Leadership

On Presence: A Tale of Two Visits

Article · December 29, 2016

My husband and I recently found ourselves with his and her ophthalmology appointments — same day, different cities.

Our visits, only 100 miles apart, could not have been more different. The differences, I think, are relevant to safety, access, quality, and satisfaction for patients, and career satisfaction for physicians.

My husband was seen at a regional academic medical center, first by a resident, then a fellow, followed by the attending physician. With each physician, he was aware of how much they typed — furiously typed. During the first few minutes of the visit, each physician discussed the situation face to face with him, with genuine concern. Another few minutes was spent on the slit lamp exam. Then each physician shifted gears. For the remainder of their visits, each was glued to the computer screen. While they typed, the patient felt like an afterthought.

My husband, who is also a physician, wasn’t angry; he felt compassion. Each of these physicians had given up so much of their lives to master their skills, to develop their craft, and to help people in need, and yet here they were spending so much of their time typing, furiously typing, instead of interacting with the patient. My husband wondered how many patients weren’t able to make appointments or see their doctors because so much of these physicians’ time was spent on this typing.

My visit, on the other hand, was at the multi-specialty clinic where my husband and I have spent our careers as general internists. My attending physician did not type much at all. The nurse checked me in, asked how things were going, did standard visual tests, and measured my intraocular pressure. She returned with the physician, who talked with me face to face. While he examined me with the slit lamp, the nurse provided him technical data from my previous visits, and then he relayed to her additional technical data from his exam, which she recorded. He then pushed the slit lamp aside and talked with me again, this time about options and next steps. He consulted previous studies in the electronic health record. But he was not furiously typing. He was talking and attentively listening.

After he left, the nurse stayed behind, provided me with medications, and arranged for a semi-urgent appointment at a referral center. We also arranged for her to check my eye pressure a few times between visits. I know her by name. She knows the details of my situation. We are no longer strangers. I won’t hesitate to call her if a problem arises.

In a word, my visit to ophthalmology included what Abraham Verghese has termed “presence.” The physician and nurse were present to me. And I was a human presence to them. To be fair, my husband was also a human presence to his physicians, but it entailed more strain on their part because of their assigned role in data entry. “Presence” comprised a smaller portion of the overall visit.

Verghese writes of the altered presence the EHR has wrought between physicians and healers:

Being with patients, being present and willing to engage directly in the manner they most want, is a form of risk. The representation of the patient in the EMR (the iPatient, as I call it) is necessary. But being with the iPatient too long is a guaranteed way of not being present with the actual patient. It can even begin to feel safer and simpler to be present with one of the many “enchanted objects” around us — computer screens, tablets, and smartphones — than with human beings.

Verghese makes the case that the central act of medicine is observation, and that the central tool is “the medical gaze.” My husband’s visit comprised a lot of “screen gaze” time. My own had more of “the medical gaze.”

As a physician, it has been the times when I push away from the computer to pause, look, and listen to the patient in which I find the most meaning, the most value. It is then that a missed diagnosis may pop into my mind, an insight into the patient’s hesitation becomes apparent, or simply when the meeting of two people in a room, in a clinic, in a community, on this planet happens.

In his essay, Verghese concludes:

There are a few things that are timeless in medicine, unchanged since antiquity, which we can keep front and center as we bring about reform. One is the simple truth that patients want us to be more present. We as physicians want to be more present with the patient, as well, because without that contact, our professional life loses much of its meaning.

It is a one-word rallying cry for patients and physicians, the common ground we share, the one thing we should not compromise, the starting place to begin reform, the single word to put on the placard as we rally for the cause.

Presence.

Period.

It is our job, I believe, as physicians, administrators, technology vendors, regulators, payers, and even patients, to come together to create the environment where patients and care teams can be present to one another.

This is one of my goals as Vice President of Professional Satisfaction at the American Medical Association: to help create the conditions where joy in practice is possible, where presence is probable. How?

