Empathy Not Included

Charles Atkins, MD

Published in American Medical News January 15, 2001

 

Over the years, snippets of dialogue have taken on great meaning for me. These usually are truisms dropped in daily conversation—frequently they are cautionary in nature. One example came from a supervisor I had when I was in medical school. I had just told her about a night out with some of my classmates, to which she commented, "Oh right, I remember when I used to have friends." She then went on to explain how after medical school her work consumed more of her time, she got married, had kids and…"there just isn’t the time for friends."

Recently, another one of these time-related poison pearls fell into my lap. It was at a symposium on Medicare compliance and documentation. The speaker was reviewing various components of the E&M note. A physician in the audience asked about time, and how could he possibly write down everything? To which the speaker replied, "I do it right as the patient is talking; it’s more efficient." A discussion ensued about quality of care, and do patients really want to come and see their physician, only to be met by the top of their head as they scribble their note. What about human contact? What about compassion and the doctor-patient relationship? The speaker’s response—and I’m paraphrasing, was ‘I no longer have time for empathy; it’s not included’.

This loss of caring and compassion has been a theme I’ve seen repeated in a variety of settings. A couple weeks back an older friend of mine was hospitalized. While many of the nurses, doctors etc. were quite kind there was also an institutionalized callousness that set the tone of her stay. For her first two nights she was unable to sleep because the head of her bed was next to the intercom, which sounded at all hours. Staff outside her room seemed unaware that patients—just a few feet away—could, and did, hear every word of their conversations. As a variety of aides, technicians and nurses attempted to draw her blood, or start an intravenous they freely discussed how various hospital downsizings had eliminated phlebotomists who were far-more skilled in drawing blood from hard-to-stick patients.

On the other side of things, I recently received a letter in response to an earlier column. This came from a physician who was desperately trying to maintain the human connection with his patients. This included making house calls and performing thorough evaluations that were truly holistic. His visits were time consuming and he found that operating in this manner he was unable to cover his costs and he had to close his practice.

Along with this general decline in caring has come a recognition that quality and cost are interdependent. This harks back to a very old truism that, "time is money" and visa versa. I’ve been in a variety of meetings and discussions where there is an open acknowledgement that the highest level of care is impractical from a cost perspective. While terms like "excellence" and "compassion" will find their way onto billboards, I see them less frequently at the bedside. A more accurate assessment would be "adequate" and "courteous".

As I write this I’m also thinking about responses I’ve received from non-physicians. These letters are often angry in tenor and berate me for discussing the woes of people with six-figure incomes. Be that as it may, the truth is that physicians, hospital executives, and health-care workers in general are faced with shrinking reimbursement and markedly increased regulatory scrutiny. Given this equation—less pay for more work, something has to go. It happens insidiously, and it’s not something that any of us are happy about.

This was anecdotally brought home when a friend of mine described a recent visit to her internist. At the end of the appointment she realized that her physician had not examined her. Instead, they had discussed medications, potential side effects, and her recent hospitalization. She asked, "don’t you want to examine me?" He didn’t. The time was up.

A lot can happen in the three to fifteen minutes people have with their physicians. I’ve even gone to seminars that explore the seven-minute office visit and help physicians cope with this reality. But as I’ve watched, and been involved with, the tightening up of our profession I come to some disturbing realities. One of which is that documentation requirements have grown to the point, where I can spend more time on the note than I do with a patient—and I write fast.

I think the greatest tragedy of the current trend in healthcare, is that whether I’m discussing, doctors, nurses or other healthcare professionals is that we were all trained—at least I like to believe this—to deliver the highest level of care. We didn’t go through four years of medical school, internship and residency to deliver adequate or sufficient treatments. I don’t think any medical school wants to discuss its mediocre graduates. But the reality is such, that what we were trained to deliver is too expensive and is frequently deemed wasteful or impractical. When I supervise residents or other trainees I’m struck at how long and thorough their evaluations are. I know that once away from the academic setting, they’re going to have to move faster—much faster. Certainly competence and experience will make this happen naturally, but if pushed too far, they’ll need to jettison some of the bells and whistles, and ones that seems headed for the waste bin are the patient connection and the human touch.