Monday, March 2, 2015

Questions, Caring and Competence

A good friend and a leader in medicine, Dr. Saul Wiener once said to me that “questions are caring.”  In the case of patient care, the asking of questions, often questions that are never asked in polite company, is not only a way of gaining information to make a diagnosis, but a way to indicate a true interest in the person who sits before you seeking help.

It used to be that the only time these types of personal questions would be used was in the sanctity of the exam room when they were combined with the physical exam.  These questions must, to some extent be intrusive to truly get at the heart of a person and of an illness.  They must mirror the physical exam as described by Dr. Abraham Verghese in an article he wrote in 2009 when he stated;

“The physical exam is really about one individual granting permission to another individual to touch his or her unclothed body, to probe the most ticklish and private places.  The exam then is about trust, about a sacred privilege.”

However, in today’s digital world, when the exam may be over the phone, via email, or via video chat of some type, the trust and sacred privilege is often built independently of that “granting permission to touch.”  Questions posed to patients must sometimes take the primary role instead of the integrated role that they did historically as part of the “history and physical” that first year medical students learn.  Personal questions, in many ways, are also about touching the most “ticklish and private parts” in a different but perhaps more difficult way.  In today’s world, the types of professional who must develop the trust and invoke the sacred privilege also goes beyond the physician and nurse of old and must include physician assistants, therapists, and even the new professionals such as the health assistants that I work with every day at Accolade.

We ignore, or minimize the asking of questions and the human “touch” that those questions reflect in our highly technical world at our own peril.  In every human endeavor questions are often more important than answers.  A famous story is told of Isidor I. Rabi, the 1944 Nobel Prize winner in physics who was once asked, “Why did you become a scientist, rather than a doctor or lawyer, like the other kids in your neighborhood?” “My mother made me a scientist.  Every other Jewish mother in Brooklyn would ask her child after school: ‘So? Did you learn anything today?’ Not my mother.  She always asked a different question. ‘Izzy’ she would say, ‘did you ask a good question today?’ That difference made me a scientist.” 

Questions are not limited to those asked to patients in order to make a diagnosis and form a trust bond with patients.  Questions asked to colleagues are equally important in helping those in need.  Medicine has always been collaborative, however informal the collaboration of old was.  The best care for the patient was the product of continuous ongoing discussion between doctors, nurses, therapists and social workers.    

We seem to be at risk of losing the power of iterative questions as medicine becomes more dependent on technology, apps and computers.  I speak of both the questions that health professionals ask patients, and the questions that health professionals ask each other.

This issue of whether technological advancements in medicine may negatively impact that ability to ask personal, interactive questions of patients, and to foster questions between professionals was reflected in a discussion by Dr. Robert Wachter, Associate Chairman of the Department of Medicine at the University of California at San Francisco, and Dr. Atul Gawande, from the Massachusetts General Hospital in the on-line magazine“Quartz.” 

Dr. Gawande starts the discussion by talking about innovation in medicine by stating that “In all of the cases, the most fundamental, most valuable, most critical innovations have nothing to do with technology.  They have to do with asking some very simple, very basic questions that we never ask.  Asking people who are near the end of life what their goals are.”  He starts with the supposition that it is the questions that are important, to drive innovation rather than the technology.  This is interesting as it is in stark contrast to the point of view put forth by Vinod Khosla, the highly successful technology entrepreneur who has stated that 80% of what doctors do should be replaced by machines, and that we are headed towards an “evolution from an entirely human-based healthcare system to an increasingly automated system.” 

Dr. Wachter, later in the conversation makes the observation that residents – the doctors in training – are often struggling to connect both with patients and with their colleagues.  Dr. Wachter states, “But it’s hard – the residents feel they’re caught up in this world where everything they need to know is on the computer screen.  That’s creating angst in their day-to-day lives.  You go up to the floor of the medical service in my hospital and there are no doctors there.  They come, they see the patients, and then they escape to this tribal room where all 15 residents hang out together, each doing his or her computer work.  That means that many of the informal interactions that used to occur between docs and nurses, or docs and patients and their families, have withered away.  Dr. Gawande replies to that with “Everything that they’re measured on and that defines their success happens outside the patient’s room.”  “Getting through the to-do list is the dominant task.”  Abraham Verghese says something similar when he states, “An anthropologist walking through our hospitals in America wouldn't be blamed for concluding (on the basis of where physician spend the most time) that the real patient is in the computer, while the individual in the bed is a mere placeholder for the real patient.” 
We must, as a society and as health professionals, get back to emphasizing the human touch, whether it is in the form of an actual touch, or touching someone by asking questions, by showing interest in who they are and not only in what disease they have. 

The question I ask is whether we can focus on using technology to build systems that foster communication and questions.  Can we take the information collaboration of the past that unfortunately appears to have become technology driven isolation, and facilitate a new platform of collaboration between the direct caregivers, other professionals and patients, built on supporting the sacred trust that should be inherent in healthcare.  We must emphasize that even in our new technology driven medicine, touching someone through questions and questioning our colleagues is not only necessary for caring, but also defines basic competence.