The clinical encounter: an about-face?

Gradually, over the past decade we have been replacing face to face conversation with virtual interaction through cybervenues such as FaceTime and Facebook. Somehow, our social intercourse has not been not the same.

Face to Face. This slender volume rests on the bookshelf, a remnant from one of my graduate courses in counseling. The course was run as an encounter group. Participants had to work out the particulars of their interactions. Some of it was rough going; some of it wasn’t pleasant. You had to be an astute observer of body language, tone of voice, facial expression. Some of us were pretty adept at guarding our emotions; others wore their hearts on their sleeves. We didn’t necessarily agree with one another, but we heard one another out — at least, those of us who chose to interact.

In a group setting mutual support evolves through empathetic listening. To do so, you must be physically and psychologically present in the moment.

Similar interactions take place every day in the clinical encounter. We clinicians spend most of our day interacting with patients in the physical realm. With the advent and widespread use of the EMR (electronic medical record), face to face time has dwindled. Now the screen competes for our attention. No longer face to face with the patient, we tend to miss or overlook those subtle clues inherent in posture, facial expression, and body language.

Third-party payers are now advocating telemedicine as the latest and greatest means to improve access to healthcare and trim costs. In turning our eyes toward the future, might we actually be performing an about-face, as our physical face time recedes into the sphere of virtual reality?

A picture may be worth a thousand words, a video transcript even more; but I question the degree of meaningful healing that can take place in a virtual universe.

Mourning a mistress

Much I learned from Medicine;
Much I saw her healing art.
Much I loved this mistress sanguine;
Much she offered from the heart.

First, the wide-eyed disbelief
In pain, to watch a young man die:
Faceless victim, carved relief:
Steeled—no breath—unseeing eye.

Early on, the ebb and flow
Of flailing heart; a pallid face—
Her story stoked with gasps and woe—
Whispered words and clouded grace.

There were the books, those countless books—
Formulae, facts, learned by heart;
Signs and symptoms, on tenterhooks
Recalled, as required by the art.

Humanness sustained me always;
Grief malnourished sleepless nights.
If not to cure, then listen always;
Don the cloak of second sight.

Then, of late, betrayal, riven;
Bought by value-added verse,
Healthcare digitally driven
By Masters of the Universe:

Enterprising party payers
Snatch their complement of coin;
Ivory-towered emerald cities
Meld the meek, together join.

Long ago I learned the taste
Of bitter copper on the tongue;
Now, at eventide, I mourn
My former mistress, lately gone.

Gone to lie with other lovers,
Spin another golden thread;
Leaving only one silk stocking
Draped across an empty bed.

Much I learned from Medicine;
Much I saw her healing art.
Much I loved this former mistress,
Much she offered from the heart.

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Cookies

“We need to have you upload your electronic signature into the EMR,” the office manager tells me. “I’ve got the file stored on my desktop. You can log in, and I’ll walk you through the process.”

I slide into the chair at her desk and log in to my account. “Click on the gear icon at the top of the screen to access the drop-down menu,” the office manager says. A few clicks later the upload is complete.

“Good, another task accomplished,” she says. “Would you like a cookie? I baked them myself: oatmeal-raisin-chocolate chip.”

“Thanks,” I say, reaching an ample specimen from the zip-lock bag on her desk. I push back in the chair and savor the first melt-in-your-mouth bite.

“How are they?”

“Wonderful! Just the thing for a mid-morning pick-me-up.”

“We don’t do a lot of treats in the office — everyone seems to be watching their weight — but it is nice to have a sugar boost every once in a while.”

Thoughtfully, I savor another bite. “You could consider addressing both of those issues by adding a cookie icon to the EMR drop-down menu,” I muse. “Anytime a staff member feels the need for a snack, they could log on, access the menu, click on the cookie icon and voilà! — an instant calorie-free pick-me-up.”

The office manager studies my face with a mixture of awe and disbelief. She opens her mouth, as if to utter a comment; then quietly closes it.

“The only thing is,” I add, happily munching the final few crumbs of my treat, “you would have to be sure to change the browser settings to accept cookies.”

Mindful practice: Drive-through medicine

Although I recognize the need for sentiments — in both the patient and myself — many times I no longer have the luxury of time necessary to provide them. more»

Interested readers can now access my latest Mindful Practice piece — Drive-through medicine: The McDonaldization of modern medical practice — recently published in the Journal of the American Academy of Physician Assistants.

