As Colon Cancer Awareness Month draws to a close — AND as the House of Representatives is poised to vote on the terrible AHCA — I’m reposting this. It has to do with any kind of hospitalization — or even office visits.
It was 2001. After being sick for awhile Melinda rushed me to the ER. They kept me, soon saying, “This is your diagnostician” and “This is your surgeon.” And “Cancer…” I had meatball surgery since there was no time to prep, and it was almost too late. Then a week in an induced coma. Next was a CCU room. I had tubes running in and out of me, and I still didn’t know if I would live. Melinda had to get some work done, so I was alone and crying softly to myself when my surgeon came in on her rounds. She had stood before, but this time she pulled up a chair, sat down, and held my hand. I don’t know if she was there for seconds or minutes or an hour, but I felt better. I had hope that I’d have a future.
I had never seen someone so yellow.
It was as if someone had taken a highlighter to the whites of her eyes and coated her skin with a layer of mustard. In actuality, the cancer in her colon had crept to her liver, where it blocked bile from taking its natural path out of the body, causing the ominous yellow chemical to spill into her blood and tissues. She had left the hospital two weeks ago, hoping to die at home, but came back with worsening pain and bloating in her belly — and because she couldn’t stand to look at herself in the mirror.
“Doctor,” she said softly — it was a title that still didn’t feel quite comfortable to me, a newly minted doctor, especially coming from a patient several decades older than me. “You remind me of my nephew.”
She asked me to sit for a few minutes and, shamefully, I hesitated. I had eight more patients to see before rounds and was already running behind. But I sat — listening to a dying woman’s fondest family memories, my mind racing through a seemingly endless list of boxes I had to check that morning. When my pager went off five minutes later, I excused myself, promising to return in the afternoon to finish our conversation.
But I didn’t.
There were new patient admissions. Emergencies on other floors. Notes to be written, consultants to be called, outside hospital medical records to be procured.
When I got home that night, I kicked myself for forgetting to stop back to see her. I briefly considered going back to the hospital but, exhausted, told myself she’d be asleep by now and vowed to arrive early the next morning to spend extra time with her.
She died that night.
The most draining aspect of medical training, it turns out, is not long hours, brash colleagues or steep learning curves — it’s the feeling that you’re often unable to be there with and for your patients in the way you want, in the way you’d always imagined you would be.
For hospitals to run efficiently, it is widely thought that they must operate like companies. There’s a certain number of patients to be seen, doctors to see them, diseases to be managed, procedures to be performed, and hours in which all this must occur. For patients to feel cared for, we must treat them like family — with all the time, energy and compassion that entails.
It’s a tension with which doctors at all levels of training struggle. But the problem may be most acute for new residents who are generally the ones expected to gather, relay and document patient information; to enter orders and coordinate care between medical services; to be the first to respond to patient, family and nursing queries.
So far, residency educational reform has focused on the quantity of hours worked, not necessarily improving the quality of time spent at work. But limiting how long residents spend in the hospital may have actually exacerbated the problem. By squeezing the same clinical and administrative work into fewer hours, do we inadvertently encourage completion of activities essential in the operational sense at the expense of activities essential in the human sense?
It’s no secret that trainees now spend less time at the bedside than ever before. Residents today spend eight minutes per day with each patient — or about as much time over all seeing patients as they do walking around the hospital, and a quarter as much as they do sitting behind a computer screen. The next wave of reform must focus on understanding how best to ensure resident time is spent on direct patient care and meaningful clinical activities.
Part of the answer may be reducing individual workload by training more residents. But, without extending already lengthy training programs, this also carries the risk of precluding residents from managing enough clinical encounters to graduate as competent independent physicians. More promising reforms are those that allow trainees to focus on the types of activities they chose careers in medicine for by off-loading or eliminating other activities. These may include: improving the ease of communication with nurses and consulting medical services; enlisting medical scribes to assist with documentation; minimizing admission and discharge paperwork; streamlining transitions to outpatient care; and automating certain routine procedures and processes.
On some level, though, efficiency-empathy trade-offs are an inevitable and inherent tension in medicine — a function of busy hospitals with complex patients and limited personnel and resources. But I wonder also if this is a trade-off we too readily accept and whether the pendulum has swung too far toward the alter of efficiency.
Surely patients want to be seen and treated in a timely manner, but when we sacrifice empathy for efficiency we fuel what lays at the core of patient — and physician — discontent with modern medicine. We hide behind buzzwords like “patient-centeredness” and “shared decision-making” without being able to offer the time that gives these terms true weight. Ultimately, reconciling this tension may mean reconceptualizing “efficiency” to include the tremendous value that exists in having more time to spend with our patients.
When I think back to that morning with my patient, and many mornings like it, terms like efficiency and productivity seem to lose their meaning. I think of the countless opportunities for compassion I squander every day in pursuit of something far less meaningful to patient and doctor. And I think, next time, I’ll sit.
Dhruv Khullar, M.D., MPP, is a resident physician at Massachusetts General Hospital and Harvard Medical School. Follow him on Twitter: @DhruvKhullar.