Leadership I

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.

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