A Country Doctor Writes:

The other day, as I was wrapping up my visit with Mrs. Brown, she said:

“Harry is no better, he is coughing and spitting something wicked.”

Her husband, silent during the visit, was unshaven and looked a little tired.

“How long have you been sick?” I turned to him.

“Going on two weeks now. The cough medicine I got last week hasn’t helped.”

I opened his chart in the computer. He had been in six days earlier. A colleague had noted that his lungs were clear and diagnosed him with a viral illness.

“Let me listen to you”, I said.

He had scattered rhonchi and a few wheezes, and at the bottom of his right lung I heard faint crackles.

“You need an antibiotic”, I said, and made sure he didn’t have a fever and that he wasn’t too short of breath.

I created a “new telephone encounter”, documented my findings and e-prescribed an antibiotic for him.

“Be sure to come back if things don’t turn around quickly”, I said.

There’s no way I could charge him for a brief visit. And that’s got nothing to do with whether I wanted to increase my productivity numbers or our clinic revenue.

In this day and age, there is no such thing as a quick visit to make sure someone is okay or to avert clinical deterioration or disaster.

In order to meet all our quality requirements for being a patient centered medical home and all the other ways we are judged and measured, a visit note has to include, even if the patient was seen just one single day before, a complete medication reconciliation, updated past medical and surgical history, social history and specific questions about any other care the patient has received since last seen. In our EMR it would be impossible to get around all these clicks by building a note template that says nothing has changed since last time; the computer tracks the actual clicks we make in the EMR.

So in cases like Harry Brown’s, I have these choices: Treat him for free right then and there, make him come back some other time when we have time for all the extras, or send him to walk-in care in the big city.

My choice is clear, but I can’t help wondering if the people who created the requirements for overambitious repetitive inquiries into the past history of people we already know quite well really understood that instead of becoming more patient centered, we would start giving free care or turn away patients and thereby fragmenting their care.

“Stop Excessive Measurement.”

Those three little words were music to my ears. The fact that they were spoken by Don Berwick, creator of the Institute for Healthcare Improvement and former head of Medicare, made them even more significant.

I was in our state capital today for a regularly occurring conference by Maine Quality Counts. The theme was “Achieving Excellent Patient & Provider Experience”. There was a lot of talk about provider burnout. Dr. Berwick spoke of the central role of the provider-patient relationship and the failures of the current quality movement.

He told a touching vignette about his brother, who is a patient in a rehabilitation facility. All his brother wants right now is to go outside for a few minutes and experience spring, but the rehabilitation hospital is so focused on keeping their falls statistics down that they haven’t been able or willing to work with him to see how he can safely meet his goal.

Berwick more or less said that if you serve your patient well and keep his or her needs in sharp focus, quality will improve, waste will decrease and provider burnout will diminish. How refreshing.

His remarks were originally made at the IHI and published in JAMA a year ago today, during a time when I fell behind in my journal reading.

He describes three eras in medicine.

The first era was the autonomous physician, serving a calling and belonging to a self-regulating profession. Science exposed variation and inconsistencies in the healthcare of the first era, and a second era was born.

That second era, which we now live in, is the era of accountability, measurements and incentives.

The ideals of those two eras are incompatible, but they point the way to a possible third era, which he calls the moral era, where providers are subject to fewer measurements because organizations trust their commitment to their patients and to the principles of quality.

I need to hear things like that now and then.

Watch Don Berwick speak about the third era:

Medicine is a love that finds us wherever we happen to be.

It snatched me, a quiet four year old boy, almost sixty years ago. I don’t know how it happened. I remember being in the hospital and having stomach X-rays and I have also been told we had a family doctor who made house calls. I couldn’t have seen doctors on TV, because television was only introduced in Sweden when I was three and I saw my first program at age 5, a show about an infantile doll named “Andy Pandy”.

At age four I simply announced that I was going to become a doctor and I never hesitated after that. It seems everything I did from that moment on prepared me for what I do now: Being a Boy scout who made do with what I had on hand; learning discipline as a military recruit in basic training; working as a substitute teacher for fifth to ninth grade students; spending a summer as the pastor’s assistant with confirmation students and in his parish, and traveling the world to interview people from other cultures.

In my day to day work I always look for the story behind each patient’s symptom and even behind their laboratory values. I often find myself circling around the concept of Narrative Medicine.

The other day I happened to read the Swedish journal for general medicine (Allmän Medicin). A doctor, who seemed to be about my age, had written about his experiences with Narrative Medicine and the tension he used to feel between it and today’s Evidence Based Medicine.

The writer’s name was Christer Petersson, and he looked and wrote as if he was someone I had known from High School. I Googled his name and found another article he had written, in 2009, in the Swedish Medical Journal, Läkartidningen.

That article was titled “I worked as a Doctor for 20 Years. Then I Became a Doctor”.

