Putting Extra 'Care' Into Health Care
Patients Cherish Physicians Who Listen Closely and Treat Them With a Personal Touch
Tuesday, May 1, 2007; Page HE01
Al Gazzini loved to eat, but surgery to remove his esophageal cancer left him so scarred that there was no easy way to reconnect what remained of his gullet to the rest of his digestive system. All his surgeon, Harry Soroff, could offer him was intravenous nutrition and the chance to chew and spit out his coveted pastrami sandwiches. On days when Gazzini's wife couldn't visit him at the Northport VA Hospital on Long Island, Soroff brought the sandwiches himself.
But Gazzini soon tired of this routine and urged his doctor to try to reattach his plumbing. Soroff finally agreed to a risky 10-hour operation, in a last effort to restore some quality of life for his patient.
At first, the operation appeared successful. When I, as Soroff's young nutritional research associate, broke the news to Gazzini that he could finally eat a regular meal, he couldn't stop smiling. His first request: a juicy steak. I brought him one, wrapped in tin foil, and he savored every morsel, nodding happily with each swallow.
Soon after, however, his wounds became infected, and Gazzini died. I went on to practice internal medicine, where I have tried to apply the lessons I learned that day when Gazzini ate his last steak: Most patients will find a way to tell their doctor their major concern -- if the doctor is listening. And that exchange can transform ordinary health care into inspired care.
In an age of impersonal medicine, marked by bottom-line thinking and rushed doctor-patient interactions, some doctors still buck the trend -- the way Soroff did -- and go to extraordinary lengths to give their patients personal care. Some let patients call them at home, day or night; some keep their offices open late; some find other ways to show that a patient's outcome matters deeply to them. (At New York University's School of Medicine, professor of medicine Marcel Tuchman, 85, has even been known to call a cab and accompany very sick patients to the hospital himself.)
Patients who encounter that kind of care don't just find the difference striking, they often credit it with improving their health.
Internist Albert Herrera is one such doctor. The former chairman of internal medicine at Inova Mount Vernon Hospital, he practices in Alexandria, where my former patient Andrea Untrojb, 38, sees him for regular checkups.
Recently, after starting a demanding new job as a public school registrar, Untrojb developed severe pain in her stomach. Herrera's diagnosis: a bacteria that thrives in stress-induced stomach acid and can cause ulcers. But he did more than treat her with antibiotics.
"Dr. Herrera talked to me for over an hour and asked about my job," Untrojb told me by e-mail. "He not only wanted to know about my physical pain, but wanted to find out what else could be causing my emotional distress. I told him that my job put such a strain on me that I was coming home crying every day, yelling at my kids and arguing constantly with my husband. Dr. Herrera reassured me that many suffered with this problem. He gave examples from his own life and told me what I could do to relieve the stress," including routines, meditation and exercise.
George Washington University medical school faculty member Jeffrey Sherman, 50, also tries to match his effort to the patient's need.
Sherman, a former National Institutes of Health immunologist who left research for clinical practice 12 years ago because he missed patient contact, gives out his cellphone and home phone numbers freely to patients and encourages them to call any time they have medical questions.
"This kind of thorough, thoughtful care is almost impossible to find," said Howard Yoon, a 36-year-old literary agent who saw Sherman recently after an outbreak of shingles. "He didn't seem rushed and sat with me to talk about my symptoms. He even took out a book and showed me which nerve endings in my head were affected by the shingles. He also talked me through the medication I was taking.
"When I mentioned to him that my wife and I might be planning our second child, he actually called me back into his office and looked up whether there were any risks associated with the drugs a future father was taking and the chance of birth defects. He found none.
"I think the worst part of being sick is fear of the unknown, which only gets exacerbated if your doctor is not communicating to you properly."
Over the next week and a half, Sherman called Yoon three times to see how he was doing and to make sure the shingles rash and pain were abating.
Why Not the Norm?
Why don't more doctors practice this way?
It's not just a matter of the demands of managed care, though the system's rigid (some say stingy) reimbursement formulas and focus on the bottom line does make it more difficult to deliver devoted care. I still accept managed care insurance, as does Herrera. Cramming more patients into my crowded schedule would sure help me pay for my kids' private school tuition and for a badly needed renovation of my house. But I can't bring myself to do it.
I can limit idle conversation with my patients, but I'm concerned that too much attention to the clock will cut down on rapport and lead to missed diagnoses or poor treatments. Dropping managed care entirely would mean giving up patients I care about.
Sherman has opted out of all managed-care insurance plans and asks for payment upfront, though he makes allowances for patients who cannot pay the full rate. Because his patients have to cover the bill, he says, they "have more expectations," which he is determined to fulfill.
While doctors often blame their lapses in attention and rushed demeanor on time pressures exerted by managed care, others say they can only preserve their identity as healers by remaining engaged and caring, regardless of the reimbursement. Pauline Chen, transplant surgeon and author of "Final Exam: A Surgeon's Reflections on Mortality" (Knopf, 2007), writes: "That honor of worrying -- of caring, of easing suffering, of being present -- may be our most important task, not only as friends but as physicians, too."
It's too bad all doctors aren't as deeply invested. Part of the fault, Chen argues, may be in our training:
"Medical students must learn to endure and even embrace what might be considered by others to be difficult or even ghastly. . . . Ultimately they will settle at a comfortable equilibrium point, and this act of creating a new moral paradigm -- detached concern, secure uncertainty, and humanistic technology -- marks an important step in the transformation of the lay medical student into full-fledged professional physician."
Call Me
Andrew Goldstein, 40, a gynecologist on the Johns Hopkins University faculty who practices in Washington, sees many cancer patients who develop vulval discomfort as a side effect of chemotherapy.
Like Sherman, he expects payment upfront: He charges $1,000 for an initial visit -- lasting 1 1/2 hours, an almost unheard-of amount of time these days -- and $250 for follow-ups. The length of the initial visit, he says, is necessary to allow patients to "work through their anger over other physicians and come to real solutions."
Also like Sherman, he gives out his cellphone and home phone numbers. Patients, he says, are reassured by his availability and call only when absolutely necessary.
His patient Linda Donald, a 59-year-old business consultant, notes that no nurse runs interference for Goldstein; he handles everything himself. "His empathy allows him to destigmatize a problem that is embarrassing to his patients. It's as if he's talking about your eardrum," she said.
As for the personal approach, Donald is sold. "If a physician is able to completely focus on you as a patient, the likelihood of an accurate diagnosis and appropriate treatment individualized to you is much greater. Not just an 'it seems like this, and therefore let's try that and see what happens -- come back next week.' " ?
Marc Siegel is an internist and associate professor of medicine at the New York University School of Medicine. Comments:health@washpost.com.
