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Friday May 18, 2018

Our Patients Want -- and Need -- To Be Heard

"Where is the patient?"

[elderly patient smiling with doctor]

I said that a lot during my residency years. If I was called in the middle of the night to go to the ER, the first thing I would ask upon arrival was, "Where is the patient?"

Later as an attending, when talking with a resident about someone they admitted to the hospital, I would ask the same question.

It seems like a simple question, but I have found myself asking it lately in a different context.

In the past, when I would ask, "Where is the patient?" it was to determine a physical location so I could talk to, listen and examine the person. Today, when I find myself asking this question, it is in the context of discussions related to the business of medicine. As in, "Where is the patient in all this?"

My concern is that the patient is no longer considered a critical part of the equation in too many conversations about health care. I noticed this was when patients first became known as "clients." Not long after that, physicians were relabeled as "providers."

What ever happened to the doctor-patient relationship?

As technology has advanced, the art of the history and physical has been de-emphasized. Technology is quick, but the H and P takes time. It is easier to get a CT, an MRI, bloodwork or an echo than it is to actually have a physician go to a patient, listen to them, get the history and do a physical exam. We have slowly gone from a complete exam to a focused exam to no exam at all. The patient has practically been reduced to a "thing" that is tested and scanned so we can make a diagnosis and then go on to the next "thing" to be tested and scanned.

When it comes to the business of health care, we hear about "encounters" rather than "visits." Patients are reduced to numbers, and their concerns are reduced to data in the form of ICD-10 codes. Data is collected on patients' lab results. Is the hemoglobin A1c in the appropriate range? Is the blood pressure within the guideline recommendations? Is the BMI in range?

Nowhere is there a concern about the patient being able to afford the meds prescribed to them. There is no data on emotional support, or availability of nutritious food. The patient disappears into a mass of data points that are grouped together with other data points to measure the quality of care their "provider" is providing.

The patient, meanwhile, has disappeared. That is the result of the health care industry and the growing business of medicine. We need to stop a minute and ask that key question again: Where is the patient?

Of course, the patient is still here, but we need the freedom to sit down and listen to them. We used to teach medical students that "the patient will tell you what is wrong with them if you will just listen."

It's still true.

The sad part is that patients still want and need to be heard. I cannot count the number of times patients have told me they went to a doctor, and the doctor never touched them, listened to them, or looked at them. The electronic health records that get between the patient and the doctor have not helped this.

We need to remember the reason we got into this profession. It was to take care of people. We did not go into medicine to have an encounter with a client but to have a visit with a patient. We should be referring to Mrs. Smith, the retired schoolteacher in room three with a diabetic foot ulcer, rather than the anonymous wound breakdown in room three.

We need to get back to the heart of medicine. We need to ask again, "Where is the patient?"

Leonard Reeves, M.D., is a member of the AAFP Board of Directors.

Posted at 10:35AM May 18, 2018 by Leonard Reeves, M.D.

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