2015 Family Medicine Experience

Refocus Attention on Patients, Says FMX Keynoter

October 05, 2015 11:49 am Chris Crawford Denver –

Abraham Verghese, M.D., M.B.A., explains why putting the patient at the center of care and avoiding distractions benefits both patients and physicians. Verghese delivered the keynote address during the Sept. 30 opening session of the AAFP Family Medicine Experience.

Abraham Verghese, M.D., M.B.A., commenced his Sept. 30 keynote during the opening session of the AAFP Family Medicine Experience (FMX) here by praising family medicine's approach to patient care.

"Your society has protected the physician/patient relationship in a way I can't say the other specialties have championed," he told a packed house of family physicians and other FMX attendees. "You are the last bastion against all of the intrusions that keep coming our way."

Verghese, who is a professor of medicine at Stanford University School of Medicine and author of My Own Country: A Doctor’s Story and The New York Times bestseller Cutting for Stone, said the advent of electronic health records (EHRs) has led to what he calls the "iPatient."

"The patient in the bed has become a mere icon for the 'real patient' who is in the computer," he said, to a round of applause. "The iPatient is getting wonderful care all across America. The real patient is wondering where the heck is everyone and when are they going to tell me what is going on."

Story Highlights
  • Abraham Verghese, M.D., M.B.A., a professor of medicine at Stanford University School of Medicine and best-selling author, kicked off the AAFP Family Medicine Experience with his opening session keynote on providing better patient care.
  • Verghese laid out four reasons why it's important for physicians to bring the patient back to the center of their approach to care: patient dissatisfaction, increased physician distraction and resulting errors, physician wellness, and loss of ritual.
  • At Stanford, Verghese has championed a retraining of residents and created the "Stanford Medicine 25" -- a list of 25 key points to cover during a full patient exam.

Verghese laid out four reasons why it's important for physicians to bring the patient back to the center of their approach to care:

  • patient dissatisfaction,
  • increased physician distraction and resulting errors,
  • physician wellness, and
  • loss of ritual.

Modern-day patient dissatisfaction is pretty obvious, Verghese asserted. He described a comment he received online on a post he had written; it was about a recurring issue a hearing-impaired patient was having during visits to her physician. She said, "When I go to my doctor's office, I have to remind him that I am hard of hearing and need him to look at me when I talk. But it only lasts about 30 seconds until he needs to shift back to the competing screen."

Moreover, physician distraction due to the EHR and other electronic devices can increase errors, Verghese said.

He pointed to a recent study(www.amjmed.com) he co-authored that was published in the American Journal of Medicine in which his team compiled physicians' anecdotes about instances when an oversight in the physical exam led to a diagnostic delay.

"The most common reason for an oversight that led to serious consequences was simply that the exam was not done," Verghese said. But he also pointed to the importance of a full-body exam, saying that "if you are only lifting shirts," you can miss important parts of a diagnosis.

The third issue Verghese raised was widespread physician burnout. "By some estimates, 50 percent of primary care physicians are depressed," he said. "Even if this data is even half true, it's astonishing. It tells you this is not a personal issue -- this is a systemic issue."

According to Verghese, the root cause of this widespread burnout is what he calls the "4,000 clicks a day problem," a characterization that drew enthusiastic applause. The number comes from an American Journal of Emergency Medicine study(www.ajemjournal.com) that found the average emergency medicine physician on a regular shift makes 4,000 clicks per day in the EHR or some other tech device. "To order a baby aspirin is six clicks; it was 130 clicks to admit somebody with chest pain," he said.

"This is our doing; we let it happen and we've got to bring it back," Verghese continued. "The people who wrote our (EHR) software have made a mistake of epic proportions in that it satisfies the billing requirements, but it's coming at the expense of our happiness and patient welfare."

The last issue Verghese addressed is the loss of very important physician-patient rituals. He cited an example drawn from when he treated patients with chronic fatigue while working in Texas. During each patient's first visit, Verghese said he would give them 40 uninterrupted minutes to tell their story. Then, during the physical a couple of weeks later, it was understood the time would be spent entirely on the examination.

As one of these patients was uncontrollably chatting to start the second visit, Verghese said, he launched into his examination and the patient began to quiet down. "I had an eerie sense the patient and I slipped back into some sort of primitive ritual -- kind of a dance -- in which I had a role and they had a role."

When he completed the exam, the patient said, "I've never been examined like this before." Verghese said he found this troubling because he was just doing the traditional full examination he had been taught in medical school and that he had been doing for more than 30 years.

Out of curiosity, Verghese went to the anthropology department at Stanford and asked about this experience. "They said, 'What you are talking about is a ritual and rituals are all about transformation,'" he said.

"You are wearing a shamanistic gown with all these shamanistic tools in the pockets, and they're wearing the ceremonial paper gown that nobody knows how the heck to tie," Verghese explained. "Tell me this doesn't have all the trappings of ritual … and when the ritual they expect doesn’t happen, they walk away somewhat disappointed."

So at Stanford, Verghese has championed a retraining of residents and created the "Stanford Medicine 25"(stanfordmedicine25.stanford.edu) -- a list of 25 key points to cover during a full patient exam.

"If we don't teach this well, we lose a precious art," he told audience members. "If we don't train our students and residents to go to the bedside and not actually be in the patient's presence, how do we model the kind of behavior that we want to see?"

Verghese closed his remarks by quoting Mother Teresa, who once said, "One of the greatest diseases is to be nobody to anybody." He followed this up saying, "Your patients may be nobody to anybody, but I know they will always be somebody to you."