May 29, 2015
By Anne Sigsbee, MD
I led her into the exam room to begin our visit. We were scheduled to get together to assess and modify her RA regimen. From the look on her face, I knew this was not to be a routine visit. The standard question, “How have you been doing?” was all this generally stoic middle aged woman needed to begin.
“Lousy!” she announced as she described the pain, stiffness and fatigue of her disease. Yet, this distress took second place to the agony of experiencing the recent death of her son by overdose. Our immune modulators were not up to the task of controlling her disease in the face of the stress and sleep loss of the past few weeks. She talked about her guilt, isolation from her angry husband and her profound sadness. After a time, we began to discuss strategies, resources, counseling, and together we developed a short term plan.
I did not do a joint count. I did not record a Health Assessment Questionnaire. I did not hit any standard benchmarks and would not have to decide how to “code” this encounter. We concluded the visit with an agreement to reschedule soon. As she left, she said, “Thank you. I’m feeling better.”
I saw my own doctor recently. It was a good visit. He reviewed my labs and reviewed our decision to manage hyperlipidemia and hyperglycemia with diet, exercise and no meds. He reassured me that both my laboratory results and the current literature meant this decision remained appropriate. He asked about my exercise regimen and gave some creative solutions to swimming with cervical arthritis. (He uses a snorkel!) He asked about how my family and I were managing my changes in status: recent widowhood and retirement from 35 years of clinical medicine.
I was aware that our time must be straying into that of his next scheduled patient, yet he gave no indication of being rushed. I noted that as he gave me his full attention, he jotted some notes on a pad. No computer was in sight. I wondered how and when he would produce the requisite documentation for today’s visit. How could he possibly code for such an encounter, whose value to me far exceeded the “evaluation and management” parameters of Medicare? It was a good visit, and as I left, I told him I was feeling better.
These experiences were on my mind when we did an exercise in our group, the Salon 21 this month at Dr. Vikas Saini’s home.
Five of us had assembled: four physicians, at difference stags of careers and a health policy author. Our mission? We were asked to assume we were patients seeking care. We were challenged to imagine the ideal attributes of the person we turned to for this care. In doing so, we’re asked to recall a specific excellent experience or caretaker that enhanced our goal of achieving health. We were instructed to write words or phrases that described the attributes of this encounter. The only rule was to express everything positively. For instance, instead of “She didn’t rush me,” we would say “She gave me plenty of time.”
Later, as a group, we pooled our responses. Here is what we produced:
Then we asked ourselves “Now what?” We discussed how such values might guide the creation of a system from the ground up. We speculated that doctors begin their careers with the desire to manifest these attributes themselves. Why then is it notable, even exceptional when patients encounter such clinicians? If this is how we wanted to be and what we want from our own doctors, why is it not an ordinary, everyday experience?
One member of the group discussed his recent research on stress and empathy. Empathy is measurably suppressed by stress and high cortisol levels. What does that say about the design of an environment that facilitates these attributes in our caretakers? Empathy, by the dictionary definition is “the capacity to understand what another person is experiencing from within the other person’s frame of reference.”
A clinician must call upon a high degree of empathy to perform well. First there is the emphatic skill required to elicit a cogent history. Simultaneously, the patient needs to be understood in the context of their own definition of wellbeing. Then a physician’s specialized knowledge must be artfully communicated to create a successful “right care” treatment plan. The best communications derives from an appreciation of the patient’s frame of reference: empathetic understanding.
If it is demonstrable that stress suppresses empathy, then a clinician’s environment can diminish the very attributes we all desire. Some stress is intrinsic to any encounter, but we all can identify modifiable stressors in the clinic. The electronic medical record and documentation serves others’ needs more than ours and our patients. Support staff doesn’t surround us to facilitate a treatment plan and meet the needs of each patient. More often, support staff is dedicated to the economics of a rapidly moving schedule that captures and submits billing codes with the appropriate “evaluation and management” levels documented. As we all have allowed these priorities to prevail in our systems, we have impinged on the quality of the office visit. Today, a “good visit” is usually in spite of the system, rather than enhanced by it.
Look back at our list of desirable attributes and add your own. What would our health care system look like if it was designed to facilitate these attributes among our clinicians? Let’s change the “benchmarks.” What would our clinics look like if the benchmark was to have both clinician and patient end an encounter with “That was a good visit. I feel better.”?
I propose this would turn around the focus of a health care system. I propose this would improve outcomes and superior knowledge collectively held in this first world system would then begin to yield superior outcomes.
Dr. Sigsbee is a retired rheumatologist in Hyannis, Mass.