Skip to main content

A novel therapeutic intervention: More time with patients

What would happen to the quality of patient care in the United States if we had more time to spend with our patients? Would we train better doctors if our residents spent more time with fewer patients? An essay in the Annals of Internal Medicine by Dr. Stanley Shi-Dan Liu, a resident at Johns Hopkins Bayview Medical Center suggests the answer to these questions is an emphatic YES!

Dr. Liu reports on his experience on the Bayview Aliki Service. Residents on the Aliki Service admit half the number of patients as other medical service teams. By having more time with each patient, they are charged with getting to know their patients as people, both in and out of the hospital. Residents spend much more time preparing their patients for discharge, call all their patients after discharge, and conduct post-discharge home visits on many of their patients.

Dr. Liu eloquently reports how having more time with patients transformed his ability to provide good care, noting:

"My patients, their families, and I all knew each other by name, and I was no longer just another anonymous white coat coming in and out of their rooms."
Relating a discussion of hospice care with the wife his patient with leukemia, he reports:
"I could sit down with her, hold her hand, and wait patiently as she cried without having the now familiar feeling of 'hurry up and get back to work on the other patients!' distracting me in the back of my mind."

Dr. Liu notes several examples where more time with patients prevented potentially catastrophic medical errors during transitions of care. For example, for one nursing home patient, time to conduct a detailed review of her medical records led him to discover that she was supposed to be receiving antibiotic treatment for a resistant infection of her prosthetic hip. This issue was not noted in her transfer to the hospital. For another patient, a post-discharge call to the primary care physician revealed that the primary physician had not received the hospital discharge summary. As a result, he had no idea what was going on when the patient showed up for a pre-surgical evaluation, including why the patient was undergoing surgery. The time to make this call made it possible to get the patient's care back on track.

Perhaps most important, Dr. Liu notes that the Aliki Service reawakened his passion for medicine:
"The Aliki Service provided a rare oasis in our training where we could practice the best medicine that we possibly could, rekindle the passion that brought us to our careers in the first place, and discover new passions."

In an age where it seems that technology has dominated medicine, and the human touch of the profession is being lost, the Aliki Service provides a reminder that the core of medicine is the time we spend with patients. Hopefully, other residency programs will choose to replicate this service at their own institutions.

The Aliki service shows how spending more time with patients can be an exceptional therapeutic intervention. I suspect the impact on patient outcomes exceeds the impact of many pharmacologic, technologic, and procedural interventions that have been introduced over the past generation.

But perhaps the fact that having enough time to provide good patient care is considered so unusual and exceptional is a sad commentary on the state of American medicine and medical training.

by: [ken covinsky]

Comments

Anonymous said…
Typical daily dilemmas of a medical student: How do I pre-round on many patients without having to strategically shorten conversations to be on time for rounds? What do I do when a patient brings up a new and important concern at the end of their 15-minute clinic visit, and I'm supposed to see the next patient? Should I use the next 10 minutes to explain to Patient A why he's about to get a CT scan, or make sure that Patient B understands his discharge medications before leaving the hospital? Efficiency has been the central focus of my training. While it will hopefully come more naturally as my clinical knowledge and reasoning improve, I’ve always wondered why we are so pressed for time with our patients . . . What’s responsible for this and how do we change it? Do we need more doctors to enter the workforce, the creation of more med schools/residency programs/hospitals? More willingness to take a salary hit in order to spend more time with fewer patients? Less years required for licensure? Less time writing progress notes (I vote for this one :) and talking about patients, and more time talking to patients (I’ve heard that Yale does rounds in front of their patients, another idea)? More physical exam, and less lab tests and interventions? Only admit supernatural medical students that have proven they can heal patients in eight places at once? Any insights from the geriblogosphere?
Anonymous said…
Sometimes I think this is really what makes the difference on the palliative care team- they make time to talk! No one else can really sit down with patients and families.
Dan Matlock said…
This is precisely what I love about palliative care - more time (thanks to a small subsidy from the hospital)

I wish we could design this trial and do it measuring a host of patient-centered and utilizaiton outcomes.

Popular posts from this blog

The Future of Palliative Care: A Podcast with Diane Meier

There are few names more closely associated with palliative care than Diane Meier.  She is an international leader of palliative care, a MacArthur "genius" awardee, and amongst many other leadership roles, the CEO of the Center to Advance Palliative Care (CAPC).  We were lucky enough to snag Diane for our podcast to talk about everything we always wanted to ask her, including:
What keeps her up at night?Does palliative care need a national strategy and if so why and what would it look like?The history of CAPC and the leadership centersAdvice that she has for graduating fellows who want to continue to move palliative care forward as they start their new careersWhat she imagines palliative care will look like in 10 or 15 years?What is the biggest threat facing palliative care? So take a listen and if you want to dive a little deeper, here are two articles that we discussed during the podcast:
A National Strategy For Palliative Care. Health Affairs 2017Palliative Care Leadership…

Advance Care Planning before Major Surgery: A Podcast with Vicky Tang

This week's podcast is all about the intersection of geriatrics, palliative care, advanced care planning and surgery with our guest Dr. Vicky Tang.  Vicky is an assistant professor and researcher here at UCSF.  We talk about her local and national efforts focused on this intersection, including:
Her JAMA Surgery article that showed 3 out of 4 older adults undergoing high risk surgery had no advance care planning (ACP) documentation. Prehab clinics and how ACP fits into these clinicsThe Geriatric Surgery Verification Quality Improvement Program whose goal is to set the standards for geriatric surgical care including ACP discussions prior to surgeryHow frailty fits in and how to assess it (including this paper from JAGS on the value of the chair raise test) So take a listen and check out some of those links.  For those who want to take a deeper dive into how GeriPal and surgery fit together, check out these other podcasts: Zara Cooper on Trauma Surgery, Geriatrics, and Palliative Car…

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …