Personal view or opinion piece
Open Access

Pause

Roger Khouri[1]

Institution: 1. University of Texas Southwestern
Corresponding Author: Dr Roger Khouri ([email protected])
Categories: Postgraduate (including Speciality Training), Continuing Professional Development, Clinical Skills
Published Date: 17/09/2019

Abstract

In this perspective piece, a resident physician discusses the pressure to provide care as quickly as possible and how this pressure conflicts with the goal of providing humanistic care. The lack of time to connect and empathize with patients compromises care and leads to physician burnout. Taking a moment to pause, connect, and empathize may be the most time efficient aspect of any encounter.

Keywords: Residency; Communication; Clinical Training; Empathy; Burnout

Pause

As a teenager, I chose to pursue medicine over engineering because of the human connection that comes from caring for the sick. Despite my love for math and science, I did not want to spend my time in front of a computer, collecting and processing data. I wanted to support people through their toughest times, bring them hope, and rejoice with them in their recoveries.

In medical school, we learned not to focus so narrowly on treating the disease that we forget to treat the patient. Patients were not data registries that needed to be processed and solved; they were people who needed to be talked to and cared for. I took pride in connecting with people at a human level and upholding the intrinsic value of their experiences. I looked forward to bringing these ideals to life with my own patients.

As a junior urology resident, I quickly learned that, between consults, surgeries, and inpatient care, a typical day left no time for these types of connections. Between OR cases, I put in notes and orders and consented the next patient. Any additional consults or inpatient care needed to be dealt with in the remaining few minutes before the next OR case. When preparing to see a consult, I first mined through the EMR to understand the history and reason for consult and prepare my note. This left a tiny window of time for the patient interview and physical exam. In an effort to avoid being late for the next OR case, I learned to think of the interview and physical as another task to collect data as quickly as possible. Connecting with patients on a personal level takes much time and yields little data.

When the healthcare system pushes physicians to be more and more efficient, the easiest corner to cut is the patient connection because it can be time consuming, and its benefits are not immediately obvious. However, a growing body of evidence suggests that patients whose physicians take the time to empathize with them have improved outcomes (Neumann et al., 2007; Hojat et al., 2011; Rakel et al., 2011; Del Canale et al., 2012). Moreover, the connections physicians make with patients provide meaning to the long and stressful days, and thereby, allow us maintain resilience in an era of physician burnout.

Unfortunately, academic medical centers are not immune to these pressures for efficiency and productivity. Unlike medical students, surgical residents are taught to work as quickly as possible. We learn that long talks with patients can lead to concerns about our efficiency. Programmed to succeed, we practice medicine like data analysts, collecting and processing data, one patient at a time. This dehumanization, coupled with the long and stressful days, leads to burnout.

In every patient encounter, physicians decide to either take the extra time and connect with the patient or simply collect and process the data and push to stay on schedule. For better or worse, I learned to pause. For a few moments at the end of every encounter, I consciously take my foot off the gas pedal. I turn the data-collecting machine off and connect with the patient on a human level. I tell them that I understand that what they are going through is difficult and that I will support them through it. They then typically tell me what worries them most about their condition and that they trust me to do what is right for them. These moments make the long and stressful days worthwhile and motivate me to become a better physician.

Medicine is not engineering. There is much more to caring for a patient than simply collecting and processing data. Empathy makes medicine human. Omitting it compromises care and leads to physician burnout. Taking a moment to pause, connect, and empathize may be the most time efficient aspect of any encounter. In this era of burnout, we must teach the next generation of physicians that we don’t have time not to pause.

Take Home Messages

  • Residents are incentivized to maximize efficiency and spend as little time as possible communicating with patients
  • This emphasis on efficiency over empathy leads to poor patient outcomes and physician burnout
  • Training this way will produce a generation of physicians ill-equipped to address the human needs of the population

Notes On Contributors

Dr Khouri was born in St. Louis and raised in Miami. He went to college at Wake Forest University and medical school at the University of Michigan. He is a PGY-3 urology resident at the University of Texas Southwestern. After residency, he plans to complete a fellowship in reconstructive urology and work as an academic urologist.