Please note that all of my previously published Humane Medicine pieces can now be accessed here.

Rainy day rendezvous

The dining room at the Dimmick Inn is packed on this mid June weekday afternoon. The waitress has found a table for my friend and his daughter and me in the back room. She’s taken our orders, brought us our drinks; soon our dinners will arrive. My friend and I have ordered our traditional fish and chips; his daughter has selected chicken fingers and fries. Meantime, we’re busy talking, making the most of our annual one-day rendezvous in this sleepy northeastern Pennsylvania town.

Today our discussions have revolved around medical practice, specifically the difficulties we’ve each been experiencing over the course of the past several years. My friend is a hospitalist, practicing in the southwest; I work in primary care in the northeast. Despite the differences in practice settings, the challenges we face remain remarkably similar in scope.

There’s the issue of the rapidly changing medical workplace with its inherent land mines. We seem to be badgered by administrators, inundated with patients, immersed in unsupportive work environments. Moreover, despite our decades of experience, our jobs remain tenuous. Over the span of the past 3 years each one of us has had to change jobs, working less desirable hours. As you approach the end of your career, you like to think that things might get a bit easier; but neither one of us has found that to be the case.

A little girl listens intently to our words while chewing her chicken fingers and fries. For a youngster of 7 years she has behaved very well over the course of the morning; but children can only put up with so much grown-up jargon. She begins to vie for her father’s attention; she whispers something in his ear. Finally she reaches up and attempts to hold his lips together with her small hands to corral the conversation.

The waitress returns to check on our progress. She offers a dessert menu, but the little girl declines. When 7-year-old girls decline dessert, you know it is time to go.

We banter briefly over the check; we gather our wraps and step out onto the veranda. The rain has tapered off. My friend negotiates one more walk with his daughter through the wet streets before closing out the day.

“Why don’t we go to the little park?” my friend says.

“I don’t want to go to the park,” the girl pouts.

The father takes her gently by the hand, whispers something in her ear, and we head out.

The park is not far away. En route we discover a stand of toadstools at the base of an old tree.

“Look, fungi!” the little girl says.

“That’s right,” the father says. “Le’s take a picture of them, shall we?”

He bends down to take a photo. On the sidewalk across the street we encounter a cluster of broken walnut shells.

“Look, this one looks like a face!” the little girl says. “Oh, swings!” She runs to the bank of swings in the grassy park. “Push me high!” she says. “Give me an underdoggie!”

My friend pushes from behind and runs forward beneath the swing, catapulting the little girl high in the air; she squeals with delight.

Afterwards we stroll back to where our cars are parked. The past 6 hours have flown by. Now it is time to say goodbye.

“Thanks for helping to entertain her,” my friend says.

“The pleasure was all mine,” I say.

“Children teach us what’s truly important in life, don’t they?”

Slowly, I nod my head.

Mine are all grown up now. This year my youngest will turn 30.

But I still remember that mad rush of delight when I pushed them on the swing in the park.

Advocating for right care

A basic tenet of right care is doing what is best for the patient. more»

Interested readers can now peruse my latest Musings blog — Advocating for right care — at the Journal of the American Academy of Physician Assistants (JAAPA) website.

JAAPA is the official publication of the American Academy of Physician Assistants.

Terminal man

Nearly all clinicians recognize that providing medical care which prolongs human suffering is anguishing, both to themselves and to the dying patient. more»

Interested readers can now peruse my latest Musings blog at the Journal of the American Academy of Physician Assistants (JAAPA) website.

JAAPA is the official publication of the American Academy of Physician Assistants.

Individuals and types

In a retrospective review of the origins of Antoine Saint-Exupéry’s Little Prince, Edward Rothstein observes that the children’s book might be ultimately “less about individuals and more about types.” It is an aviator’s perspective, sweeping across the landscape, only mildly hampered by earthly ties and human requirements, being guided by the stars. On the other hand, the message of the character of the fox is “far more grounded, empathetic, more concerned with others.”

“Saint-Exupéry may have often been caught between these two perspectives,” Rothstein writes. “He fought against detachment but also relished it, fleeing for atmospheric vistas whenever possible.”

There, briefly stated, you have the same dilemma faced daily by thousands of clinicians in medical practice.

