Just before a colleague retired, I asked him if he could tell me how medicine had changed during his long career. He could, he said. In one word: time.
“Back in the ’60s and ’70s,” he said, “I spent at least an hour with a patient who came in for an annual physical and half an hour for a follow-up or an urgent call.” That’s twice as long as I’m allotted — and my practice is more generous than most.
I had two reactions: first, that the schedule he described sounded heavenly; and second, that I would never have a chance to experience it.
It turned out I was right about the first, wrong about the second.
Not long ago, a few weeks after I had shoulder surgery, an occupational health nurse at my hospital determined that I wasn’t quite mobile or strong enough to resume my usual routine. She recommended a three-week transition during which I would take twice the amount of time as usual to see patients. In other words, I was to travel back to that era my older colleague recalled.
During those slowed-down three weeks, I felt more relaxed and — was it my imagination? — my patients seemed more relaxed, too. I spent less time scribbling notes (if I typed in front of patients, a practice I’ve resisted, I suspect I would have done less of that as well) and more time looking at my patients and listening to them.
Instead of interrupting, I waited as my patients gathered their thoughts or struggled to find just the right word. I felt less tempted to order tests, write prescriptions, or send a patient to a consultant. These things all have their proper place. But during those three weeks, I realized how often I had used them simply to move things along.
My first week back, I spent 30 minutes talking with one woman about her heartburn. Does that sound unreasonable? More unreasonable than increasing the dose of the expensive medication she was already taking, or sending her to a gastroenterologist to have a tube snaked down her esophagus under anesthesia?
We spoke about how her diet, her weight gain, and her emotional stress — all of which she opened up about during the second half of our visit — may have worsened her condition. Then we devised a few strategies to make her feel better, and scheduled a follow-up appointment to assess whether they had worked.
My 21-day experiment in “slow medicine” convinced me that longer visits made me a more empathic, more cost-effective, and happier physician.
So why can’t I practice this way every day?
Mostly because of money. Under a fee-for-service system, seeing patients more quickly means more revenue. But not much of that extra money makes its way to physicians — especially primary care doctors; adjusted for inflation, physician incomes have actually gone down in the past 15 years. Instead, it goes toward a bloated, inefficient system that often does not make us healthier.
With payments tightening from private insurers, Medicare, and Medicaid, doctors are pressured to cram more and more patients into a day’s schedule to keep practices afloat. Then there are these: an aging and sicker population; increasing incidences of obesity and poverty and their associated medical problems; requirements for more complex record-keeping; and more preventive health recommendations to be passed along to patients. The result: You have a situation in which most primary care doctors I know feel like Lucy and Ethel working at that ever speedier candy-making conveyor belt.
Group medical visits, which allow a physician to see several patients at once, and team-based care, which partners doctors with physicians’ assistants, nurse practitioners, and other professionals, have shown promise both in improving the patient’s experience and in slowing doctors’ frantic work pace.
But even these innovations, even a radical change in how we finance health care, won’t soon undo the subtle and often subconscious expectations of doctors and patients that medicine — like everything else in our culture — is supposed to work fast.
A new mother may consider herself a failure if she isn’t ready to leave the hospital in under 48 hours and if her body doesn’t feel back to normal by her six-week postpartum visit.
A widower who’s grieving deeply or a teenager distraught after a romantic breakup may be given antidepressants — sometimes helpfully, but sometimes simply because their intense emotions have gone on “too long.”
And a doctor who can’t address all of a patient’s needs in a brief visit may feel inadequate.
But the body and mind don’t always cooperate with the timelines we’ve constructed.
I recall a patient, a middle-aged woman who developed daily nausea that went on for months. A battery of tests yielded no diagnosis. I suspected that her very stressful job might be at least partially responsible for her symptoms. Leaving the job did help — but not entirely.
Eventually, the nausea abated as mysteriously as it had started. Had I played any useful role in the patient’s recovery? I had ruled out several possible causes of her nausea, given her medication to lessen it, expressed my concern, and signed disability papers. But was there any therapeutic value simply in my spending time with the patient during her many visits?
I think so. When I was a patient, such “treatment” was therapeutic to me.
My recovery from shoulder surgery took longer than anticipated. During the second month after the operation, when I was supposed to be increasing my range of motion and strength, I was in too much pain to do more than drag myself to my physical therapist’s office for an ice-down.
Instead of rushing me, the physical therapist sat and talked with me and let me ice. Over weeks and now months, she has continued to talk with me as she has slowly coaxed my injured joint back into normal function.
She’s an excellent clinician, and an excellent companion with whom to pass the long time it has taken me to heal.
I’m not sure those are so different.
Suzanne Koven M.D. is a primary care internist at Massachusetts General Hospital. She writes a monthly column about the uncertainties, dilemmas, and stories that patients and doctors share in practice. Read her blog on Boston.com/Health. She can be reached at firstname.lastname@example.org. Her website: www.suzannekovenmd.com.