Acknowledgements

None.

Bibliography/References

Canale, S., Louis, D.Z., Maio, V., et al. (2012) 'The relationship between physician empathy and disease complications: an empirical study of primary care physicians and their diabetic patients in Parma, Italy’, Academic Medicine, 87(9), pp. 1243-1249. https://doi.org/10.1097/ACM.0b013e3182628fbf

Hojat, M., Louis, D. Z., Markham, F. W., et al. (2011) ‘Physicians’ empathy and clinical outcomes for diabetic patients’, Academic Medicine, 86(3), pp. 359-364. https://doi.org/10.1097/ACM.0b013e3182086fe1

Neumann, M., Wirtz, M., Bollschweiler, E., et al. (2007) ‘Determinant and patient-reported long-term outcomes of physician empathy in oncology: a structural equation modeling approach’, Patient Education and Counseling, 69(1-3), pp. 63-75. https://doi.org/10.1016/j.pec.2007.07.003

Rakel, D., Barrett, B., Zhang, Z., et al. (2011) ‘Perception of empathy in the therapeutic encounter: effects on the common cold’, Patient Education and Counseling, 85(3), pp. 390-397. https://doi.org/10.1016/j.pec.2011.01.009

Appendices

None.

Declarations

There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Ethics Statement

Ethical approval was not required for this article as it did not reporting research findings.

External Funding

This article has not had any External Funding

Reviews

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Alexander Woywodt - (31/10/2019) Panel Member Icon
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I really enjoyed reading this personal view piece. I agree with the other reviewers that the author's statement that "medicine is not engineering" sums it up very well. I am curious as to how the author makes this work in the real world. How long are the patient slots are on the clinic template and how much time can the author spend on taking the foot off the gas pedal? Also it would be nice to see a more detailed reflection on how care providers can connect. Perhaps there are other ways of doing this other than empathy? I often connect with patient through the artwork in my consulting rooms or when I take an occupational history. Finally the author focuses on time pressures in a busy clinical environment but isn't lack of continuity one major obstacle for health care providers to connect with their patients? Perhaps its stating the obvious but the author could briefly reflect on lack of continuity and the increasing factory-like character of medicine as a factor in this.
Helena Filipe - (22/09/2019) Panel Member Icon
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The statement “ Medicine is not engineering” summarizes the core of this meaningful, very well written article.
In the category of “perspective”, the article reads well, with a fluid writing and articulated ideas portraying the Author’s view, thoroughly supported on evidence.
The chosen topic is critical within the healthcare delivery context and has significant impact on medical education in terms of available time and motivation of the clinical educator to impart experience as well as the kind of role modeling thus possible to offer.
The Author emphasizes the relevance of the chair time in the clinical encounter to enable the doctor-patient relationship development. I completely agree there should be no subtracting or delegating this fundamental component of medical care in order to reach the best patient outcomes and ultimately the community health well being. This is a physician’s role and responsibility.
The Author underlines well how it serves both parties maximizing the physician’s job satisfaction and reducing burnout liabilities as also nurtures patients’ compliance for clinical best outcomes.
“Medicine is not engineering”. Medicine is about people and breathes through meaningful professional relationships.
Well done!
sathyanarayanan varadarajan - (21/09/2019) Panel Member Icon
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In this important article of personal view, the author raises a significant issue on spending time for patient connection and empathy.

He feels that we as doctors are programmed to succeed, so we practice medicine like data analysts, collecting and processing data, one patient at a time. This dehumanization, coupled with the long and stressful days, leads to burnout.

So the author learnt to pause for few moments, connected with the patients on the human level and communicated to them with empathy. He realized that these moments made the long and stressful days of him worthwhile and motivated him to become a better physician.

He concludes strongly that empathy makes medicine human and omitting it compromises care and leads to physician burnout.

He urges that we must teach the next generation of physicians that we don’t have time not to pause.

I totally agree with him that Empathy and Connecting with patients are vital components of effective patient care and it’s high time now to take active steps to educate the coming generation of doctors to practice these.