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."