Fast Medicine

Richard Gunderman goodAmericans tend to like fast things: instant coffee, sports cars, and speed dating. Many share a fascination with record holders, such as the world’s fastest runner or texter. And increasingly, the same goes for medicine. The number of minute clinics is exploding. Some emergency rooms now post their current wait times on roadside billboards. And increasingly, physicians and other health professionals are under pressure to increase the speed at which they see patients.

A friend of mine, a family physician, was recently advised by the new manager of his practice that he will be penalized if he doesn’t increase the number of patients he sees each day in clinic. A thorough and compassionate physician who is known for the quality of the relationships he builds, he asked the man, “How am I supposed to work faster and still provide good care?” The practice manager thought for a moment and responded, “Why don’t you stop asking open-ended questions?”

To be fair, there is something remarkable about fast medicine. Consider Robert Liston, a 19th-century British surgeon who is said to have called out to his students, “Time me, gentlemen, time me!” It was widely known that Liston could amputate a leg in under three minutes, a hastiness attributable in part to the fact that inhalation anesthesia had not yet been invented. Yet such speed has drawbacks. In one of Liston’s most celebrated cases he removed his patient’s testicles, and in another he also amputated his assistant’s fingers.

In medicine, the pressure to shorten visits is being exacerbated by demands to devote more time to non-patient care activities. For example, a study of emergency room practice published last year showed that, on average, physicians are now spending twice as much time entering data into the hospital information system as they spend on direct patient care, recording no fewer than 4,000 mouse clicks per shift.

Some things simply cannot be rushed, at least not if high quality is the objective. Part of the problem is the fact that haste leads to errors. But moving too fast can also rob life of meaning. Consider conversation, friendship, and intimacy. When it comes to such relationship-based activities, going too fast can prevent them from really happening at all.
What happens to a medical encounter when the patient senses that the physician is rushing? In many cases, patients end up feeling as though they have been taking a multiple-choice examination. It may not take long for a physician to compose a list of a patient’s prior surgeries, but to delve into marital problems, depression, or the prospect of dying is a different matter, requiring a different tempo.

Good medicine is grounded in relationships. And because good relationships take time, good medicine often equals patient medicine. To focus on the patient means listening, interacting, and practicing patiently. It means taking the time to let deep concerns express themselves, and investing the time needed to build real relationships.

We physicians sometimes forget how truly impatient we are. Consider, for example, Dr. Jack MacKee, the rock-star cardiovascular surgeon in Randa Haines’ 1991 film, “The Doctor.” MacKee is a technical virtuoso, but he has allowed his interactions with patients to become superficial and brusque. Only when he is diagnosed with throat cancer and gets a like-minded physician does he begin to appreciate the insipid taste of his own medicine.
Carlo Petrini launched the slow food movement in 1986 in protest over McDonald’s plans to open a restaurant on the Spanish Steps in Rome. He argued that globalization and industrial production represented a threat to something important – namely, the cultivation of local culinary traditions and foods. As he saw it, speed and value were supplanting something important – community, taste, and conviviality, the capacity to truly enjoy the experience of dining together.

A former student of mine recently expressed his bitterness at being asked by his employer to see a different patient every 11 minutes. At this rate he feels he will no longer have time to get to know any of them. Such pressures to increase productivity, which is always measured in relation to time, are transforming medicine into an anxious profession, in which many practitioners sense they no longer have time to take proper care of their patients.
Medicine at its best is not just a collection of clinical processes, such as delivering the right immunizations or prescribing the right antibiotics. It isn’t merely a matter of optimizing throughput, cutting costs, or enhancing efficiencies. Truly great medicine is built on relationships. It is about people. And taking good care of people means taking the time to know and care for them as persons. Regardless the effect on the bottom line, sometimes we simply need to slow down.

15 replies »

  1. very good article.in todays world everyone wants to fast & instant relief from there health problems.but its a difficult if not impossible conundrum to deal with .and the natural health supplements are more useful for all type of health problems…..

