I have the pleasure and honor of serving as President of the College for the next year. In that role, I will have the opportunity to travel to ACP chapters around the world and represent the College in many different settings. I also have the opportunity, through this monthly column, to express reflections on the College's work and how it relates to a career in internal medicine and the ever-changing world of health care delivery.
As we physicians entered the culture of medicine and learned how to be internists, the experiences that shaped us led us to develop certain behaviors to get through our day. Many of these behaviors are second nature or rote habits by now.
I was recently struck by a relative describing a visit with a family member to see a medical subspecialist for a consult. There was a good bit of complicated lab work to consider, and while speaking to the patient and family members in the room, the physician said, “I need a few minutes to think about this.” And they sat there while he perused various pieces of information in the electronic medical record (EMR), stopping to think occasionally, with no conversation, for a full five minutes! The relative reported to me how thrilled they were that he was really taking the opportunity to focus in an uninterrupted way.
I realized that the doctor was very overtly exhibiting “The Pause.”
We all do it at times. Some do it much more thoughtfully than others. It most frequently occurs at the moment of transition before we enter an exam room in our office/clinic or a patient's room in the hospital. We simultaneously do several tasks: We transition from the patient we just saw, needing to clear our mind and be ready for the next person with complete focus. We reflect on what has been going on with that next person (clinical changes, test results to review, other physicians seen). We compose how we might explain all that, how we plan to react to delivering news, good or bad, and we start to consolidate all this into next-step plans.
“The Pause” originated in part with explicit techniques around interviewing, history taking, and data gathering that we learned as medical students. And some of that learning and role modeling likely became fine-tuned during residency training.
We learned this behavior as students and residents in the hospital on morning rounds, seeing our patients with the team. The team would stop in the hall outside the patient's room, and the responsible clinician, usually the intern, would explain current status and plans for the day and entertain questions from the rest of the team. Then the resident or attending physician would frequently use the opportunity to make teaching points.
At those times, we were experiencing an appropriate pause to gather our thoughts before walking into the room and interacting with our patient. We didn't call it that, but it is what we were doing. It is a behavior that became part of our physician culture.
Imagine merely walking into the room without having that pause and opportunity for review and planning. We can see multiple reasons why that would not work well. Yet, in the ambulatory setting, we do that far too often. We find ourselves looking in the computer for recent notes and results as we are simultaneously greeting the patient. We find ourselves fumbling through EMR screens looking for the correct location of a given report, not knowing whether the result will be reassuring good news or something bad.
Do we realize the pressure we are putting on ourselves when facing such uncertainty in the presence of an anxious patient watching our facial expression for any hint of what is to come? Those situations are not fair to patients and not fair to ourselves. So why do we allow it to happen?
The thinking we do must be given adequate opportunity. We might enter the room and feel time pressure to evaluate the patient and make a plan in short order. But our patients do not always need or want that. My family members truly appreciated the thinking time they observed. The reality is that much of our busy day is spent reacting, not thinking, and that makes us stressed and harried. Clearly, we cannot control all that. But when there are opportunities to control the situation, we need to do so.
Pauses can only occur when we are not overly distracted by administrative burdens. We can only make that transition from one patient to the next when we can clear our mind. The current buzzword for being in the moment and focusing on the patient or the situation in front of us with adequate attention is being “mindful.” But instead, we are too often “mind-full” of the list of pending patient messages (calls and emails), lab results, refill requests, and other concerns that are circling around inside our heads.
How to switch areas of focus quickly and efficiently with constant reprioritization is one of the great challenges we face getting through every day. When I do it well, it is extremely gratifying and even invigorating. Problem solving and helping patients effectively and efficiently is what I truly love about being a physician. But when the flow of information or number of demands gets overwhelming and I find myself frustrated in efforts to make progress, it can be an exhausting and demoralizing day.
I am proud that ACP has been a leader in emphasizing this problem and the need for regulatory reforms in this area, as outlined in the position paper “Putting Patients First by Reducing Administrative Tasks in Health Care,” published in Annals of Internal Medicine in May 2017. College leadership was delighted that several months later, in October 2017, CMS announced a “Patients Over Paperwork” initiative, a welcome focus by Medicare on these issues.
Work in this area is ongoing but showing progress at an advocacy level, with ACP having input. So despite the challenges you still encounter every day, please give yourself the moment to pause and reflect on what you are doing and on how gratifying our profession can be. It is not always easy, but I am sure it will make you feel better, whatever your state of mind.