I was rushing because it was 7 past the hour and that meant the standard allotment of “Harvard time” had been used up. And sure enough, as I walked into the first floor Boylston hall classroom, I was met with a room just shy of overcrowded and plenty of pizza boxes that had been discarded in one corner, their contents distributed on plates throughout the room. The evening dinner discussion with Professor Arthur Kleinman, a well known physician-anthropologist and Harvard Professor, was still missing its guest of honor. Good, I thought. I’m not that late. Soon enough though, just as I had finished saying Hi to a few friends and grabbed one of the few remaining seats, Professor Kleinman ambled in with his characteristic corduroy jacket, sauntering gait, and hat tilted slightly to the side atop his crop of graying hair. He had as much the air of a university professor as he did the quintessential grandfather. Taking his seat at the front of the room, he surveyed the crowd and the dull roar of chatter quickly died down. I could sense the audience leaning in ever so slightly, a few stragglers still chewing quietly on their pizza slices–all were eager to hear what the Professor had to say about tonight’s discussion topic: Ethics in Caregiving.
“You have 19 seconds to tell your story.”
It was clear that he wanted us to let that figure sink in. The discussion had gotten underway and the Professor was talking about the patient-physician dynamic within the hospital setting today. 19 seconds was the average amount of time that a patient had to explain his or her story and symptoms before the doctor would jump in with a diagnosis and prescription, he told us. This was the time allotted despite the fact that studies show that it’s the latter part of a patient’s story that matters most to his diagnosis. And what’s the rush? Well, a patient only has an average of 17 minutes to see his doctor, so by all reasonable logic, the imperative is on both parties to talk quickly.
The Professor threw out a few more figures before he got to the meat of tonight’s talk:
“My contention is that medicine has little to do with caregiving today.”
It was a depressing statement to say the least. Caregiving, after all, is the reason why so many of the eagerly listening pre-meds in the room aspired to enter the medical profession. Caregiving, Professor Kleinman explained, consists of the emotional and moral components of the human response (i.e. acknowledging, affirming, etc.) whereas medicine is often defined purely in terms of the practical aspects of healthcare delivery (i.e. drugs, equipment, physician hours logged, etc.).
So, how do we restore the connection between these two–medicine & caregiving? This was the challenge that Professor Kleinman said he frequently presents to every class of medical students that he speaks to across the country. It’s our very own crisis in caregiving and certainly most medical schools in the country are trying to address it, he explained. “Find for me a medical school that is not undergoing curriculum reform?” he asked skeptically. No one in the audience said a word. “Exactly; everyone is trying to address this.”
That doesn’t mean that we have found success yet, though. Certainly the delivery of health and care depend on the availability of both time and resources. Where either or both are constrained, financial implications come into play that often place hospitals in the position of either turning away patients or seeing more of them in less time–many have chosen the latter. And still, costs have skyrocketed across the country. Especially in light of the current debates surrounding the Affordable Care Act, there is increased discussion about costs and the fact that the American health care system is one of the most expensive in the world despite providing poorer quality of care than systems that are far more economical. This is a problem that many, including surgeon and journalist Atul Gawande, have tried to tackle.
I think that Gawande’s writing has been particularly effective in communicating some of the finer nuances of the debate. Despite the many instances of disjunction between cost and quality of care, Gawande’s writing has presented examples of health centers and systems that seem to have achieved the allusive balance between the two. One such example is the Mayo Clinic. In his 2009 article The Cost Conundrum, Gawande demonstrates that the goals of keeping costs down and increasing doctors’ latitude to spend more time with patients are two ideas that need not be antithetical. He writes:
“I talked to Denis Cortese, the C.E.O. of the Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country. A couple of years ago, I spent several days there as a visiting surgeon. Among the things that stand out from that visit was how much time the doctors spent with patients. There was no churn—no shuttling patients in and out of rooms while the doctor bounces from one to the other. I accompanied a colleague while he saw patients. Most of the patients, like those in my clinic, required about twenty minutes. But one patient had colon cancer and a number of other complex issues, including heart disease. The physician spent an hour with her, sorting things out.”
It would seem that the Mayo clinic, then, has managed to reconnect medicine and caregiving so as to effectively address the crisis that Professor Kleinman was talking to us about while also responding to the financial considerations that dominate our national healthcare debate. How does Mayo’s model make this possible? Gawande asked Cortese to explain. In Gawande’s words:
“It’s not easy,” he [Cortese] said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focussed first on what was best for patients, and then on how to make this financially possible.”
Replicability and scalability are key issues of concern with regard to the Mayo model–but the clinic has successfully expanded to places such as Florida where the costs of healthcare are traditionally among the highest in the country. Recruiting physicians who are willing to work for a salary remains a challenge, however, and goes against the “culture of money” that has long been ingrained in some of the places that are plagued by the worst disparities between cost and patient satisfaction. Still, though, Mayo’s ability to achieve a semblance of balance between costs, medicine, and caregiving is promising and suggests that many healthcare systems around our country have much to learn from their model. As medical schools continue to restructure and reshape their curricula in order to re-infuse medicine with the caregiving that is so essential to it, perhaps they would do well to look at examples like the Mayo Clinic which have managed to address the financial considerations that underlie every debate of this nature.
“19 seconds to tell your story.” That was still the fact that stuck with me most as our dinner discussion wrapped up and people began gathering their things to venture back out into the cold night beyond the classroom. I kept thinking about how many words I thought I could get out in 19 seconds, especially if I were meeting someone for the first time. Not many, I decided. Standing in line at Starbucks afterwards, I knew that it would take more than 19 seconds just to give my coffee order. Walking home, I felt fortunate that coffee could help lift the weight of the caregiving crisis from my mind at least temporarily–but I felt determination and encouragement too, in knowing that facing that crisis and working to combat it is something that I hope to one day devote my life’s work to.