Commentary on “Patients Will Record Encounters, and Docs Must Adjust”

Commentary on Patients Will Record Encounters, and Docs Must Adjust

I read a brief review in Med Page Today, regarding the use of secret recorders during outpatient visits to a physicians’ office.

And I got mad as hell.

And then I wept. Truly.

I have been a medical oncologist for over 3 decades. For most of that time I remembered every word of every first interview I had with each new patient I saw. I made no effort to do it. But the impact of that interview on me, whatever the effect on my patient, was strong enough to make it almost instantly retrievable from my modest memory banks.

Why would such a statement make me so sad?

Simply put, it was because I shared a little bit of the terror, spoken or not, in the eyes of each new patients and their families.

Over the years, I’ve thought about it a lot. I’ve concluded that if the shoe was on the other foot, my first thought after being given a cancer diagnosis would be,

“Oh, my God. I’m going to die.”

And my second thought would be,

“I’m going to SUFFER and then I’m going die.”

I spent years in settings where my first thought and my first action were critically important. When someone arrives in the E. R or the ICU, dead or near-dead, there is no time for ethereal mental masturbation.

But cancer rarely kills like that. So I learned that my first responsibility as a doctor was to address the terror. It was not done by skillful placement of an I.V., or a surgical procedure. I learned quickly that I that I to soften a soul searing fear with words, and with my presence. I can be tough work.

I took that responsibility upon myself, and allowed no one else but me to do it. I had loving, competent staff and nurses, but that job was mine. It could be no one else’s.

Only then could I begin to describe what I perceived to be the truth about my new patient’s disease. An information base had a calming effect on me, and my patient. For me, it was to clear my mind of the pain and anxiety in the room. It was a kind of reboot: first thing first, second thing second, and like that. For my patient, it likely did much the same. Now we’re could get to work on how I propose to fight this threat.

It was a kind of process, albeit a compressed one. It enabled family members to hear and learn facts essential to what I hoped would be partnership-a small-determined team to fight a cancer-or to prepare for a death with grace. There weren’t many of us, in the early days, especially: me, my staff, the patient, his/her loved ones and a few cancer-killing drugs.

It had little to do, in its substance, with how well I had internalized endless volumes of information as a medical student at Baylor or as a resident at Yale or during my fellowship in Medical Oncology. What I had learned was critical however, to follow my earnest effort at bonding with the reality of thorough explanation and teaching to someone who was un comfortable-in fact, was terrified-of language I took for granted.

My solution? I spoke slowly and quietly. I looked for ways to insert humor-usually about me. I drew reams of pictures, usually on patient examination paper sheeting. (On occasion, my ‘creation’ trailed after Aunt Lil like a massive roll of toilet paper.) I provided survival statistics, if needed. I once gave a 7-year old young man an old surgery text. He wanted to study its pictures so he could help explain what was happening to his mother with a breast cancer. Patients took the data home to study. Everyone had my home phone number.

What has all this to do with a MedPage review?

In my view-everything.

I put singular effort into each patient because it was my chosen job. Shorn of all technology, physical skills, ego, and the like, it was why I had signed on to be a doctor. This was, to me, the quintessence of the doctoring craft. I was a craftsman of some order. From date X, (I cannot remember when it was, or why) I had chased a dream of my own making. I became a Journeyman, I strove to join the ‘Order of Physicians’. Once accepted into the Order, I worked as apprentice for 16 years.

It was not my intent to seek fame, notoriety, or riches (although in this day and age, that may seem hard to swallow). I wanted to use the skills I’d learned, to brandish them about like a gold chalice or a perfect pair of shoes. I wanted to show that all the time that had been invested in me by countless teachers had not been wasted.

This was not rocket science; it wasn’t the ability to use one’s intellectual prowess and spar heartily with the other small handful of wizards who shared a passion for Energy and the stars.

This was the human body, studied since the 14th century as cadavers stolen from their graves or from the river Thames. More contemporarily, it was Dr’s. Banting and Best, who crystallized insulin, or Dr. Rachmael Levine, who used it to control human blood sugar levels. It was Dr’s Watson and Crick, who unraveled the simple, elegant secret to DNA. It was the simpleton’s guide to X-rays, and MRI’s, which had been designed using principals I was too terrified to learn in their elegant, mathematically precise detail.

But this craft is about more than shoes or gold cups. It is about human suffering, and human need for succor and comfort. Over however many years, we have sought people to quiet our fears and to heal our bodies. Shamen, leech wielding ‘physicians’, Voo doo, Healing Touch, (study of the bumps on the skull). The shaman of today is a quack and a liability. The shaman of 50,000 years ago was a healer!

There are those who are ‘called’ to do this work, just as some lead prayers, and others build tall buildings. I believe that each of us has something in his/her heart that he is driven to try to do. And pursuing that goal brings us as close go God as we ever get.

In stark contrast, there are those who are convinced that Healthcare is a set of algorithms, defined by experts (as defined by whom)? And undeniably, the treatment of runny noses with/without fever can be mundane, a duty relegated to a person with little training who makes little money for performing his/her task. But what is an acceptable error rate.-.the per cent of patients who are misdiagnosed and who suffer or die due to the limits of accuracy of the screening process?

Unhappily, it is all about money. Care for the worried well costs far more in manpower attention time than care for those who don’t know they’re ill, and usually don’t care.. That is, one can run a single blood test 1,000,000 times for the same cost as 50,000 tests plus time taken for assessment, evaluation, examination, followed by a decision to do the test.

