Should a doctor feel guilty, or be criticised, if a patient walks into the consulting room and leaves four minutes later? (I think my record is two, if I am honest.) If I see a patient on a ward round and spend no more than three minutes by the bed, I do ask myself – on walking away – ‘where was the quality in that?’ Where was the care?
A typical day is peppered with such rapid patient-doctor interactions. The decisions made are about drugs, results, tests – the purely ‘medical’ side of medicine, and the information shared purely factual. However, every article one reads about patient-centred care elaborates on the work required to make a connection, to understand the patients’ concerns, to develop empathy, to truly understand in order to truly help. This complex process cannot occur during a fleeting visit. Nor even a series of visits. The fact is that much of medical interaction is devoted to algorithmic decision-making in response to the physical manifestations of illness. There is accuracy, there is safety, there may be ‘quality’, but there is little evidence of active compassion.
Behind each verbalised physical complaint there may be a flurry of unspoken anxieties. Those anxieties may be disproportionate to the severity of the illness (a 25 year old with food poisoning who worries they might have cancer for instance), but that lack of proportion is obvious only to those who know, the medically initiated. It is just this sort of patient who is likely to receive a very short visit on a ward round. Unless you ask, you won’t find out how deep their unease goes. So why not ask? Why not explore? There isn’t enough time. It is efficient medicine. It is fast medicine. Is it bad medicine?
Imagine the alternative. The universally compassionate doctor, intent on giving each patient a full opportunity to interact and expose those niggling concerns that would otherwise remain hidden and fester, might spend a good 15 to 20 minutes with each on a ward round. There may be 25 people to see. 15×25m = 375 minutes. Over 6 hours. That is unfeasible. Even 10 minutes (the average time spent per patient in a study on the use of a checklist, and a threshold mentioned in a Royal College of Physicians report) would result in 4 hours without a break – which is a stretch.
A junior doctor on a five hour ward round will become tired and lose focus. They will become anxious that there are only so many hours left in the day to complete the list of tasks. There will be less time to check blood tests at the end of the day, more jobs will be handed over to doctors unfamiliar with the patients, scans will be requested after the shutters come down in radiology. A consequence of spending more time at the bedside may be a sense of hurry away from it. There is a place for speed, it seems.
Most would agree that not every patient requires 15 or 20 minutes. Many patients expect nothing more than a quick update. If they have come in with a chest infection they may wish to know nothing more than the diagnosis, the treatment plan and the estimated length of stay. Others will require far more, and will not reveal their fears, or the impact that the illness is having on their lives unless time and space are provided and a degree of trust has developed. The experienced doctor may anticipate their questions. They may even coax them out, or formulate them, based on what he or she has seen before.
But speed is addictive. Everybody likes speed. It makes the place look efficient; it makes people happy. If the ward round can be wrapped up before lunchtime there may be time for relaxation and chat. The important administrative or multi-disciplinary meeting can be attended on time. If a clinic finishes promptly the nurses in outpatients will congratulate you.
The danger of developing a speed habit is that the default approach becomes little more than a fly-by, a surface skim, such that the visual or verbal clues indicating the patient needs more time are missed. This habit explains the experience of many – the worried or confused patients who ‘barely sat down before he closed my notes and discharged me,’ or those who report that their doctor ‘barely looked up from the computer.’ So how can one be fast and compassionate?
To achieve speed without leaving a trail of patients with unresolved questions and unvoiced anxieties, adequate time must be given to those who need it. The only way to do this is to be fast with those who can take fast (the simple cases and the easy cures, the untroubled, inconvenienced patients who are as anxious to leave as you are to move on), while remaining ready to slow down when the situation demands it. This requires a doctor to be adept at judging the deeper needs of their patients, and a willingness to step out the fast lane for a while.