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The Bedside Manifesto

“Most of us went into medicine because we love spending time with patients,” said Johns Hopkins Hospital’s Leonard Feldman, MD.

Dr. Feldman is co-author of an article published April 18 in the Journal of General Internal Medicine which reveals that medical interns spend only 12% of their time examining and talking with patients, and more than 40% of their time on computer tasks. 

“Our systems have squeezed [patient contact] out of medical training,” said Dr. Feldman.“ All of us think that interns spend too much time behind the computer. It’s not an easy problem to solve.”

For three weeks a year ago, investigators observed 29 interns at two Johns Hopkins University internal medicine residency programs for a total of 873 hours. Direct patient care accounted for only 12.3% of interns’ time, and computer use for 40%. The paucity of direct interaction may explain previous studies’ findings that only 10% of hospitalized patients know which resident physicians are responsible for their care. “I think we can do better,” said Dr. Feldman.

He’s right. Unless we want healthcare to devolve ultimately into a system of vending machines, we need to restore its traditional personal intimacy. But medical sages have been chanting that mantra since the 1920s. What holds it up?
I spend plenty of time surfing the web for “caring in healthcare,” “humanism in medicine,” and the like. In more places than you might suppose, experts are deploying medical curricula designed to impart healing skills. Almost fifty years ago I took an admirable course in medical school in which we read moving depictions of suffering and compassion by Tolstoy, Dickens, and Steinbeck. But afterward, when we arrived on the wards, we found our time totally occupied by physical necessities—draw that blood, do that spinal tap, start that IV. It was clear then that there was no time to simply sit with a patient. And it’s far clearer now. In the 1970s I left a group practice that had me see four patients hourly because the pace made me feel like an assembly line worker. Today the average medical visit is six minutes.

What’s moved us away from actual patients and toward their electronic avatars are financial pressures. The office or hospital or university requires remuneration. The corporation requires profit. Our backsides require liability coverage. The monies involved are not only huge—now almost one out of five dollars spent for anything—but have grown at a staggering rate: $2.6 trillion in 2010, over ten times the $256 billion spent in 1980. That’s such serious bucks that any slacker who stops to listen to a patient is seen as something of a saboteur. And that’s why humanistic curricula, no matter how well designed, will run off the tracks. They’re simply no match for medical economics’ monolith.

What can we do, then, to put care back in healthcare?

If you’re a doctor, I suggest following Gandhi’s suggestion, “Be the change you want to see in the world.” In other words, spend appropriate time with patients, period. Of course, the bean counters won’t appreciate that, and it won’t ease your place in the current practice community. It could even get you fired (which might, after all, save your life).

Sustainable change begins with a solitary person here and there, and then two. When there are three, according to Arlo Guthrie, it’s a conspiracy, and beyond three, a subculture. Let the wild rumpus begin.

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Kathleen Myers
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Hi Dr. Kane, A colleague just forwarded along your interesting blog to me. Eight years ago, I started a medical scribe program because I wanted to spend time taking care of patients instead of functioning as a data entry technician. In the ED literature, the average time spent working on an EMR is now 30- 40% of the total time on a shift – an obvious detriment to providing good patient care. While working with a scribe, I can sit down and look at my patient without being distracted by a computer or chart. Everything the patient says is entered… Read more »