The Best Patient-Centered Care for Many Would Be Time
In an all-too-common patient story that will frustrate any patient or doc who’s been there, regular contributor Stephen Schimpff explains what’s wrong with primary care through one patient case.
A primary care physician needs, of course, to be well-educated, well-trained and up to date. But that’s not enough. He or she also needs to be a deep listener and critical thinker. And, to be most effective, the physician needs a team with the patient at the center – the patient-centered medical home concept. Listening and thinking require time, and so does quarterbacking all of the other providers and team members needed to care for patients with chronic disease.
Time is the element that’s been lost in primary care practice over the past decade or more. Without time to listen, the full picture of a person and their illness does not emerge. Without time to think, the diagnostic process suffers immensely. The physician is then no longer a healer but rather a well-paid caregiver. He or she is quick to send the patient off to a specialist. The opportunity for outstanding preventive care is diminished. And without time to coordinate all of the other providers that are required for someone with a serious chronic illness, the care becomes disjointed, quality suffers, and expenses rise.
A patient story will illustrate the problem:
Not enough time for patient-centered care
Monica is 68, married, retired, on Medicare and in generally good health. She has a primary care physician whom she sees intermittently. She began to have a strange “shooting” sensation in her chest, almost electrical or vibrational in nature, that stretched from high up in her right mid-chest down into a narrow line over her rib cage and just onto the abdomen. It seems to be immediately under the skin. It starts and ends intermittently. Nothing she has found triggers or stops it. She visited her primary doctor and offered this description, adding that she was concerned that maybe it was her heart. The doctor asked additional questions and did an exam and an electrocardiogram. All were normal, save the sensation.
Her doctor was now about out of time. Here was a fork in the road, two paths to choose between. Given that Monica was concerned about her heart, the doctor chose to send her to a cardiologist for further evaluation. The cardiologist found nothing abnormal but nevertheless suggested a stress test and an echocardiogram. Both were normal. Since the sensation crossed over to the upper abdomen, the cardiologist suggested it might be a good idea to see a gastroenterologist. The GI doctor found nothing. Nevertheless, he ordered a CT scan of the abdomen. All was normal except that in her uterus there was a small cystic structure. The radiologist read it as a probably benign cyst but – feeling the need to be cautious – recommended Monica visit a gynecologist. The gynecologist also said it looked benign but just to be on the safe side, she could remove it. Monica would be out of the hospital the same day and feeling fine in a day or so! The cyst was benign. Monica still had the strange sensation in her chest and no one had found an answer. But given that it seemed to run in a line with an electrical sort of feeling, the gynecologist suggested that maybe it was a nerve issue. So she visited a neurologist who of course found nothing, commenting that nerves run around the chest, not up and down.
Monica illustrates the problem that is so common in primary care. The doctor did not truly listen to the patient. And he did not think the issue out carefully. He had no time. He had to see the 24 other patients in the waiting room. So he took the easier path and referred her to a cardiologist since the strange sensation was in the chest and the patient was personally concerned about heart disease.
Had he taken the other side of the fork in the road and listened long enough and then thought about it, he would instead have concluded that the patient was hypersensitive to minor – albeit real – sensations. He would have offered reassurance that it did not represent a life concerning ailment. He would have said that it was real but of no concern. He might have offered a few weeks of a low dose anti-anxiety medication, offered further reassurance and told her to return in two weeks for a follow-up. At the follow-up, he would have explored the anxiety-producing issues in her life – financial, marital, a disruptive child, an overbearing in-law. And he would have soon discovered that Monica was deeply concerned and feeling guilt about a family issue. What Monica really needed was assistance to overcome her sense of guilt and shame – not months of specialist-hopping. Anxiety and stress are often components associated with a physical symptom, which can only be addressed with time to listen and time to respond with suggestions.
But Monica was shipped from doctor to doctor, test to test, and even into surgery without anyone really listening to figure out her problem. All each specialist could do was say it wasn’t in their “organ system” and leave her floundering and without a sense of closure. Each one said it wasn’t in their sphere – not the heart, not the stomach, not the nerves. And the “surgery went fine.” But she still had the unpleasant sensation. So it resulted in far less than adequate medical care and obviously cost a king’s ransom. Neither was necessary. But that is what all too often happens today. And, I assure you, Monica’s saga is not uncommon.
Monica’s experience is all too common and results largely from her primary doctor’s lack of time – time to listen and time to think. The result is less than adequate care, certainly not humane care, not healing care, and very high costs.