Its centerpiece was a primary-care practice that consisted of five physicians, a small staff and, at its peak, 1, high-risk Medicare patients.
Yet almost everyone allowed me to sit in and write about whatever took place. The receptiveness to the presence of a stranger — potentially representing millions of other strangers — in these private moments puzzled me but did not seem to surprise Meltzer. Only much later did the question of why they said yes come to seem central to both his project and mine.
How much distance doctors should maintain from their patients is a debate that goes back at least as far as the invention of the stethoscope in This special knowledge and apartness earned new respect for what was then a trade. After the Civil War, as transportation improved and more people moved to cities, often without their families, agrarians and urbanites alike increasingly turned to doctors instead of neighbors or relatives for help when they were ill.
But not long after physicians coalesced into a professional class, advances in research and technology made it increasingly untenable for any practitioner to master the entire medical canon. At the same time, many experienced physicians argued that medical schools were churning out experts in ever-narrower portions of the body who lacked empathy for the whole person. Ultimately, these unique relationships empowered physicians to reject intervention by any regulatory third party, including national government.
Demand for reform led to the passage of Medicare in , but the program, eager to avoid angering doctors and hospitals, embraced the same reimbursement practices of most private insurance plans, arbitrarily assigning flat fees to services, like outpatient checkups, regardless of the benefit to patients. For primary-care doctors — paid the same for a simple exam of a relatively healthy patient as for a more involved consultation with a chronically ill one — this created a perverse incentive: see as many healthy people and as few sick people as possible.
The same study estimated that more than a third of Americans on Medicare who were 65 and older and who had a regular physician had been seeing him or her for a decade or more — and those with the longest ties had lower medical costs and were less likely to be hospitalized than those with the shortest. Yet concrete proof that the patient-doctor relationship was responsible for these better circumstances remained elusive.
Only gradually if ever did the medical relevance of these conversations reveal themselves. The first patient needed a high-calorie, easy-to-swallow meal supplement; the second, a recovering alcoholic, could avoid passing a liquor store by switching routes; the third was not discharged until his doctor called his building manager to make sure he could get into his apartment and plug in his oxygen.
One afternoon I watched one doctor, Ram Krishnamoorthi, examine L. Kizer, who had just turned He was wearing a new-looking ball cap with a trout on it and pulling an oxygen tank. He suffered from congestive heart failure and was still breathing heavily from the trip down the hall. What happened? Krishnamoorthi rolled up his pants legs and probed his ankles. He pressed a stethoscope to his back. He asked if Kizer wanted to be admitted to the hospital, where he could get additional medications; Kizer declined.
Krishnamoorthi eventually agreed to let him go home if he turned off his tank, waited for 10 minutes and had his blood-oxygen level checked. They call the doctor first. Meltzer insists that doctors spending more time with their patients actually saves money. After a year in his clinic, for instance, patients have 20 percent fewer hospitalizations than their control-group counterparts.
Or if it had been, it might have been checked by a professional-care coordinator in consultation with doctors. That permits more face time between doctors and patients, according to Meltzer.
He still sees many of the patients that he began seeing then. In the early s, primary-care doctors typically made daily rounds at their hospitals to oversee the treatment of their patients there.
But this was about to change. As an economist, Meltzer read their forecast with interest. When, soon after the publication of the article, the University of Chicago Medical Center hired its first two hospitalists, Meltzer volunteered to study their impact.
His plan was to compare how patients fared when they were cared for by a specialist a hospitalist versus a generalist. He began keeping records — which physicians treated which patients, for example — and hired two students to interview patients in the hospital and then again over the phone a month after they were discharged to learn about their health.
Meltzer noticed, though, that when the Chicago hospitalists got the weekend off and an attending took over their patients for just 48 hours, the handoff completely erased the cost benefits the model otherwise seemed to generate.
It stood to reason, then, that separating patients in community hospitals from their longtime doctors might be having a significant negative impact. But running a clinical trial in a community hospital to directly compare the hospitalist model to the primary-care model it was rapidly replacing was widely considered impossible.
