A step towards mindful doctoring

I am not an efficient doctor.

Actually, I’m not particularly efficient at anything in life, but that’s probably a story for another day.

Specifically, though, I spend a lot of time in appointments with my patients. I’ve realized that — in order for me to enjoy clinical medicine — I need to take the time to really listen to my patients. I need to know their agendas, concerns, and goals. If I’m too rushed, I feel crappy about providing poor care, and they (probably) feel crappy about not being heard. So, suffice it to say, my clinical encounters take time.

A couple of years back, I went through a very rough patch in my career. It was something that Brené Brown would liken to her ‘2007 [Breakdown] Spiritual Awakening’. I’d been out of fellowship and in practice for just over two years, and I’d been trying to establish an academic research program while seeing as many patients as I could. Suddenly, I had way too many patients and not enough clinic space/time.

I was seeing new patients in 45 minute slots, for the most part, which wasn’t too bad. But my follow-up slots were only 15 minutes. Sometimes, it took so long for the office staff to get the patient down the hallway and settled into the clinic room that their appointment slot had already ended by the time I walked in. This meant I was anxious before even starting the clinical encounter because I was already running behind. I’d do my best to get them in and out of the room as rapidly as possible like many of my colleagues were so good at, but I always felt like either I was missing something (I forgot to ask an important question or clarify something that was critical for my clinical decision making process) or the patient was missing something (I didn’t give them the opportunity to share what was actually important to them).

It took me an embarrassingly long time to figure out why I was so miserable in my clinical practice, before I realized that I had a ‘time-expectation’ mismatch problem. Even once I’d figured out the problem, it wasn’t an easy fix. I had accrued a large practice with more referrals coming in every day.  Eventually, I hit a breaking point. I had to cut down on my clinic time, and I had to lengthen my follow-up slots. The flip side of this was that I couldn’t see as many patients. I started feeling like a drain on resources and dead weight to my division (more on this another day), but, for patient care, it was the best thing I could have done. I now book new assessments in 45 minute slots and follow-up visits in 30 minute slots. I recognize that many other physicians won’t be able to swing this (or may not need this amount of time), and while implementing this involved many challenges and compromises, it was the right thing to do for me and for my patients. Now, I feel like I can take the time to listen, elicit what is important for each patient and actually provide shared decision-making.

That’s why I was pleased to see a study published last week in the Journal of the American Medical Association by Donna Zulman and colleagues, which discusses evidence-based practices to help physicians connect with patients. Some of these I already do, but sometimes it feels like I’m being frivolous when I take the time to do them, so it was nice to see my practice style being validated.

Here I’ll share the top three things I took away from this article. Actually, I’m cheating and sharing five takeaways, because the article identified five practices that physicians can use to foster presence and connection with patients:

1. Prepare with intention. Personalized preparation for each patient (this could take the form of the good old ‘pre-clinic’ chart review, an intake questionnaire, or having an allied health staff elicit relevant information from the patient before you go in the room) as well as taking a moment to pause and focus before going in the room with the patient. The pause and focus might take the form of a ritual: something you do before knocking on the door, or while washing your hands.
2. Listen intently and completely. This involves adopting receptive body language (like sitting down, facing the patient, leaning forward) as well as avoiding the urge to interrupt the paper. There’s an oft-cited statistic that physicians interrupt patients within 11 seconds (!), but research unsurprisingly suggests that patients communicate more medical information and report being more satisfied with their medical visits when physicians avoid interruptions early on in the office visit, often when patients are sharing the reason(s) for the visit.
3. Agree on what matters most. This paper recommends collaborative agenda setting early on in the visit, to make sure you and your patient are on the same page in terms of what should be addressed in the visit. Side note: Agreeing on what matters most is important not only for agenda setting, but also for shared decision-making regarding whether to proceed with investigations and treatments, and Atul Gawande describes this extremely well in his wonderful book, Being Mortal.
4. Connect with the patient’s story. This practice entails considering the circumstances that influence a patient’s health (like socio/economic/cultural background and current life circumstances and stressors), and as the authors write: ‘acquiring personal knowledge about patients through questions rather than making assumptions‘. They stress the importance of making personal connections (I particularly like their suggestion to ask questions like ‘What brings you joy?’). Finally, this practice also entails positive reinforcement (encouraging what patients are doing right) and empathy.
5. Explore emotional cues. The authors recommend paying careful attention to verbal and nonverbal emotional clues, asking questions to elicit how patients are feeling, and validating the elicited emotions with empathic statements (i.e. ‘I can see this is affecting you deeply.’)

Based on my early career experiences, I think all of these practices are extremely important for physicians to consider adopting — potentially to improve patient outcomes (although more research is needed in this domain), but also just to be good, empathetic humans.

However, it’s crucial to remember that all of these practices take time. As the authors point out (and as I think most physicians are well aware), if we want a medical system in which the therapeutic relationship between patient and physician is honored and prioritized, the system needs to facilitate it. Having more time for consultations helps. So would having more support from allied health staff, especially in clinics that deal with complex medical conditions.

The system still has a long way to go, but publication of articles like Zulman and colleagues is a step in the right direction. In the meantime, I’ve tried to implement a few things in my practice to improve workflow while still being able to make meaningful connections with patients in my clinical encounters. These include: clinic intake questionnaires, pre-clinic preparation (although much of this does happen in the evening so I’m not sure how time-efficient it is), making an effort to focus when I do my clinical administrative tasks (dictations, referrals, lab review, etc).

I’m not very good at pausing and taking a moment (and perhaps a deep breath), before I see each patient, so this is something I plan to work on in my next few clinics.