Diane H. Schetky, M.D.
Having recently become a frequent “consumer” of healthcare, I have had ample time in which to reflect upon the increasingly impersonal nature of contemporary medicine. I have encountered nameless, robotic nurses taking blood pressures with a perfunctory “how are you today?” I once replied “Not so good!” and the nurse, apparently still on autopilot, said, “That’s good.” Most medical practices have merged and rather than familiar and comforting office personnel, patients are now confronted by an ever changing cast of medical assistants and clerks who address them by first name only, names they only know from looking at their charts. I suppose that is preferable to being called “dear” or “hon,” terms that leave one feeling antiquated or infantile. Medical personnel, other than physicians, typically only reveal their first names. This sends a mixed message of parity and wanting to be a patient’s friend even though they do not engage in the reciprocity of friendship. Perhaps they worry about being stalked should they reveal their last names. I continue to be amazed when someone shares with me that he is in psychotherapy at a mental health clinic but he does not know the last name of his therapist, let alone his or her specialty and training.
Paper work and computers increasingly encroach upon the doctor-patient relationship. When seeing a specialist for the first time, I often spend more time filling out forms than with the physician who, all too often, lacks time in which to even read the forms. The cynic in me wonders if forms and checklists are for my benefit or are merely time saving devices and attempts at practicing defensive medicine.
As a forensic psychiatrist, I have seen malpractice suits collapse on information entered by a patient on a medical questionnaire filed in his chart but never read. Electronic record keeping now poses a challenge to establishing and maintaining rapport with patients. I recall a visit to an ophthalmologist in which an assistant took my history and sat with her back to me for five minutes as she entered it onto the computer and then left. The ophthalmologist appeared in the dimly lit examining room, barely said “hello,” and turned his back to me to read my history on the computer. He then turned around to examine my eyes leaving me feeling as if I were nothing more than a pair of eyes. This computer do-si-do gets played out endless times as, increasingly, physician extenders take medical histories and physicians spend less face-to-face time with their patients. I marvel at my internist who is able to enter data onto her laptop while maintaining eye contact, listening, and extending concern and compassion. Unfortunately, in my experience, she is an exception, as many physicians have not mastered keyboarding and this delicate balance of accuracy and empathy. In focusing solely on the keyboard, physicians risk missing a lot of nonverbal information and also distance themselves from the patient.
Medicine has become disease-focused and, in a rush to make a diagnosis, the physician may fail to establish rapport and see the totality of the patient, which goes beyond mere symptoms and disease. The luxury of allowing patients to tell their stories in their own words has been compromised by reimbursement systems that reward volume of care. In addition, they demand extensive documentation of care, which entails more data entry and less time for patients. In one survey, it was found that doctors start to talk 22 seconds after a patient begins to talk. Such interruptions may cut physicians off from learning important information and leave the patient feeling she has not been heard.
Fear of malpractice leads to over-utilization of tests and more referrals to specialists, who outnumber primary care physicians in many communities. The increased use of specialists has led to fragmented and more expensive care. This does not always equate to better care, and may actually increase the risk of errors due to lack of communication between caregivers. In addition, hightech diagnostic procedures may take the place of extensive history taking or be done defensively. Lying in an MRI machine for 30 minutes listening to it jack hammer away is no substitute for discussing one’s symptoms and concerns with a physician. Furthermore, MRIs are not capable of empathy. The explosion in the field of medical information technology cannot become a substitute for listening, nor a substitute for the doctorpatient relationship. For a patient, the endless array of procedures and specialists can leave him feeling as if he is on an assembly line. He may wonder who, if anyone, is putting all the pieces together and whether all of these myopic organ-focused specialists actually communicate with one another?
As psychiatrists, we have the luxury of spending more time with patients than do other specialists. However, this time is often usurped by paper work, battles with insurers, pagers and cell phones going off, and an inadequate supply of psychiatrists to share the workload. Increasingly, under our current system of medical care, our services are being marginalized to doing medication or crisis management while the full array of our training and talent goes unutilized. It is important to take time to get to know the whole patient and to practice listening skills. Not only is this good medicine, but it also minimizes the likelihood of getting sued. We need to remember that our patients are persons with diagnoses – not just a diagnosis. Along with the move to integrate psychiatry in medicine, we will have greater opportunities to consult with other specialties and foster integration of care that tends to the whole patient and their needs.
In my retirement, I find myself increasingly acting as a patient advocate. I suggested to my physician that if she and her colleagues hung soothing art in their barren examination rooms that blood pressures might go down. Better to look at a beautiful Maine scene than stare at purple nitrile gloves cascading from a dispenser and menacing instruments on a counter top while waiting for the physician to enter the examining room. I also suggested that the employees in her group wear nametags. She appreciated my input and at my next appointment the staff was wearing nametags. Most recently, I wrote to our chief of radiology about lack of auditory privacy between the waiting area and interview room in the MRI area. I received an immediate reply from him saying he would look into it right away. These are small steps towards improving quality of care, yet they are steps many patients would not think/or dare to take. We need to offer patients the opportunity to give feedback on our practices and then value their input.