Where Has All the Time Gone
This blogpost is an excerpt of a chapter I wrote in Collaborative Caring: Stories and Reflections on Teamwork in Health Care. a book I co-edited with David L. Feldman and Michael Leonard.
The other day, I had an amazing experience. I went to see my primary care provider, a physician named Jane Himmelvo, whom I have talked about in an earlier post, to discuss the pesky issue of my elevating blood pressure. As I age, it has gone from lower to higher – like 155/90 sometimes. Problem is, given what I know about healthcare, and a terrible experience I had with a complication following surgery (one that my surgeon tried to blame on me and for which I received no apology, which would have been much appreciated), I have developed white coat hypertension. So whenever anyone takes my blood pressure in a healthcare facility, zoom, it goes way up. Jane and I have been trying to figure out how to get an accurate BP reading and so I have been doing the readings at home.
So I was in Jane’s office to report on the data I had collected. We sat and discussed it for a few minutes and noted that my regimen of aerobic exercise, lowering salt, meditation and dealcoholized red wine was actually working and we decided – and I use the word “we” deliberately here –that I would keep up the regimen for three to six months to see whether it would continue working over the long term.
With the problem addressed – at least temporarily – in about ten minutes, I was about to jump up and leave, knowing that ten to fifteen minutes is all you usually get with your PCP these days. But then Jane started asking some further questions. They were not: “how’s your stress level, or let’s check that cholesterol one more time (mine it turns out is just peachey). She asked me how I found living in the Bay Area after having moved from Boston two years ago. When I told her I loved it, she asked about my kids. I asked about her’s. We began to segue into our different ethnic backgrounds and religions (I am a lapsed Eastern European Jew, she’s a Vietnamese-American sort of Buddhist). We talked about prejudice, films. I kept peeking at the clock. I had exceeded my 15- minute limit ten minutes ago. Shouldn’t I leave? But no, we kept chatting, getting to know each other. After 45 minutes, our time together seemed to naturally end and I left, feeling flabbergasted. Was she really a PCP? Was this really a doctor’s visit?
Of course, she is, and it was. This particular physician has arranged her practice so that she can actually spend time with patients. There’s never more than one person in the waiting room at a time (rather than four or five). She never seems rushed or stressed or staring at her watch. And she talks with her face to you rather than with her back toward you and eyes glued to the computer screen as she hurriedly types in notes so she can get you out and the next patient (who’s probably been waiting for an hour, because the doc has booked four patients for the same 15 minute slot) in.
I write about this because one of the things that is missing in discussions of teamwork, patient centered care and patient safety is time – time with the patiient. Physicians, nurses, pharmacists, pretty much anyone who works in healthcare at any level today, is working too long and too hard. They are taking care of too many patients, listening to too many histories, ascultating too many lungs, charting the rhythms of too many hearts. When I began writing about healthcare almost 30 years ago, the average primary care doctor had a patient panel of maybe 800. Now it’s up to 2500 maybe even 3000. At a major teaching hospital, which shall go nameless, some PCPs work from early in the morning till late into the night. Some actually sleep in their offices. This is not in India, but California. In North America, resident hours have been reduced – a smidgen – but doctors who have finished their apprenticeship training have no restrictions on how long they can work, how much they should rest, and how many patients they can see, operate on, assess etc.
The kind of stress people experience with these kinds of workloads and hours is, we know, a significant barrier to teamwork and a patient safety hazard. Stress makes people irritable if not angry, frustrated, and possibly even abusive. Similarly fatigue has a serious impact on teamwork because it does the same. When people are constantly interrupted, they can become slightly frustrated, particularly with the supposed team member — or patient – who is responsible for the interruption.
Yet once again, I ask, where are conversations about reducing patient load and increasing time with patients as central to patient centered care. I recently attended a conference at a prestigious medical center on the patient experience in which physicians discussed their efforts to teach one another to be more empathic. The aim was to increase patient satisfaction scores and thus hospital reimbursement. The hospital in question was putting its physicians through empathy training. What it was not doing was changing their workload or work hours. Indeed, the physician presenting at the lecture emphatically stated that productivity demands were off limits and that nothing was going to change in that regard.
So I ask you, how can we have patient safety, patient centered care and teamwork if there is no willingness to deal with the issue of time with the patient?