American College of Physicians: Internal Medicine — Doctors for Adults ®

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Economic pressures turn art of medicine into rote practice

From the September ACP Internist, copyright © 2009 by the American College of Physicians

By Joseph W. Stubbs, FACP

Continuing from previous columns the examination of a modern Hippocratic Oath, this month looks at the art of medicine and the pressures that turn its practice rote.

The modern Hippocratic Oath says in part, “I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.” (The full oath can be found online.)

While much of a clinician’s stature among peers depends on encyclopedic understanding of the scientific literature, his or her effectiveness depends largely on well-honed skills of communication and relationship building. Never have such skills been more critical or more challenging than they are today. Patients and physicians face a dizzying array of diagnostic and therapeutic options. The sources of health information are approaching infinity. Armed with legions of information off the Internet, patients frequently enter my office with a mindset that overtreatment is synonymous with state-of-the-art care. Any thoughts of a wait-and-watch strategy are dismissed as Neanderthal. At times, I feel less like an internist and more like a “medical waiter” through whom patients can order up a delicious assortment of genetic tests, MRI images and bioengineered drugs.

Time pressures add to the challenge. I cannot get many of my older patients on the examining table before the end of their allotted 15-minute office visit. Add to that the time it takes to unfold their handwritten list of concerns and questions, and I begin to wonder if selling Amway products might not be so bad after all.

Effective communication with patients who have chronic diseases involves more than a transfer of information from doctor to patient. It’s a transfer of knowledge and skills that enables patients to self-manage their chronic diseases. Yet, studies show that 80% of what patients hear in the doctor’s office is forgotten by the time they walk out the door, and half of what is remembered is remembered incorrectly (J R Soc Med. 2003; 96: 219-22). Further, about 75% of those with chronic diseases have low health literacy, making effective communication even more challenging at a cost of $50 billion annually (Nielsen-Bohlman L, Panzer AM, Kindig DA, eds. Health Literacy: A Prescription to End Confusion. National Academies Press, 2004).

With the art of medicine at once so critical yet so formidable a goal, what can ACP and our membership do?

First, we need health care reform that recognizes the value of the art of medicine, which contains our most powerful salves, empathy and relationship. Yet, sitting and listening without interruption to a patient’s story, treating not just the disease but the patient with a disease, and providing comfort by means of presence when there are no cures all take time. Patients value these services the most, but the system reimburses them the least. Health care reimbursement policy is not only depriving patients of a valued part of health care but is furthermore making the whole system unsustainable.

We need to advocate for health care reform that incorporates innovative models such as the patient-centered medical home. This approach allows the physician’s team to handle much of chronic management, leaving the physician more time for communicating, as well as making the office visit more about building relationships than documenting bullet points. The model enhances the art of medicine and includes a coordination fee that recognizes the important value in caring for patients.

We desperately need solutions to the growing burden of unfunded third-party administrative hassles. These ever-enlarging time pits rob physicians and their staffs of precious time that could be spent caring for patients. The annual price tag physicians spend in time and lost productivity due to these hassles is estimated at $31 billion. I welcome the day when I can have confidence that the prescription or test I discuss in the office with the patient is actually the prescription or test that gets implemented without 10 additional phone calls to insurance companies or pharmacy benefit managers.

Finally, we need better tools to help with communication and literacy. ACP Foundation offers HEALTH TiPS that provide patients with evidence-based information about key chronic conditions and serve even those with low health literacy. The Diabetes Portal, a joint initiative of ACP and ACP Foundation, has been an outstanding success in enabling patients of all literacy levels to participate in shared decision making with their primary care physician and develop effective action plans to manage their diabetes. A similar portal has now been developed to address COPD.

While the science of medicine keeps the heart beating, it is the art of medicine that keeps the doctor-patient relationship going. In the final analysis, the words of William Osler remain as true today as when they were first spoken: “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.”

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