  2. This is an abomination and corruption of the spirit of being a physician. It is a difficult, if not impossible conundrum to deal with. As time progresses it becomes more acceptable to some physicians and patients. This will continue and get worse as long as physicians do not sign their own paychecks and immoral administrators and government continue on the path to the destruction of American Health Care. I am not certain if quality measures as currently are being promoted will improve care or decrease costs. Each level of bureaucracy and regulation increases cost instead of reducinit.

  3. Very good article. The drive for more patients is the need for more revenue. More money – answer to all our problems in our free market fundamentalism. We must resist this juggernaut. People matter.

  4. Dr. Palmer

    I agree completely, but I am not as pessimistic. Here is why:

    Over the past decade high deductible plans linked to Health Savings Accounts have proliferated….now approaching 30% of private insured. A high deductible means that the payment flows through the patient (until the deductible is met)….and this ” system reinforces good behavior on the part of the doctor and induces patients to properly question the value of their care”….acting in a fashion as your indemnity plan.

    The ACA is hugely unpopular and remains riddled with problems. There will be political pressure and opportunities for significant reform if not replacement with systems that give power and control to patients and doctors.

  5. Hey, @william_palmer

    Did you ever try to collect $500 from a demented alcoholic/drug addict that is your fee but was sent to the patient by the health insurance vendor?

    What are your strategies, exactly?

  6. Dr. Palmer
    We are working on the insurance money passing thru the patient first.
    If the patient negotiates a better cash price than the insurer’s network payment, we will credit the lower cash payment toward his deductible.
    That is assuming there is a deducible.
    Our plans are typically sold with a zero deductible.
    Don Levit
    Managing Partner
    National Prosperity Life and Health

  7. Insurance money should pass through the patient first, who then pays the doctor. This old indemnity system was hated by everyone except the patient, who would occaszionally keep the dough. But the system reinforces good behavior on the part of the doctor and induces patients to properly question the value of their care. A bonus was that it served as a teacher of prices. People begin to realize what things cost.

    The system was not abused by patients because a failure to pay the doctor wouls naturally end that particular doc-patient relationship. Sometimes patients would have dual payments from two insurers and they would rejoice until it was straightened out….or not.

    It would be a useful step in patient-centered care I believe, but it is probably fanciful at this time: too much control handed to patients…relegated from too much financial power. I.e. our dysfunction is too extreme to fix.

  8. I agree, but, you are dealing with people who are more often characterologically disordered as administrators, so appealing to reason and empathy is a big waste of time.

  9. most physicians are employed by hospital systems who hire the practice administrator who tell the docs what the system wants and that is usually see more patients. I am in that exact system and due to no compete clauses it is very hard to leave. But i would suggest telling the administrator the line i use. “I have a job because i am a doctor, and you have a job because i am a doctor” it gets nothing accomplished but feels good.

  10. Face time w Duncan in Dallas was brief. Costly, no? EHR does Dallas!

  11. What do you think Obamacare unchallenged will do to the quality of health care come another few years.

    My bad, I am sorry I assumed you could use the word “quality” when talking about Obamacare.

    Everyone who voted for Obama twice and is now hurting as a health care provider, please, SHUT UP!

    Oh, and this example of the practice manager telling the physician what to do, why the hell is this manager still at that office a day later?!

    Tells you who really is in charge of health care decisions today, folks!!!

  12. one our local hospitals has the ability to book your er visit online, they also have the signs around town that say wait times. if you can book online and are concerned with wait times i think by definition it is not an emergency.
    Now back to seeing my patients every 10 minutes and giving them what they want because my press ganey scores are dropping

  13. The McDonald’s medicine approach is only going to make medical care in this country even more inefficient and impersonal. This is how we miss cases of Ebola in the ER. EHR use notwithstanding, taking the time to communicate and interact with the patient is one of the best ways we have to practice the “art” of medicine. This also gives doctors the time to observe and let their inner voice communicate any “red flags”.
    If this is the way things are going, I don’t want any part of it.