At the outset medical education consists largely of learning how to recognize and diagnose illness. Students are taught to look for disease patterns, clinical signs that when taken together as a whole point to one specific medical malady. Unfortunately this method cultivates an attitude toward human beings as disease entities. Students, residents and even attending physicians are apt to refer to “the cholecystectomy in Room 508,” “the schizophrenic in 212,” “the diabetic in ketoacidosis in the ED.”

Such shorthand nomenclature provides a synopsis of the clinical condition and by implication, a plan for treating it. Yet if we are not careful, referring to patients as diagnostic entities or classifying them as types allows us to dehumanize them. If we come to regard patients as mere disease entities, we are less likely to suffer emotional attachment, more likely to maintain our clinical objectivity; but at what cost?

Patients who perceive that their providers are not interested in them tend to linger longer in the throes of illness than those who feel validated and nurtured as individuals. It has been shown that providing terminally ill patients with good palliative care dramatically improves the quality of life during their waning months.

At some point in their medical education it would behoove clinicians to move toward an attitude of empathy, to take a compassionate stance in dealing with patients entrusted to their care.

Perhaps that is what Saint-Exupéry’s Little Prince has to teach us grownup clinicians who have chosen a career in medical practice.

In the words of the fox: “Here is my secret. It is very simple. One only sees rightly with the heart. The essential is invisible to the eye.”

On becoming a caregiver

Back in the 1970s, responding to what he saw as the depersonalization of medical care, psychiatrist and cross-cultural researcher Arthur Kleinman began to examine the difference between illness as experienced by the patient and disease as diagnosed by the clinician. Such was the beginning of a hopeful attempt to reverse the trend of depersonalization in medical practice. more»

Interested readers can peruse my latest JAAPA Musings blog post, newly published in the Journal of the American Academy of Physician Assistants.

After work

It was not a particularly stressful Saturday morning to work in the office. Only three prescheduled physical examinations and a handful of sick children came in by morning’s end.

One child, a 1-month-old, my first patient of the morning, had colic. His mother reported that he wanted to feed constantly; whenever she didn’t give him a bottle he fretted, sucking on his fingers and hands. I had evaluated him one week ago for similar complaints. Since then the child gained 1-1/4 pounds, nearly three times the expected weekly weight gain. Obviously, she was overfeeding him. I suspected that part of the reason might have been because her first child was born prematurely and had a difficult time gaining weight.

Mothers nurture through feeding; a thriving baby exemplifies good maternal care, but sometimes too much of a good thing is not best.

As the morning wound down I ruminated behind my desk and reviewed the remainder of outstanding laboratory reports, signed off on a stack of physical examination forms and phoned in prescription renewals. The medical assistants finished with the filing and departed, locking the front door behind them.

I snugged the bow tie at the base of my throat, picked up my blue blazer and stepped out the side door. It was a short drive to the funeral home. By the time I arrived the lot was nearly filled with vehicles.

Inside people milled about, speaking in low tones, touching one another briefly on the arm or shoulder, exchanging whispered words. Some paused before the large displays of photographs mounted on easels in the hallway.

I stepped into the parlor, signed the guest book and found the end of the receiving line. There were stands of flowers everywhere, roses mostly — pink and red and white — done up in intricate arrangements identified by cards signed by family, friends and well-wishers.

A small silver urn stood in the center of the table; a golden crucifix rested against it. On either side lay two stacks of books — three on the left, two on the right. I noted the author of the two on the right — medical titles reflecting her area of expertise.

Most physicians don’t leave any written creative works behind; she had left two — these two texts, in addition to her two teenaged sons, who stood in the receiving line on either side of their father. Each of the three wore a pink tie. Pink, the color of the ribbon supporting breast cancer research; pink, the color of the delicate rose in full bloom; pink, the color of fading rose petals at the close of day.

My words were inadequate — “I’m sorry for your loss” — followed by handshakes and brief smiles.

“How are things at the office?” the father asked.

“Busy,” I said. “Back to school physical exams, you know. It’s the same every fall.”

He nodded. “Thanks for stopping by.”

I left by the side door and stepped out into the heat of the early afternoon sun.

As practicing clinicians we are granted the high privilege of glimpsing the struggles of families entrusted to our care. For brief periods were share in their triumphs, their joys and ultimately, their grief.

But many times it’s the grief that seems to linger the longest.

2012 © Brian T. Maurer