Perspective
Empathy in 10 Minutes: A Medical Oxymoron
All physicians, but especially residents, need more time with patients to assure good care.
By Robert Knopp, M.D.
Imagine you are a patient waiting to see your physician. She arrives, greets you, sits down, and asks about your family and recent vacation. Next, she inquires about your ongoing medical problems, listening intently, maintaining eye contact, and eliciting pertinent information with skillful questioning. She gives you the impression that she is empathetic. Then she suddenly looks at her watch, stands up, and says: “I’m sorry, but the 10 minutes allotted for your appointment are up. I’m afraid I don’t have time to review your current medications, examine you, recommend appropriate treatment and preventive measures, or answer any questions you may have. You’ll have to schedule two more visits.”
At that point, you would likely express strong sentiments, and they would not be empathetic. Although this scenario is contrived, it exemplifies a real-world dilemma and raises a question for physicians: Can we provide quality care (defined by the Institute of Medicine1 as safe, timely, efficient, effective, equitable, and patient-centered) in 10 minutes? For most physicians, and especially for residents, the answer is no.
In the recent New England Journal of Medicine article “The Value of DNKs,”2 author Susan Mackie, M.D., an internal medicine resident at Beth Israel Deaconess Medical Center in Boston, describes her struggle to provide patient-centered care during 10-minute clinic appointments. She explains how she survives the grueling pace of her clinic only because of “DNKs,” an acronym for the patients who “did not keep” their appointments. These no-shows allow her and her fellow residents to spend more time with their other patients.
Relying on DNKs to solve the time crunch, however, begs the question: What happens on days when there are no DNKs? How can a resident or any physician, for that matter, provide patient-centered care in 10 or even 15 minutes, especially to patients with complex medical problems who are taking a long list of medications? Of course, there are patients for whom brief appointments may be appropriate—for example, those with minor trauma, sore throat, and earache. They often can be evaluated and appropriately treated in a short amount of time. But even for those patients, such brief appointments may not be sufficient. For example, a clinician may need to explain to a parent why she would not immediately recommend antibiotics for a child with an ear infection and why it’s important to see if symptoms resolve within 48 hours before prescribing them.
If experienced physicians find they cannot provide what they consider to be quality care for most patients in 10 minutes, why would we expect residents with less than two years of training to be able to do it? Until 2009, the Residency Review Committee for Internal Medicine, the committee that certifies internal medicine training programs, limited the number of patients a second-year resident could evaluate to six during a half-day clinic. The committee has since removed those limits and now requires that residency programs promote patient safety, adjust schedules to mitigate excess service demands or fatigue, and not rely excessively on residents for service.3 It is unclear whether the new requirements’ lack of specificity led to residents in Mackie’s program having only 10 or 15 minutes with a patient. (An informal survey of internal medicine residency directors in Minnesota indicates that residents in their programs do not have such short appointments.)
In her article, Mackie describes what she’s learned from her preceptor about how to make the most out of a short appointment: “My preceptor, a seasoned primary care physician, has been teaching me how to ‘make a 10-minute visit feel like a 60-minute visit.’ I’ve learned to incorporate some of her tricks—constructive listening to demonstrate empathy, adept questioning to elicit pertinent information, and good doses of eye contact thrown in at every step.” But after having the luxury of an extra 20 minutes with a patient, thanks to the day’s DNKs, Mackie questions whether these techniques can really make up for the lack of time. She explains how the longer visit allowed her to discuss whether the woman was taking her medication as prescribed and to talk about deep-breathing exercises as a way to control anxiety-associated pain—conversations that would not have happened otherwise. “My impression,” she wrote, “is that there is no substitute for time. Either I am not skilled enough to make 10 minutes be 60 minutes, or there is something real about clock time. I suspect it’s the latter … Yet I firmly believe that adequate time—not simply perceived time, but real time—is an indispensable component of our encounters with patients if we are to be good doctors.”
During the past decade, physician leaders have focused on providing more supervision for residents and reducing their duty hours so they can get more rest as strategies for ensuring patient safety. Those same leaders must continue that commitment to foster professionalism and patient-centered care by eliminating excessive service demands that require residents to work at a pace that can compromise safety and cultivate cynicism and burnout.
Although I have strong misgivings about any residency program that expects residents to see patients in 10 or 15 minutes, it appears that Mackie has learned an important lesson—she knows how she does not want to practice medicine. MM
Robert Knopp is a HealthPartners physician, professor of emergency medicine at the University of Minnesota Medical School, and member of the editorial board of Annals of Emergency Medicine.
References
1. Institute of Medicine: Crossing the Quality Chasm. National Academies Press; 2001.
2. Mackie S. The value of DNKs. New Engl J Med. 2010;362(17):1561.
3. ACGME Program Requirements for Graduate Medical Education in Internal Medicine; July 2009. Available at: www.acgme.org/acWebsite/downloads/RRC_progReq/140_internal_medicine_07012009.pdf. Accessed December 13, 2010.