How many longtime patients of a general practitioner who was still making hospital rounds would agree to swap her for a hospitalist so that researchers could see whether doing so was good for them? By , the hospitalist model had become the norm. That year, Meltzer published a theorem describing why the model had taken hold so quickly; in the past 15 years, the number of practicing hospitalists had jumped from several hundred to 30, Meltzer practices as a hospitalist himself.
The math itself was basic. This gave Meltzer an idea. For patients, he recruited Medicare recipients who had been hospitalized in the past year and were therefore statistically likely to require future hospitalization. A standard survey would assess their overall health.
Did he or she know their values and responsibilities? Give clear instructions? Seem caring and kind? It turned out that many hospital patients his team approached did not have one.
Within four years, the researchers had signed up 2, subjects. On a Monday morning in August , I went on hospital rounds with Krishnamoorthi, as he performed the same duties a hospitalist would with one key difference: He already knew the patients.
His first job was at the Veterans Affairs medical center associated with Loyola University, where he did his residency, as a primary-care physician for patients with mental health problems. He was responsible for at least of them — not many, compared with traditional primary-care physicians, who nationwide manage 2, to 3, patients apiece.
Still, he was in the office until 9 every night, making phone calls and filling out paperwork. He began to worry that he would make a mistake, forget to order a test. After a year, he switched to a job as a teaching hospitalist, supervising residents; the schedule was less extreme, and when he clocked out, his responsibilities and his interactions with the patients he was treating ended.
In , at a party, he was introduced to Meltzer, who was just beginning to staff his clinic. When Krishnamoorthi heard that its five doctors would manage patients each and work regular hours, he decided to apply. That Monday morning, his first patient had head and neck cancer and needed an M. Krishnamoorthi had him practice lying flat and slid pillows under his head and adjusted the bed angle until they found a position the man could tolerate in the scanner that afternoon. That, sometimes, means simply to listen to their fears, concerns, and struggles.
It is, however, easier said than done when you get only 15 minutes per patient and it takes 10 minutes just to sort through the 25 different medications he or she is taking. I was quite cocky, and felt very important and put upon, running this complicated show. On my last night as an intern, I had an anaphylactic reaction, went unconscious, and woke up on a gurney in that same room.
My first request? A pillow. That was a big lesson. It has made me a more caring doctor. I went to the Dentist a few weeks ago. I needed impressions made for whitening and the trays to cover the teeth and hold the molding material were made of metal and they were very large causing me to gag. She said they pratciced on each other in school so they could learn the process. It felt good that she understood but I seriously doubt dentists do the procedure time and time again in school.
I am writing a masters essay for a degree in bioethics. It considers the often unconscious assumptions, attitudes and biases health professionals hold toward patients with disabilities and their affect on care given and received.
Empathy, rather than pity or indifference, requires awareness. This book will go as long way toward increasing it, especially important for those with disabilities because we are frequent, yet underserved, consumers of healthcare. Sure, MDs are much more sympathetic when they have been patients. Likewise, journalists are much more sympathetic when they have been targeted or merely have suffered from sloppy reporting , and everyone becomes much more sympathetic when they actually go through the day with someone with a challenging disability, or live for awhile as the one person who looks different from, and cannot understand the language of, the people who surround them.
Part has to do with a limited world view and experience. I have been a pain management physician for twenty-two years, twenty of which were spent as a chronic pain patient. My experience as a patient ranged from bad to abysmal; I carry this with me to work each day as surely as any piece of equipment. At all times I at least attempt to give the kind of treatment that I would have wanted, personally, in my own darkest hours.
Being a patient — and a father of one — was my own personal destiny, and one in which the development of empathy and spirituality was the only way to make sense of human misfortune and misery.
