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Medical Humanities

Too Much Time With Patients

Charlotte Grinberg

March 15, 2016

I have begun my clinical rotations of medical school. That dream of taking care of patients, the one that makes all the years of memorization and standardized testing worth the stress and dedication, has arrived. I get to put on my (short) white coat with my stethoscope and pocket manuals before sunrise to be part of the healthcare team. I get to see patients for the entire day, to humbly enter their lives and witness the clinical reasoning doctors use to diagnose and treat illnesses. I get to create a cohesive story of the diseases and medications scattered throughout my brain by seeing people rather than textbooks. I get to be a caregiver. 

Yet my dream does not seem to be the reality on the hospital floors I have wandered so far. Instead I enter the rooms of two or three patients at 6:30 in the morning shortly before they will be seen separately by the nurse, the intern, the resident, and the attending physicians (sometimes one patient sees multiple teams for a total of twelve different providers in one morning). We ask the same set of questions and perform the same physical exams. We then spend five minutes with each patient as a team to go over the assessment and plan for the day, while the intern inserts orders on the computer or answers pages. It’s not yet lunchtime when we finish seeing our list of patients and head to the computer station, where the rest of the day will be spent. In other words, if a nurse does not page one of the doctors with an acute event, patients will not see their doctor until the early evening. There is much (electronic) paperwork to be done. 

The orientation lectures all had the same message. “As a medical student, you will spend more time than anyone else on your team with your patients. You will become their number one advocate.” So I went to the rooms of my patients with every free moment to answer questions about their illnesses, to solve barriers to their care, and most importantly, to be present.  I updated Mr. T with metastatic prostate cancer on the chances of him recovering from his fever so he could fly to South Korea to visit his family for the last time. I apologized to Mr. D with a possible bile duct obstruction that he will need to fast again because his endoscopic procedure was rescheduled for the fourth time in a row.  I listened to Mr. R with end-stage liver disease explain how he most worries about who is going to take care of him since his wife works full-time and already takes care of her 92-year-old mother.  

Then I sat down with the supervising resident for my final feedback evaluation and he quickly got to the punch line:  “You spent too much time with your patients.” I blinked at him. “I am telling you this for you to succeed on your future rotations.” He told me it is unnecessary to have long conversations or respond to all the concerns and questions of patients. He explained how more time with a patient means less time with the team, and that I should have been around to be available to help with paperwork and tasks.  I smiled, nodded, and started to feel guilty. 

Looking back, I wish we could have had an open conversation about the effectiveness of spending so little time with patients compared to having our time filled with navigating the (far from user-friendly) computer and paperwork systems to place orders, consult teams, and fill out discharge forms. Although I have not received similar feedback since, the resident’s comment helped me realize just how little providers interact with patients when delivering care in the hospital. This has raised an important question in my mind: is all this time away from patients actually translating into better outcomes? 

I’m not very popular when I try to bring up such topics on the hospital floors. The teams are overworked, tired, disillusioned, or just simply uninterested. But something feels terribly wrong when physicians can’t even recall the name or gender of their patient when presenting to the rest of the team. We are treating the pathology, not the person, because we don’t know the person. It becomes a vicious cycle: we don’t spend enough time with the patient because there’s too much paperwork and consequently over prescribe treatments, medications, and tests because we don’t know enough about the individual. This leads to a whole lot more paperwork and still not enough information about what the patient needs to best help them.  

As medical technology advances while the financial strains of the healthcare system continue to grow, we need to have a more open conversation about what happens when documentation hinders rather than facilitates communication. We need to improve the coordination of information. As it currently stands, every new admitting and consulting team goes on a lengthy scavenger hunt for data in the electronic or paper medical record. Often, the information is stored in another electronic medical record that we cannot access. There is now an abundance of data but no comprehensive patient story. While one could argue that this repetition allows for proper checks and balances, each provider writes his or her own note that is slightly different, and the differences remain unexplained and buried. In other words, we just keep adding to a chaotic pile of information that becomes increasingly confusing or inaccessible for subsequent providers. 

Although it is easy to feel hopeless, the system does not need to be this way. This is a complex issue and multiple political, economic, and social factors impact the current reality of medical care and its future. I recognize there is also no single solution as each hospital and electronic medical record is different. But hospital teams and medical records need to better synthesize and share information, as well as agree on coherent patient narratives. We should not ask for the same information over and over again, but rather build upon each other’s work and actively involve the patient in this process.

First, instead of having each member of the medical team see the patient individually, we should see the patient together. The medical student can ask the initial questions, while the intern, resident, and/or attending can elicit more detail, and everyone can perform the necessary physical exam maneuvers. While this might seem unrealistic at first to busy medical professionals because of their time-consuming administrative burdens, one of the reasons such burdens exist in the first place is poor care coordination. In the end, this model will save time, as there will be less redundant communication and administrative logging. Providers would also learn better this way, by constantly evaluating each other; patients would avoid repetition and frustration.

Second, we can take further advantage of the “sign-out” log (the non-permanent text box in the electronic medical record that is used to update and rewrite notes on the patient). The sign-out log should be updated more consistently and shared not only with the main medical team, but also with the consulting medical specialists, nurses, pharmacists, social workers, and chaplains. These providers are essential to the patient’s care and need the information anyway; providing direct access would only save time. 

I hope to be more ready with a response the next time I hear my colleagues and teachers criticize the amount of paperwork in the hospital. I will say we need to learn how to think critically and creatively about how we can more efficiently care for our patients with compassion, because ultimately that will lead to less paperwork. With belief in change and better coordination, we can begin to spend more face time with hospitalized patients and better understand how to heal them. 

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