I did a quick double take and continued to read, finding exactly what the title suggested: He had studied medicine because the science interested him and it seemed like a good thing to do. He was a young man with big thoughts and big ideas. But he felt uninspired by learning about the digestive system and was uncomfortable with the notion of treating mundane things like bleeding, boils and open wounds.

He writes:

“It took about 10 years and quite a bit of agonizing before I discovered that I was exactly where I was supposed to be, and it took another 10 years to understand that I actually was a doctor and didn’t just work as one. During that time I learned that man is more than his digestive system and the most important events in life often happen in the seemingly uninteresting space where blood flows, boils burst and wounds heal.”

And then, he paraphrases Hippocrates’ first aphorism:

“And I saw that it is equal parts suffering and joy to deal with all this as a doctor: to cure sometimes, treat more often and comfort the best you can.

It doesn’t get any better than that, does it?”

Different journeys to the same destination.

The patient, I surmised, was the one in the wheelchair, with nasal oxygen and an unhealthy red color of her cheeks. The younger woman in the room with her looked like she might be a daughter.

I introduced myself. I had been right about the other woman being her daughter.

It was Saturday clinic, urgent care at our country doctor practice, and the plastic holders with “express check-in” history forms and a scribble sheet for the doctor and the medical assistant were piling up in the pocket of my office door.

“So, what can I do for you today?” I asked.

The woman in the wheelchair gave me a sturdy look and said:

“Did you read my chart?”

My mind raced, thirty years into the past and back again.

As an intern and resident admitting patients to the hospital, I would routinely read up on the patient’s paper chart before entering the room. Each admission took as long as it needed, and the only time pressure I felt was usually my own. The emergency room doctors had already ordered the initial treatments each patient needed.

In practice before computers, I would glance at the problem list and flip through the last few notes, labs and imaging tests while pausing in my office or at the nurses desk, sometimes actually while walking toward the exam room.

Now, with computers that go black after just a few idle minutes, I’d have to log on in order to see any information, and the moments that takes feel like forever. Besides, I can’t very well sit in the last exam room I used and do this, since my nurse needs to room the next patient.

Also, now, with all the checklists we must complete in even the simplest visit, there really is no time during or in between visits to actually sit down and “read the chart”; our time is so pressured and the medical records have become so bloated that we end up just asking the patient, because the pertinent information drowns among the mandated minutia.

“No, there is seldom time to read the chart anymore”, I said.

My patient sighed and gestured to her daughter, who recited her medical history in a monotone voice as if she had done it too many times to count.

The woman had leg cramps, and it was probably because of low magnesium. Her exam was fairly similar to the last note by her own doctor. I did compare my findings and his.

So I prescribed magnesium and two days later we got a call that that had done the trick.

But I don’t think she will ever accept that when she sees a different physician, they will talk to her first, before deciding if it would be worthwhile to steal the time from someone else’s appointment to sit down and read her chart.

Snowed in by a fierce Nor’easter, with our clinic as well as every other outpatient facility within 100 miles closed for the day, I stoked the fire in our wood stove, pulled up my high back chair and read for a couple of hours.

I returned to my treasured, signed copy of Harvey Cushing’s biography of Sir William Osler, the father of modern medicine. On page 431, under the subheading ’He Knew Not Idleness’, Cushing quotes a senior assistant’s account of Osler’s daily routine.

This description may be surprising to those who only know Osler by his famous quote, “Look wise, say nothing and grunt”:

“At 7 he rose; breakfast before 8. At a few minutes before nine he entered the hospital door. After a morning greeting to the superintendent, humming gaily, with arm passed through that of his assistant, he started with brisk, springing step down the corridor towards the wards. The other arm, if not waving gay or humorous greetings to the nurses or students as they passed, was thrown around the neck or passed through the arms of another colleague or assistant. One by one they gathered about him, and by the time the ward was reached, the little group had generally grown like a small avalanche.

(W.S. Thayer, ‘Osler’. The Nation, N.Y., Jan. 24, 1920.)

It makes me reflect:

Time, my old arch enemy, is always on my mind. Over the years, I have managed to adopt a somewhat Oslerian persona, which tries to make every minute, and every brief encounter, count in the mind of my patients and in my own pursuit of forward movement in each clinical case I encounter.

But most days I don’t know that I am anywhere nearly as skillful as the old master in navigating through it.

He probably capitalized on his larger-than-life reputation and position in the world of medicine. I have only a local reputation and the position that career longevity and mature appearance bestows me, like my silver haired temples and my wrinkled hands and face.

But the one thing I know and sense every day in the clinic is: If for a single moment my love of my profession or the connection I feel with my patients and my coworkers is clouded or briefly forgotten, the pace of my workday becomes almost unbearable.

It is only when I am carried by the momentum of my greater purpose that I can make every one of my brief encounters with my fellow human beings count and be healing in any sort of way.