  • At the practice level, by working smarter, not harder. At the AMA we are creating free online practice transformation toolkits to help practices reengineer their work. Advanced models of teamwork allow the mandatory work to get taken care of, but not at the expense of the important work.
  • At the regulatory level, by debunking urban myths and reducing regulatory pain points, so that physicians don’t spend most of their days doing the wrong work for patients.
  • At the technology level, by creating technology that supports rather than hinders healing relationships.
  • At the measurement level, by imposing fewer, more meaningful, and manageable measures.
  • At the institutional level, by making the quality, safety, and financial case for a joyful, purposeful workforce.
  • And at the individual clinician level, to learn the skills of empathy, resilience, workflow optimization, and teamwork that collectively can save several hours per day for many practices.

While my husband and I both received kind, expert care, his physicians were limited in the number of patients they could help by virtue of the amount of their day they spent doing work a non-physician could do.

That semi-urgent referral I mentioned? The soonest I could be seen by a physician I had seen before was 4 months hence. It is likely that he can’t see me sooner because he is spending much of his day typing, furiously typing.

Health care needs to build structures that support presence, both for the patients already on the schedule, and for those who need to be seen but can’t get in.

New call for submissions ­to NEJM Catalyst

Now inviting longform articles

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Leadership
The CMO Role of the Future - Baptist Health Survey Results

Examining the Continuously Evolving Role of the Chief Medical Officer

Hospital and system leaders need to sharpen the focus of CMO roles to include system-wide considerations beyond the walls of the hospital.

Meyer01_header - Seven Challenges and Seven Potential Solutions for Large-Scale EHR Implementation

Seven Challenges and Seven Solutions for Large-Scale EHR Implementations

Salient lessons learned over multiple electronic health record implementations.

Zuckerberg San Francisco General Hospital ZSFGH A3 thinking Personal Development Plan A3 leader standard work improvement management example board

Changing Leadership Behavior Gets Real Results

Zuckerberg San Francisco General Hospital deployed its new leadership culture, which emphasizes staff decision-making, self-reflection, and clarity in defining problems and goals, to successfully address a crisis involving record-high patient volumes.

Khatri02_pullquote Connectors

The Crucial Role of Connectors in Large Health Care Organizations

Creating a truly collaborative community involves connecting the right people at the right time and in the right places.

Women of Impact Checklist - Advancing Workplace Equity

Lead In: Women of Impact in Health Care on Advancing Equity in the Workplace

Raising the standards of equity and wellness in our workplaces so we effectively advance health for the populations we serve.

Historical and Projected Numbers of Physicians, Nurse Practitioners, and Physician Assistants.

Growing Ranks of Advanced Practice Clinicians — Implications for the Physician Workforce

The number of NPs and PAs is growing rapidly, while physician supply has slowed. This research projects the number of NPs, PAs, and physicians through 2030.

IBM solutions to physician burnout roundtable participants: Christina Maslach, Paul DeChant, Tait Shanafelt, Namita Seth Mohta, Karen Weiner, Edward Prewitt

NEJM Catalyst Roundtable Report: Seeking Solutions to Physician Burnout

An NEJM Catalyst roundtable sponsored by IBM Watson Health brought together four experts, all deeply engaged in reducing physician burnout from different perspectives, to share in a robust discussion.

Pottharst01_pullquote - value-based health care leadership personas

Personas of Leadership in Value-Based Care

The deliberate nurturing of specific types of leadership personas seems to be a critical factor in the success of value-based care organizations.

Few Truly High-Performing Health Care Organizations

Survey Snapshot: What the High Performers Have to Say

NEJM Catalyst Insights Council members from high-performing institutions share their perspectives on what’s working and what needs improvement.

Morris-Singer01 pullquote clinician burnout community-building

Combating Clinician Burnout with Community-Building

Improving morale and reducing turnover with peer-support meetings and shared group email lists for clinicians.

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Leading Transformation

236 Articles

The Evolution of Primary Care: Embracing…

Primary care must leverage disruptive innovations to ensure that patients receive first-access, comprehensive, coordinated, continuous…

Team Care

99 Articles

Balancing Mission and Margin

How do health care organizations without much margin balance that with their mission to provide…

Physician Burnout

42 Articles

Health Care Teams with Grit

Four key elements that characterize gritty individuals, gritty teams, and gritty organizations.

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now