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- Anthony N. DeMaria, MD, Editor-in-Chief, Journal of the American College of Cardiology⁎ ()
- ↵⁎Address correspondence to:
Dr. Anthony N. DeMaria, Editor-in-Chief, Journal of the American College of Cardiology, 3655 Nobel Drive, Suite 630, San Diego, California 92112
It has been said that nearly everyone has details in their lives that they are anxious to keep secret. These are issues, often involving guilt, that we carry inside hoping that they will never become known. In this regard, there is one aspect of my professional life that I have hidden as much as possible, fearing the ridicule it would bring were it to become public. However, the stress that this secret has caused has become too great to bear, and I have reached the point that I need to get this burden off of my shoulders. They say that open admission is the first step to recovery. So, I confess: I am an inefficient provider.
The University of California–San Diego, the institution at which I work, does not enforce strict time periods in which to conduct outpatient visits. However, they do schedule outpatient evaluations in certain time blocks: allowing so many minutes for a new patient, so many for a return visit, and so on. The clear expectation is that you will limit each patient to the time appropriate for their specific class of service. In fact, patients who have been seen in other clinics have told me that, when they presented multiple complaints, they were told that only one could be addressed in the time for that visit, and new appointments would have to be scheduled for the others. In addition, data regarding the number of patients seen per unit of time in each examining room are regularly reviewed to determine whether the facilities are being utilized to capacity. So, the net effect is to clearly convey the message that an efficient provider will see each patient in a certain period of time. I often exceed this limit when I see patients in clinic, spending extra time with them and demonstrating how inefficient a doctor I am.
The problem began early in my career when, as a cardiology fellow and new faculty member, I had my first real continuity clinics. Confronted with patients who were truly mine and would be so for the foreseeable future, I made an effort to get to know them. I would squander time learning about their families, where they lived, what they did as an occupation, and how their illnesses affected their lives. I would devote unrealistic periods to explaining their illnesses to them, describing procedures that would be performed, and stressing the importance of lifestyle changes and prescribed medications. So, even early in my career I was identified among the “slower” doctors at seeing patients. People marveled that I could perform procedures and read echocardiograms so rapidly, but would often get bogged down when interacting with patients.
As my career progressed and I gained experience, it was anticipated that my ability to rapidly see my patients would increase. However, such was not to be the case. While the time I spent with most patients was certainly reduced, it still frequently exceeded the expectations of the schedule. Try as I might to prepare myself to exit an examining room as quickly as I could, I just could not seem to get the knack. Conversations with patients about home life, medical problems in general, or concerns about medical information that they had read or seen on television just seemed to distract me without my realizing it. In addition, I was often sidetracked by noncardiovascular complaints, such as skin eruptions, painful joints, abdominal discomfort, or depression. I just had a hard time saying no when a patient wanted to ask me about a problem outside of my specialty.
Having now been in San Diego for 19 years, my problem seems to have gotten a bit worse. Over the years my friends have often become my patients. More importantly, my patients have become my friends. I usually know their families, their interests, and any issues they are dealing with in daily life. In fact, I often socialize with my patients outside of working hours. So, when they come in for an office visit, it is not uncommon for me to while away minutes talking politics, economics, or athletics, before getting down to the healthcare issues at hand. For those patients whom I have not seen for some time, there is always some catching up to do. And, of course, they frequently inquire about my family or what is going on in my life. Thus, the time saved in delivering medical care provided by the experience of many years of practice is often offset by this personal interaction with the patients. In addition, my patients are now more apt to inquire about noncardiovascular complaints, and I am even more loathe to ignore them. So, I can never seem to fulfill the capacity of the examining rooms that are assigned to me in the clinic. I fear that I am destined to remain an inefficient provider forever.
Now, I recognize that I am somewhat enabled in my penchant to talk to patients by the fact that I am in an academic practice. The multiple missions of education, research, and clinical care along with the varied income sources in academic medicine often serve to soften the enforcement of and necessity for efficiency. It is likely that I could not be afforded this luxury in a busy private practice. So I am thankful for the situation that I am in, and I am sympathetic to the many physicians who harbor the same inclination to personal interaction with their patients and have had to stifle it in the name of efficiency.
Heavy as the burden has been of knowing that I am an inefficient provider, I must admit that it has had its rewards. I absolutely relish my relationship with my patients. I take pleasure in seeing them in the clinic, and I thoroughly enjoy our conversations, brief though they may be. I value the intimacy that being a friend as well as a physician can enable. The satisfaction of rendering effective medical care and the gratitude that it generates is amplified when there is a personal relationship. The personal interaction puts a human face on the medical disease and intensifies the trust that the patients have placed in me and the responsibility I have as their doctor. And, I must admit, my patients have not seemed to care that I am an inefficient provider. Despite my inability to see them quickly and get them off to other activities, they keep returning; in fact, my practice is growing. So, I guess if I have to have a deficit in the practice of medicine, being an inefficient provider is probably the best one I could imagine. Now that I have publically acknowledged this fault, I hope it is one from which I am never cured.
- American College of Cardiology Foundation