By Clare Hawkins, M.D., M.Sc.
TAFP President, 2013-2014
Do you ever think that your day is going slowly? Do the mundane features of patient care make you feel slow? Or perhaps, by contrast, you feel it is going too fast, like that proverbial hamster on the treadmill.
My treadmill involves dealing with difficult patients, paperwork requests, and the idiosyncrasies of the electronic health record. In spite of the speed, however, I don’t always feel efficient. Even when I feel I can complete a patient encounter quickly, this does not feel like a triumph. The speed comes at the expense of a lack of connection with the patient, or less fulfilment with medicine than I had expected.
Yes, I feel that it goes too fast, almost frenetic. Are there too many patient encounters? Perhaps the multiple components of the patient encounter are distracting. Rather than focusing on the patient, I am counting documentation bullets for E&M compliance, responding to care reminders, completing imaging requests, or making medication formulary substitutions. Many of these are necessary components for getting my patients the services they need, or for getting me the reimbursement I seek. However, few of these feel rewarding.
What would it take to focus on the patient? What would it take to be only peripherally aware of the multiple physician agendas of quality, preventive medicine, compliance, and to be able to really listen to the patient? Research shows that we usually interrupt a patient within the first seconds of their chief complaint. If we were to listen more carefully, then perhaps we could get to the heart of the matter at hand.
The “slow medicine” I’m referring to in the title is the art of medicine, when I can slow down and listen to my patient’s story and, rather than interrupting to get to the point, gently guide the dialogue toward meaning, respect, and understanding. By delineating their needs and preferences better, more is shared. We share in making decisions, and we avoid unnecessary workups and irrelevant discussion.
The slow food movement is a response to the fast food industry. Hence the name, “slow food.”
Physicians have adapted the name to apply to a countercurrent in the medical world where value is placed on time spent with a patient. The first published article I can find on slow medicine appeared in the January 2002 supplement of the Italian Heart Journal, by Dr. Alberto Dolara, an Italian cardiologist, entitled “Invitation to ‘slow medicine.’”
More recently, family physician Dr. Dennis McCullough, who practices mostly care of the elderly in Dartmouth, is a very articulate proponent, and has published a book entitled, “My Mother, Your Mother.” These physicians recognize the inherent value in slowing down to focus on the patient.
In my previous column, I discussed the pressures of being measured. Yes, the pressures to demonstrate quality are increasing, but the obligation to hear our patients have not gone away. I want to talk about the refuge of the doctor patient relationship and its healing opportunities. I say refuge, because often I find the interaction between a patient and physician to be insulated from the pressures of reimbursement, quality management, audits, etc. I like to block out the rest of the world and practice being 100 percent present with the patient. Yes, it takes practice.
This is indeed a challenge to focus on my patient and not my computer. I like my laptop, and I try to use it within an encounter to animate our interaction by showing growth curves for children, or weight loss progress. Sometimes I enter data in front of a patient to demonstrate my attention to detail and laborious work collecting data and e-prescribing. I do this partly so the patient sees the value of my time spent on their behalf. But often I hear a voice inside my head saying it’s time to close the laptop and be fully present with my patient.
There is some research to support that by being slower and more deliberate with a patient, you can prevent unnecessary workups, or even important workups that a patient doesn’t want. Defining a patient’s goals, as well as their illness, can allow us to be selective and tailor our approach to the patient. This, I believe, is the essence of being patient-centered, and perhaps the core of being a patient-centered medical home. Yes, there are all the important issues of access, preventive service reminders, and population management, but the center of the PCMH should be the patient-physician relationship.
We are taught through a long process of medical education to dissect the disease into its components. In so doing, we can scientifically identify the disease process. This is very important, but the side effect can be that we continue to deal with the person in pieces rather than as a whole. Within my office or hospital, I must constantly reorient my process so the patient and the things that really matter stay at the center.
It is not easy while I’m surrounded by fast medicine, but with time, I can develop skills to focus on the patient. Sometimes this means I need to slow down. I need to listen to my patient’s story, and I often need to listen to my own heart. This way, in addition to restoring health, I can focus on the things that are life-giving.