A middle-aged patient was referred to our clinic with a mass in his liver. It had been detected the preceding year, and the patient underwent a battery of investigations with scans and biopsies to reach a diagnosis of metastatic lesion of the liver. After appropriate consultations with oncologists, chemotherapy was initiated. Following a few cycles of chemotherapy, the patient was referred to our clinic for a surgical consultation.
After reviewing all the relevant prior investigations, it was decided the patient would need further workup to determine his suitability for surgery. I had a lengthy discussion with the patient and his family about the treatment plan going forward, and they appeared pleased with the next steps. It was decided that we would meet again in a few weeks. All of this seemed quite normal and suggests we provided good patient care in congruence with current evidence-based guidelines. We developed a good physician-patient relationship, which made both the patient and his family comfortable with the treatment plan.
Chandrakanth Are, MBBS, MBA, FRCS, FACS
As I was on my way out of the room, my nurse wished the patient a happy birthday. I immediately followed with my birthday wishes as well. I did not ask him about what he planned to do on his birthday, considering that he spent most of the day with the clinic appointment and related travel. Besides, it would take an enormous amount of optimistic fortitude for someone to make the joy of a middle-aged birthday triumph over the sorrow of a cancer diagnosis.
Professional Disconnect
And here comes the disconnect in our well-intentioned profession. We spend an enormous number of years training to provide the highest quality of care. Many of us have an unyielding passion for what we do and would not switch to any other occupation, even if offered a fortune. We treat patients to the best of our abilities, guided by the principles of safety, quality, and evidence-based medicine. We offer compassion as much as possible within the time constraints of our hurried schedules, governed by the dictates of medicine and business. In essence, we treat the majority of our patients competently, and our health-care system, despite its imperfections, serves our citizens well.
Although we treat the patient in front of us proficiently, we sometimes can be oblivious to the person behind the patient. While the patient carries the diagnosis, it is the person within who carries the patient. This becomes important because it is the person and the vicissitudes of his or her life that determine the patient’s presence, absence, and behavior.
By leaning into the person, I realized many aspects of my interactions with this patient. He was supposed to see us almost 3 to 4 weeks earlier but did not make the appointment. It made me wonder why he would choose to delay the appointment to get a specialist’s opinion, until I found out that he was attending to his gravely sick parent infected with COVID-19 in a faraway town. Only after that parent’s passing a few days prior to our meeting did the patient decide it was time to take care of himself, and hence he made the appointment.
Add to this some of the inevitable social determinants of health, which don’t always play in our patients’ favor. The patient’s job was already at risk due to work interruptions related to the cancer diagnosis. A lack of health insurance compounded many of the problems the patient was already going through. Even a routine CT scan could turn out to be a free ride into the lanes of American health-care bureaucracy and a major test of patience.
I found that the patient was well informed and had every intention of taking care of himself. But it is not the intentions of the patient that determined the course of his care. It is the person behind the patient and the uncontrollable circumstances that dictated what he finally did. This happens more often than we think, and the resulting incongruence may not fit neatly into the construct of the science-based care patterns we practice. At the same time, failure to learn about and understand the realities of the person’s life is unlikely to get us very far in improving the patient’s life.
Challenges of Life
Any or many of the no-shows in our clinic could be unintentional. A no-show for a colonoscopy could have been because the patient’s ride did not materialize at the last minute. This could have been because the driver could not take time off from an hourly wage job. We mark these events as simple no-shows, without a hint of the extenuating circumstances that led to them.
Failure to take prescribed medication could be due to an inability to afford the drug despite the best social assistance and reluctance to admit those circumstances. These circumstances are not unique to any particular patient population, and no patient is immune from it. They can happen to well-informed, well-educated, and well-insured patients.
The challenges of life can be severe enough for some that they may not find the time or circumstance to inform us about what happened. Most patients would not willfully neglect their own health if they could avoid it. It is the adversarial circumstances of life that may be unfathomable for others and that drive instances of unexplainable patient behavior.
The personal aspects of a physician-patient relationship that go beyond professional needs can improve the quality of patient care in several ways.— Chandrakanth Are, MBBS, MBA, FRCS, FACS
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In an ideal world, or in days gone by, we had ample opportunities and time to build sustainably compassionate relationships with all our patients. The personal aspects of a physician-patient relationship that go beyond professional needs can improve the quality of patient care in several ways. They can provide a comfortable environment for patients when our questions seek answers, not only about their disease, but also about themselves. And when patients feel comfortable, they are more likely to be compliant with their appointments or medications.
Evolving Landscape
Our health-care landscape has changed significantly over the past few decades. With increasing automation, advancing technology, and the pressures of modern-day health-care delivery, the nature of the physician-patient relationship has also changed significantly. With preset dedicated time slots on clinic templates, it can be difficult to find those few extra minutes to get to know more about the person beyond what is needed to treat the patient.
In a modern clinic, you can be as compassionate as you want, but it has to be limited to the preset time limit. Any desire to go beyond the time limit to weave in more compassion is likely to disrupt the entire clinic template and take time away from the ever-hungry, mandatory, and compassion-immune electronic medical record. Similarly, in the preoperative area, you can be as comforting as you want, but you better not take too long, so the patient can be carted away and the procedure started on time.
Our health-care delivery model has evolved into a rigidly structured conveyer belt of efficiency, which transports patients to well-intentioned and caring people who can provide measured amounts of compassion, which has to fit into the compressed slot of time. As we continue down this pathway of improvements in health care driven by technology, we will witness many benefits for our patients. It would be wise to ensure that we continue to impregnate every aspect of the changing health-care environment with the seeds of compassion as well.
So let us continue providing expert patient care. But maybe the next time we meet with a patient, let us try to see more of the underlying person. When you see both the patient and the person in equal parts, it can prove to be very beneficial and equally gratifying for both the patient and the physician.
Dr. Are is the Jerald L & Carolynn J. Varner Professor of Surgical Oncology & Global Health; Associate Dean for Graduate Medical Education (DIO); and Vice Chair of Education, Department of Surgery, University of Nebraska Medical Center, Omaha.
DISCLOSURE: Dr. Are reported no conflicts of interest.
Disclaimer: Some of the facts of the case discussed in this commentary have been changed to protect patient privacy.
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.
