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.



“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.