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A Modest Proposal: There is No Substitute for Time in Medicine

The following manuscript was submitted to the May 2018 Mental Health theme issue.

Physician burnout has emerged as an increasingly concerning phenomenon in medicine. As high as 51% of physicians in a Medscape survey report symptoms of burnout. Doctors face higher demands with less time and support. Academic medical centers, which historically have been insulated from outside forces, are now seeing larger patient censuses, leaving less time for physicians to work through each patient’s case carefully. William Osler’s days of conducting a thorough history and physical and William Carlos Williams’s days of making house calls and penning poems between visits appear to be stories from the distant and mythical past. Now, medicine has become all about checklists, quality metrics, algorithms, or even replacing doctors with more disposable labor forces such as artificial intelligence systems.

I picked psychiatry as my career because it was one of a few specialties that still require doctors to spend time with patients to develop a diagnosis and a treatment plan. Psychiatry is what medicine used to be before the advent of cardiac catheterization, MRI, and antibiotics. Practicing psychiatry is like practicing medicine back in Osler’s days. Psychiatrists conduct a thorough history and physical examination of patients without laboratory tests and imaging studies to fall back on. While many of my colleagues in medical school did not enjoy the uncertainty of psychiatry and sometimes even found it scary, I saw psychiatry as an opportunity to return to the old ways of practicing medicine.

Then, residency started. I noticed that patients were often seen quickly and attendings taught residents to assess patients in an efficient manner. I was encouraged to rely on diagnostic scales such as Zanarini, PHQ-9, or PCL-5 to make rapid diagnoses. Under the banner of team-based care, diagnoses and treatment decisions were largely made based on observations by nurses and therapists. We prescribed higher medication doses just because there was room to go up, and because writing and thinking about medications took less time than counseling patients and conducting psychotherapy. In some ways, psychiatry felt no different to me than any other specialties in medicine. I began to wonder, why bother seeing patients when you can make a diagnosis based on checking CT or lab results? Amidst endless streams of patient visits and documentation, I focused on surviving residency: typing notes during conversations in the exam room, conducting efficient interviews, checking off lists of psychiatric symptoms and safety questionnaires, starting medications based on evidence based guidelines, and furiously typing discharge summaries in order to leave the hospital as soon as humanly possible.

Residency was humming smoothly until I received a phone call during one of my few golden weekends. One of my patients had committed suicide. I still grieve this loss. The reason why I have not been able to find closure is that I really did not know the patient. I could give his age, recite all of his risk factors for suicide, his list of medications, psychiatric symptoms, and provide the diagnosis of a major depressive episode. I knew he had been suffering from mental illness for a long time. I knew the basics of his social history: that he recently lost his job, divorced from his wife, and was on the verge of losing his house. What bothered me so much upon his death was the fact that if I were ever asked to give his eulogy, I would not have anything to say. I didn’t know what made him tick, any of his hobbies, his favorite ice cream flavors, what he valued, what were his parents like, why he got a divorce, how he ended up in Vermont, what his neighborhood looked like growing up, or anything about his hopes and dreams.

My journey to recovery started at the state hospital rotation. Although the building was relatively new, the design and decor were reminiscent of an old-school psychiatric hospital. There were locked doors, broad hallways, patients pacing, and a nice tea garden. It was a place where orders were still handwritten. It transported me back to the ancient days of medicine. A patient I met initially appeared like every other teenager admitted to the inpatient adolescent unit: he carried a diagnosis of major depressive disorder, he had frequent suicidal ideations and attempts, and he came from a dysfunctional family. However, this time, I chose to sit down and listen and get to know him better. He was in tenth grade. He had light dark hair, a slightly round face, and patchy facial hair. He was also charming, full of charisma, and with a rebellious edge. If he had not been hospitalized for a serious mental health issue, he would not look any different from a typical high school student. Still, beneath the surface, he was full of darkness and angst. He recalled growing up in a small New England town with a mom who struggled with depression and dad who was frequently absent due to work. He described going to school, hanging out with friends and putting up a pretense that everything was going all right in his life. When he returned home, he plunged into darkness, turning to drinking bottles of whiskey from his parents’ liquor cabinet, with his mom nowhere to be seen. He used Bob Marley’s songs as lullabies to fall asleep. In the midst of numerous hospitalizations, he and I managed to form a bond. We started talking about Bob Marley, learned about the neuroscience of depression, discussed his dream of working in a mental health field, and found a way for him to step back from suicide. I drove home physically exhausted as a result of spending more time with my patients, but I started to enjoy showing up to work.

When I moved on to another rotation, I was excited to share this newfound magic with someone else. A medical student and I were asked to see a consult on a medical unit for a safety assessment. We went through a typical checklist of symptoms for DSM diagnoses and asked questions to assure of ourselves that this patient was not at an imminent threat to himself or others. Although our job was done, I wanted to show that psychiatry was more than a checklist of symptoms and matching medications for diagnoses. I thought this patient would benefit from therapy given his diagnosis of post-traumatic stress disorder. I gave the student a task: to conduct a motivational interview to assess the patient’s willingness to proceed with therapy. I hoped the student could first conduct a thorough history like William Osler to get to know the man well enough to turn this “PTSD patient” into a living, breathing human being. Through this challenge, we learned that despite the horrific things that happened in his life, he managed to work 80 hours a week at a security firm to provide for his family. He joined the military to fight for our country, but now was unable to work due to his symptoms, and felt unsure of the cause of his medical illness. He was a typical New England guy: lots of facial hair, hardened exterior thanks to long winters, afraid of discussing anything personal, and fiercely protective of his manhood and independence. Despite the fact that he knew therapy would likely reduce his PTSD symptoms, he had been refusing therapy referrals for the last few days. We spent an hour talking with the patient, and as the sun slowly set, my hope of convincing the patient faded as well. Nevertheless, I asked him, “Are you ready to see a therapist?” Surprisingly, he replied “yes.” I asked what changed his mind. He answered, “I liked talking with you guys. I don’t think I have ever talked about this stuff before. I think I can do therapy.” Feeling accomplished, we went back to our work room to discuss the interview. The medical student turned to me and asked, “Do you have any tips for conducting interviews more efficiently?” I uttered without much thought, “There is no substitute for time.”

We live in a world that requires physicians to do more with less time. Technology, checklists, and algorithms that were initially created to help physicians are now taking away the joy from our clinical work. I have a modest proposal. Physicians who are in less procedure-oriented specialties should be fairly compensated for the time that they spend with patients. Health care providers are finding their own solutions to spending more time with patients: creating concierge primary care practices, or in psychiatry, private, cash based practices. However, this trend is unsustainable and does not provide adequate care to the underserved. Among private practice psychiatrists, already almost half of practices don’t accept any insurance. The result is that vulnerable patients who require the most amount of time given complexities of their illnesses are left with physicians who rely more on diagnostic tests, checklists, and shortcuts. Still, I plan to follow the advice given by William Osler to medical students: “Take no thought for the tomorrow. Live neither in the past nor the future, but let each day’s work absorb your entire energies, and satisfy your widest ambition.”

Image credit: Time by petter palander licensed under CC BY 2.0.

Kevin Chun, MD Kevin Chun, MD (1 Posts)

Resident Physician Contributing Writer

Dartmouth-Hitchcock Medical Center

Kevin studied Public Health and History at Johns Hopkins University. He then stayed in Baltimore for another 4 years to finish medical school at University of Maryland School of Medicine. He is currently a second year psychiatry resident at Dartmouth-Hitchcock Medical Center in Lebanon, NH.