“When you go in to see a patient, you need to be focused. You need to have your agenda clearly in mind.”
As a physician educator offered this advice to hundreds of clinicians at a recent primary care update conference, heads nodded in agreement. It seemed like reasonable counsel given the wide range of complex goals of today’s primary care. But my heart sank as the address continued. Underlying the call for focus was a perspective that patients often bring up issues during a visit that distract us from priorities.
Both the sentiment expressed and the audience’s acquiescence indicate how far we have moved away from our patients’ agendas. I don’t think any of us in that convention center chose our careers thinking we would someday experience patients’ concerns as distractions in our work day. This incident was a sign to me that we need to chart a course back to the type of care that listens to and responds to patients.
The conference encapsulated a tension I had been feeling in my own practice for years. I was a family physician in what I consider an excellent, mission-driven community health center. We had motivated staff, interdisciplinary team care, electronic medical records, and many organizational efforts for quality improvement. Clinically, I found myself moving from room to room, pressured by time, trying to keep up with a multitude of health maintenance or quality metric items, and often feeling unable to engage with “yet another” issue that the patient in front of me wanted to talk about. While it was my goal and the goal of our practice to give compassionate, holistic care to patients, too often it seemed that the time and mental/emotional reserve to listen to patients were crowded out.
How May I Help You?
I was taught in residency about a decade ago to begin a medical interview by asking, “How may I help you today?” After listening to the patient’s complete response, I learned to say, “Was there anything else?” and then to continue asking this until the patient had verbalized everything that he or she wanted to cover. In this process, the clinician must be aware of his or her own agenda as well. We may want to talk about cholesterol or blood pressure even though they aren’t on the patient’s list of topics. When it is clear that there are more agenda items than time will permit, we negotiate what can be deferred to another visit.
This understanding of distinct agendas is crucial so that we can intentionally focus on the patient’s agenda as having primary importance. I believe that this approach is congruent with the historic heart of the doctor-patient relationship. Compassion and caring are demonstrated by our attention to the patients’ felt needs.
I believe we have lost this focus because of “agenda overload”–taking on expectations to accomplish more tasks than are realistically achievable. With the expansion of medical knowledge, technology and informatics, opportunities to perform potentially beneficial tasks far exceed our individual and systemic capacities. In 2009, Yarnall, et al. concluded that it would take 21.7 hours/day to do all of the tasks recommended by national guidelines in addition to addressing acute complaints. By embracing computerized prompting about preventive services and disease management recommendations, we have too often created systems that efficiently track unrealistic expectations rather than increase capacity or streamline our agenda.
Without acknowledging limitations of our capacity, we have loaded our plates to full and overflowing. Things are falling off the plate, but we are not consciously choosing which things to let fall. I fear that compassionate care, relationship-building, and the ability to listen have already been crowded out by tasks and goals of much lesser importance.
One might say that we have arrived in this bad situation by trying to do too many good things–so many good things that we let the best things fall from our plates unnoticed. We have to reverse some of the agenda overload to make space for the primacy of relationships in primary care. System change can help in this regard. I am particularly hopeful about the development of team-based care to increase the capacity of our healthcare system while upholding caring human relationships as the basic interface with patients and communities. However, we would be wrong to place hopes in the possibility of infinite capacity increase through system change. We have to make deliberate choices to limit our agenda.
We need to learn the discipline of saying “no.” When the next cancer screening or public health initiative arises as a possible new area of work, we have to ask, “If we can’t delegate or increase capacity for this new task, what will we stop doing to make time for the new item?” For example, CT scanning for lung cancer screening has recently been proposed as a new agenda item for primary care. The history-taking and counseling necessary to implement this new screening will certainly require time. Our question cannot be simply, “Is this new screening beneficial?” We have to compare the value of the new screening to the value of colon cancer screening, smoking cessation counseling, diet and exercise counseling, depression screening, domestic violence screening, sleep disorder screening, etc. Are we ready to take one of these items off of our clinical plate to make room for the new initiative? This is an uncomfortable question.
Failure to recognize agenda overload has already been deleterious to the doctor-patient relationship. Moving forward, we need to evaluate existing and emerging opportunities and limit our agenda to preserve the real heart of our care for patients.