It has changed my life utterly: surely personally and — I would like to think — professionally. You bet! I have practiced family medicine for nearly 20 years, first as full-time faculty in a family medicine residency program, then as a public health medical officer with the State of Tennessee. When I was diagnosed with vocal cord cancer last summer, I met with my personal physician, a close friend and professional colleague.
In discussing my illness, and the approach we would take to treating it, Larry shared his own personal experiences.
Yes, experiencing serious illness can make doctors become better doctors. Thank you for this fine article. We know that the OR is kept at a colder temperature level so that the surgeons and nurses working under intense pressure and a lot of layers can be more comfortable.
So, please, feel free to post more about the wonderful nursing care you received when you were a patient, and how you now have a better appreciation for the nursing profession and all we do. For starters, try lying on your kitchen floor for a couple of hours and staring up at the lights while a fan blows cold air on your backside.
No kidding, doctors ignore fatigue. It took me 35 years and probably as many doctors to be diagnosed with narcolepsy. I was a textbook case—one of those rare people who had all the symptoms. I had been to several neurologists, not one of whom ever asked about my sleep or other symptoms relating to narcolepsy.
I think this is a marvelous and much-needed book…but one thing that none of the posts above address is the incredible time-crunch both residents and attendings face to see patients. I am a fellow at a busy teaching hospital and one of my attendings aptly pointed out that as soon as a patient can stand up, they are out the door.
Insurance companies and utilization committees have dramatically reduced the amount of time we have with our patients. It is a shameful reflection on the reimbursement scheme today which drive our hospitals and clinics—which pays the M.
Those of us in thinking fields are penalized rather than rewarded for the very values integral to being a good diagnostician and listener. When trying to get the history, I often explain that I am not in their body, and I need their words and anything else to try to understand what they experience d.
I was learning this skill of interviewing and doing physical examinations PDog, in the vernacular when I sought help about something as mundane as a common knee problem. Just thinking about how to describe this ailment according to the 7 standard parameters was daunting. But, as I also explain to patients, the retelling of the story also helps as some other aspect of the experience comes out or is recalled. Depending upon the relationship, the receiving end, this telling can also be aggravating or therapeutic.
As for training: my psychiatry med school rotation had almost daily seminars using literature. This can give a better sense of what the patient experiences. These were true wordsmiths, and often as Styron writing from experience. In some respects, that can be the closest I will get to actually experiencing what the patient may experience. But it is invaluable. Her symptoms are worse in the morning. She also has morning stiffness that lasts approximately 3 hours after awakening.
She takes ibuprofen as needed with minimal relief. She has a 6-year history of a chronic rash limited to her knees but has never sought medical care for this condition. The current system treats the medical encounter, the doctor-patient relationship, as no different than your check out from the grocery store — as a commodity, each identical to the next, with throughput as the only parameter that counts. We are viewed as check lists, not experiences. This applies to nurses as well as physicians.
Nurses, especially in hospitals, now have a greater duty to assure that the JCAHO parameters are checked off, not that they minister to the patient. As a family doctor, I think the diagnosis is only partially accurate and the prescription is sometimes not realistic. Some specialties have a workload and stress level similar to that of combat. And of course empathy is time-consuming.
Educating doctors about empathy is a useful, relatively easy thing to do. But it is no magic bullet. I think physicians should undergo some experiences…for one, facedown recovery. After some eye operations, a gas bubble is inserted and you have to keep your face parallel to the floor for up to two weeks. They told me this had to be 24 hrs a day.
The implication was that if my head came up, it would ruin this horrifying and disgusting surgery. I sent my frisky dog away and he was killed by a car. Later, I learned most top retina surgeons let you look up 5 mins of every hour. If they made doctors try a week of facedown, this would not have happened. This is just one example.
I could name a dozen more. As for the nurse, who said we should really be talking about the great care nurses and their staffs give, I have had this go both ways. I have been yelled at by nurses! And I have had some who truly were angels who sneaked in. I wonder when the changeover happens, between thinking you have everything to thinking you will never get anything? See next articles. Robert Klitzman Charles Manley.
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