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Putting Extra 'Care' Into Health Care
Putting Extra 'Care' Into Health Care
Washington Post
By Dr. Marc Siegel
May 1, 2007
Al Gazzini loved to eat, but surgery to remove his esophageal cancer left
him so scarred that there was no easy way to reconnect what remained of his
gullet to the rest of his digestive system. All his surgeon, Harry Soroff,
could offer him was intravenous nutrition and the chance to chew and spit
out his coveted pastrami sandwiches. On days when Gazzini's wife couldn't
visit him at the Northport VA Hospital on Long Island, Soroff brought the
sandwiches himself.
But Gazzini soon tired of this routine and urged his doctor to try to
reattach his plumbing. Soroff finally agreed to a risky 10-hour operation,
in a last effort to restore some quality of life for his patient.
At first, the operation appeared successful. When I, as Soroff's young
nutritional research associate, broke the news to Gazzini that he could
finally eat a regular meal, he couldn't stop smiling. His first request: a
juicy steak. I brought him one, wrapped in tin foil, and he savored every
morsel, nodding happily with each swallow.
Soon after, however, his wounds became infected, and Gazzini died. I went on
to practice internal medicine, where I have tried to apply the lessons I
learned that day when Gazzini ate his last steak: Most patients will find a
way to tell their doctor their major concern -- if the doctor is listening.
And that exchange can transform ordinary health care into inspired care.
In an age of impersonal medicine, marked by bottom-line thinking and rushed
doctor-patient interactions, some doctors still buck the trend -- the way
Soroff did -- and go to extraordinary lengths to give their patients
personal care. Some let patients call them at home, day or night; some keep
their offices open late; some find other ways to show that a patient's
outcome matters deeply to them. (At New York University's School of
Medicine, professor of medicine Marcel Tuchman, 85, has even been known to
call a cab and accompany very sick patients to the hospital himself.)
Patients who encounter that kind of care don't just find the difference
striking, they often credit it with improving their health.
Internist Albert Herrera is one such doctor. The former chairman of internal
medicine at Inova Mount Vernon Hospital, he practices in Alexandria, where
my former patient Andrea Untrojb, 38, sees him for regular checkups.
Recently, after starting a demanding new job as a public school registrar,
Untrojb developed severe pain in her stomach. Herrera's diagnosis: a
bacteria that thrives in stress-induced stomach acid and can cause ulcers.
But he did more than treat her with antibiotics.
"Dr. Herrera talked to me for over an hour and asked about my job," Untrojb
told me by e-mail. "He not only wanted to know about my physical pain, but
wanted to find out what else could be causing my emotional distress. I told
him that my job put such a strain on me that I was coming home crying every
day, yelling at my kids and arguing constantly with my husband. Dr. Herrera
reassured me that many suffered with this problem. He gave examples from his
own life and told me what I could do to relieve the stress," including
routines, meditation and exercise.
George Washington University medical school faculty member Jeffrey Sherman,
50, also tries to match his effort to the patient's need.
Sherman, a former National Institutes of Health immunologist who left
research for clinical practice 12 years ago because he missed patient
contact, gives out his cellphone and home phone numbers freely to patients
and encourages them to call any time they have medical questions.
"This kind of thorough, thoughtful care is almost impossible to find," said
Howard Yoon, a 36-year-old literary agent who saw Sherman recently after an
outbreak of shingles. "He didn't seem rushed and sat with me to talk about
my symptoms. He even took out a book and showed me which nerve endings in my
head were affected by the shingles. He also talked me through the medication
I was taking.
"When I mentioned to him that my wife and I might be planning our second
child, he actually called me back into his office and looked up whether
there were any risks associated with the drugs a future father was taking
and the chance of birth defects. He found none.
"I think the worst part of being sick is fear of the unknown, which only
gets exacerbated if your doctor is not communicating to you properly."
Over the next week and a half, Sherman called Yoon three times to see how he
was doing and to make sure the shingles rash and pain were abating.
Why Not the Norm?
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Why don't more doctors practice this way?
It's not just a matter of the demands of managed care, though the system's
rigid (some say stingy) reimbursement formulas and focus on the bottom line
does make it more difficult to deliver devoted care. I still accept managed
care insurance, as does Herrera. Cramming more patients into my crowded
schedule would sure help me pay for my kids' private school tuition and for
a badly needed renovation of my house. But I can't bring myself to do it.
I can limit idle conversation with my patients, but I'm concerned that too
much attention to the clock will cut down on rapport and lead to missed
diagnoses or poor treatments. Dropping managed care entirely would mean
giving up patients I care about.
Sherman has opted out of all managed-care insurance plans and asks for
payment upfront, though he makes allowances for patients who cannot pay the
full rate. Because his patients have to cover the bill, he says, they "have
more expectations," which he is determined to fulfill.
While doctors often blame their lapses in attention and rushed demeanor on
time pressures exerted by managed care, others say they can only preserve
their identity as healers by remaining engaged and caring, regardless of the
reimbursement. Pauline Chen, transplant surgeon and author of "Final Exam: A
Surgeon's Reflections on Mortality" (Knopf, 2007), writes: "That honor of
worrying -- of caring, of easing suffering, of being present -- may be our
most important task, not only as friends but as physicians, too."
It's too bad all doctors aren't as deeply invested. Part of the fault, Chen
argues, may be in our training:
"Medical students must learn to endure and even embrace what might be
considered by others to be difficult or even ghastly. . . . Ultimately they
will settle at a comfortable equilibrium point, and this act of creating a
new moral paradigm -- detached concern, secure uncertainty, and humanistic
technology -- marks an important step in the transformation of the lay
medical student into full-fledged professional physician."
Call Me
_____
Andrew Goldstein, 40, a gynecologist on the Johns Hopkins University faculty
who practices in Washington, sees many cancer patients who develop vulval
discomfort as a side effect of chemotherapy.
Like Sherman, he expects payment upfront: He charges $1,000 for an initial
visit -- lasting 1 1/2 hours, an almost unheard-of amount of time these days
-- and $250 for follow-ups. The length of the initial visit, he says, is
necessary to allow patients to "work through their anger over other
physicians and come to real solutions."
Also like Sherman, he gives out his cellphone and home phone numbers.
Patients, he says, are reassured by his availability and call only when
absolutely necessary.
His patient Linda Donald, a 59-year-old business consultant, notes that no
nurse runs interference for Goldstein; he handles everything himself. "His
empathy allows him to destigmatize a problem that is embarrassing to his
patients. It's as if he's talking about your eardrum," she said.
As for the personal approach, Donald is sold. "If a physician is able to
completely focus on you as a patient, the likelihood of an accurate
diagnosis and appropriate treatment individualized to you is much greater.
Not just an 'it seems like this, and therefore let's try that and see what
happens -- come back next week.' " ?
Marc Siegel is an internist and associate professor of medicine at the New
York University School of Medicine. |
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