Saturday, June 18, 2011

Too Much Data, Not Enough Conversation

Health is not a commodity. Risk factors are not disease. Aging is not an illness. To fix a problem is easy, to sit with another suffering is hard. Doing all we can is not the same as doing what we should. Quality is more than metrics. Patients cannot see outside their pain, we cannot see in, relationship is the only bridge between. Time is precious; we spend it on what we value. The most common condition we treat is unhappiness. And the greatest obstacle to treating a patient's unhappiness is our own. Nothing is more patient-centered than the process of change. Doctors expect too much from data and not enough from conversation. Community is a locus of healing, not the hospital or the clinic. The foundation of medicine is friendship, conversation and hope.
Dr. David Loxtercamp author of A Measure of My Days: The Journal of a Country Doctor

I read these words just after I had written my Philosophy of Teaching Statement which reflected heavily the need for evidenced based nursing practice. I had failed to address the topic of quality and conversation- afraid of it not being academically rigorous perhaps. Experience is a teacher, and I ignored my own insights in trying to reflect a more scientific approach. There is as much of need for listening and being present in nursing and health care as there is for numbers, algorithms, and data points. Slices and tidbits are not the same thing as the whole. Health care insurers don't pay for wholeness but for bits and pieces and so providers of health care respond by asking only for the relevant data points.

Recently I had an ear infection which involved an emergency room and a medical office visit that went something like this: "How tall are you? How much do you weigh? When was the first day of menstrual cycle? Do you smoke? Do you drink? Do you feel safe at home?" Eventually it was, "What brings you here today?" The particular issues were reviewed by the provider, but from a patient's perspective I found the questions disjointed, nonsensical, and more to the interests of paperwork than me. Every time I have an appointment more time is spent on these questions than my actual visit. A checklist in the waiting room would be more tolerable- any changes? Hell, I can weigh myself- it is better than guessing. I too have asked those type of questions as a nurse admitting a patient into the hospital. On more than a few occasions, working with older people, I would get a "grump" who would outright refuse to answer. I understood, but I was obligated by my employer to do it. Health care has been hijacked by the corporate administrators who have forgotten what it is like to be a provider or the recipient of health care services or perhaps have never known.

My hospital work experience was to some degree an evolution in processes- solving problems through paperwork. Sometimes the paperwork framed the care received such as care maps or care plans for certain surgeries such as open heart surgery or medical problems like congestive heart failure to help keep everyone on track; I liked these generally. Three ring binders that detailed every step of a procedure which might include some of the rationale or evidence behind the practice could also be useful for something not done often or for teaching someone new to the unit. Then there were forms and notes and assessments to be completed. Carrying out all of the details felt sort of like the vision of a waiter with several trays of glasses piled high and in motion- a balancing act- with little time allotted for listening let alone completing the tasks appropriately. And yet my years on the nightshift, often as a charge nurse, revealed a consistent need for listening. No one wanted to do it because we had more than enough work, but inevitably someone would be cantankerous enough to complain about this or that- it was usually that no one listened, or perhaps someone would be slowly falling apart- they needed more attention than they were getting for cleaning, feeding, walking, turning, or even help to understand what was happening to them. Paperwork doesn't insure we are meeting someone's needs or helping them get better even if the paperwork looks perfect.

If the idea was to use paperwork to guide care, it has become the paperwork that delivers the patient's experience as seen by rote questions I answered two times in the past five days that had nothing to do with my medical problem. My point here is that instead of using the time to go over the paperwork details i.e. questions, it could have been given over to me to fully state my problem- instead of it being choppy and interrupted. I don't think I completed a sentence before someone was trying to cut me off at the pass or maneuver me to some other line of questioning- so the papaerwork could be completed I am sure. My ear was looked at and antibiotics were prescribed, but the manner of listening fully was profoundly absent. This speaks to our model of health care delivery more than any one provider. Listening is a missing and necessary component that I cannot put my finger on how to measure, but that I think we all value particularly when we are on the receiving end of healthcare as the patient. Now if only we could actually admit corporations for a taste of the medicine they deliver to us.