To be sure, preventative healthcare, is thought to be cheaper by preventing more serious illness later in time, although definitive data are not yet available for large populations. Is such practice more cost effective than the historical alternative?

So when I am told by a third-year medical student that physicians should simply “adapt” to the potential presence of a recorder in each patient’s pocket, I recognize how very little she can know about what makes American Medicine what it was and should be: a venue for Healthcare providers with a whole constellation of dreams and skills, but united by one fundamental quality: real empathy delivered with affection and understanding.

In the realest sense of our job, it shouldn’t matter a whit. But the predictable, and often operational, changes in the doctor-patient relationship can be scary.

Of course, the adversarial position implicit in the pocket recorder is valid. The suspicions of doctor and patient alike are brought to bear by its use. But the author, while she admonishes us physicians to keep our mouths shut and “go” with it, seems to have forgotten (or to have consciously omitted) role of the doctor as comforter, or as deliver-er of essential information.

Who is to fill this important empty space? I have trained and worked with RN’s who could replace me in the doctor’s chair in an instant. But it took us years together to make us interchangeable in routine situations. But every couple of days, I’d get a call.

“You’d better come. Now.”

The physician’s training gauntlet is in a very real way an apprenticeship. It is humdrum memorization, standing at the foot of a patient’s bed and reciting silly numbers. But the rare and occasional example of “whatever-it-is”, and the challenge of recognizing, and treating, while being ombudsman to a terrified family, cuts to the very core of what it means to be a physician. That’s what the “Do No Harm” part of the Hippocratic Oath is all about.

MedPractice may be designed to keep the public, and physicians, up to date on new developments-and the new medicine.

The Paper’s titular sponsor, Dr. Gupta, is clearly a proponent of streamlined approach to patient care. But what are its drawbacks? Sometimes, one has to be a patient to find that out.

It’s been my extreme misfortune to have been on the OR table for some 20-odd major surgeries in my life. I took more medicines than Carter had pills. And much of the time before an operation I was too scared or in too much pain to pay much attention to what was said. And I usually had abundant knowledge going in!

Did this experience make me a better doctor? Should all physicians in America have a little taste of the ‘other side of the bed’? That’s pretty harsh. But not a bad teaching experience…

I have an idea. Senators, Congressmen, even Dr. Gupta, and the doctor-to-be Ms. Martinez. Picture yourself, and only you will do, with a severe, painful illness in need of care NOW…and perhaps for the foreseeable future-however long you fear that may be. You’re scared, and more than a little suspicious. Cousin Jenny, who came with you, is just plain angry. She doesn’t understand many of the words your doctor says, and is certain there’s something unsaid. But it’s critically important here. And whatever the doctor omits from Jenny’s expectations, makes her more leery of him.

Now picture yourself with a physician who has been just instructed that he/she “must adapt” to the recorder you have in your pocket. You wonder,

“Will my doctor be defensive or angry? Righteous or scared?”

Or, perhaps you don’t you care? Is it your right? Not in California, at least, unless the doctor agrees. That’s like having your phone tapped!

Why do you need that recorder? To make sure someone’s not lying to you, somehow? And how will you do that? Or to review what was said to understand it better. Will a restatement of the most frightening thing you’ e ever heard in your life really help you? Or do you need more information?

Where can you get it? The pamphlets in the lobby? The Internet? The Medical Library? A second opinion?

The task is incomprehensible.

On the one hand, you cannot see the hidden bias in something written by a specialist on the Internet? Usually, he is counting on it. (If you’re clever, you consider,

“Why does he use the Internet to advertise himself? My doctor’s busy as anything, and he doesn’t advertise. Everyone knows he’s the best”

Ultimately, the issue becomes one of trust. Whom do you understand and trust more, the brother you grew up with, or cousin Matthias, whom you saw once at a weeding?

That was pretty long-winded. But the questions are in your head, whether you are listening or not.

Consider. You’re afraid of feeling badly, of hurting, or losing weight. Your deathly afraid of what it might be, and want the very best-for your own sake, or your family. And you do not want to suffer. That fear is almost worse than the fear of dying.

Now pause and consider what is in the doctor’s head, and how it affects you?

It’s easy. In fact it’s already happened. Takes about a nanosecond. Look your doctor in the eye. Really look at him/her. What does he see?

He sees Time. Can he gain your trust in a second? Then he’s good at selling himself, but he may not be best at what he does.

He’s seeing the time it will take to gain your trust, the time it will take to answer your questions, the time it will take to answer all the family’s questions. It goes on, and on, and on. Maybe he has to urinate, too! Make no mistake, he’s sizing you up, even if he has a big, big heart and is oozing with empathy.

True empathy. Agape the Greeks called it. It meant placing you first, even before his own needs.

Then picture that his schedule demands he see twelve of you in the next hour. And while he’s doing it explain to you and your loved ones, (each of whom may understand something different from you) the details of what makes you feel bad. But you note he’s looking sidelong at the clock. Because if he doesn’t, he will be scolded, or worse, he won’t get paid, and his kids won’t get those new shoes, or his wife that new (or used) car. The one he can’t help pick out because he doesn’t have Time. Partly because he’s with you.

And if he takes his craft seriously, those conflicts are tearing him apart.

My conclusion is as follows: time is simply not compressible when it comes to human fear, psychological suffering, and the need for and expectation of relief.

But medicine today is the enemy of time. That may have something to do with why Sweden, long known for its national medical program, has announced that they’re s scrapping their model for something based more in the private sector. What U.S. medicine is about is Money.

Peter Kennedy, MD