pictures of the kids colonizing the front hall; the scent of cigarette smoke hanging furtively in the air despite numerous efforts to quit smoking.

So while we primarily knew about our patient's blood sugars in the office, the house call allowed us to see their humanity, their singularity.  These insights went far in caring for patients as they hoped we would, with our efforts anchored to their beliefs and values.

Moreover, the attentive and open-minded physician had much to learn from patients on their home courts as they not infrequently led very interesting and informative lives.

Nowadays, knowing one's patients well is really quite challenging.  For one thing, insurance coverage availability and cost of coverage, oftentimes results in a musical chair like coming and going of patients that is disorienting to both doctor and patient.  It barely allows familiarity let alone bonding.

Then there is the  matter of the computer in the exam room, the big gorilla. 

Patients regularly report that the doctor barely looks at them but gazes fixedly instead at the computer's screen, bringing to mind the the pop hit immortalized by Frankie Valli, "Can't Keep My Eyes Off of You."

With the computer, often large, planted on the desk squarely between physician and patient, the possibility of doctor and patient seeing each other becomes somewhat theoretical,  giving each the sense of being alone in the room.

While the computer is not without its virtues in patient care and might even be thought to be indispensable, it can make it quite hard for doctor and patient to connect.

Part of the problem is that the standard fifteen minute appointment is littered with clerical tasks that the clinician is personally required to do, leaving fewer opportunities to see or even talk to the patient.

The clerical mandates vary but partially include documenting on the computer that the diagnosis list has been reviewed, the problem list reviewed, the feet inspected, if a diabetic, and the medication list updated.  

There is nothing unsavory about data entry, it is honorable work, but when done by the doctor, valuable time is lost with the patient.  So by the conclusion of office hours many practitioners feel a murderous disdain for the computer along with the sense that the day had been bleached of value by the relentless stampede of computer clicks documenting this and that.  No wonder the computer is so well casted in the role of the endlessly hungry little furnace.

It should be said that there is nothing fundamentally wrong with documenting.  Indeed there are cases where it improves care.  But it is worthwhile to remember that not all information is knowledge and therefore might very well not deserve collection.   

In the early going of the computer age, we seem to gather data incontinently so we need to become much more thoughtful about what we collect.  Moreover, when we do document, we need to ask at what price we do so.  Surely not at the expense of time interacting with patients.

Answers to the computer and insurance issues that make it harder to know our patients remain for the software designers and health care reformers to solve respectively. Physicians also need to take an active role in solving these problems.

In the meantime, it would do us well to remember the author Evelyn Waugh's response when asked by a young man what was the key to becoming a good writer.

Waugh said, "Only connect."