Verghese Lecture at ACC: Don't Just Second That Emotion

Editor's Note: At the opening session of the 2015 American College of Cardiology (ACC) Scientific Sessions in March, the Simon Dack lecture by Dr Abraham Verghese was titled "I Carry Your Heart" after an ee cummings poem. In addressing cardiologists, the best-selling author and physician noted that the words of the poem define what "heart" means outside of a meeting like this.

Where Have Our Relationships Gone?

This is Seth Bilazarian on theheart.org on Medscape at the ACC meeting in San Diego.

The keynote lecture at the ACC was by Dr Abraham Verghese, an infectious disease specialist, who is the vice chairman of medicine at Stanford Medical School, where Dr Robert Harrington, of Medscape, is the chairman. Dr Verghese spoke about the relationship of patients to physicians and how much has been lost in the medical treatment of patients.

Dr Verghese highlighted the sacred nature of our relationship with patients. He made several quotes that have become part of the discussion in and around the ACC. He says that patients' feelings for their physician are like the feeling of love, that they crave the relationship more than their numbers, and that our relationship with our patients starts with trust. It is the default position. Those weren't his words, but that is what I took from them.

He said that patients will tell us things that they wouldn't tell some other person who is presumed to be trusted, such as a rabbi or a priest. They won't tell other people things that they tell us, and they also expect us—they allow us and expect us—to touch them, which is something that is very unusual in our society.

By their very nature, our uniforms, our white coats, and the disposition of the patient and their disposition towards us are incredible things that we, in large part, have lost for a variety of reasons.

Dr Verghese highlighted the fact that currently medical students spend about 40% of their time on the computer when they are on the clinical wards. For an emergency department physician to admit a patient, it takes 140 clicks of the computer, and the electronic health record is a problem. He implied that it has a significant negative impact on our relationship with patients. It has been an impediment to that.

The Burdens of Bureaucracy

As I left this talk, my reaction was that everything he said was true, and it certainly made me quite sad that this has all happened. I feel that fixing this is a significant challenge because in no way did Dr Verghese suggest that we should not continue to commit to technical expertise, for those of us who do things that require technical expertise. Reading echocardiograms, performing cardiac catheterizations, and conducting stress tests require technical expertise.

We need to continually approve our fund of knowledge. I am sure that Dr Verghese wouldn't disagree. In our practice, the meaningful use stage 2 requirements require additional checking to prove that I am doing certain things, such as documenting that I talked to patients about their diet or smoking or updating the family history. The burdens of bureaucracy take away from the time that I spend with patients.

I think about the time that I have with patients as being very finite, and anything that is added to that requires me to lose valuable time that I could use to build a relationship.

Just this week, our practice administrator decided that it will no longer be permitted for the medical assistants to review the patient's medications and do an initial evaluation and update of the medication list when patients are brought into the exam room. I complained that that represents 2 or 3 minutes that I will now have to spend doing that. I have always done a second check, but now I have to type in medications that have been added by other physicians and update the medical record, which represents 2-3 minutes that will be lost from my 15-minute visit. It didn't resonate with our administrator that this is time lost from the opportunity to build the sacred relationship that Dr Verghese talks about.

A Range of Emotional Responses

I have been talking a lot with other physicians, as many people who come to the heart meetings see friends from prior life, from residency or fellowship, and I found that this talk by Dr Verghese has really been a springboard to a conversation about the status of medicine. That is very valuable, but there has been an absence of enthusiasm and hope and eagerness for the future for many physicians.

Many physicians who I spoke to are mid- to late-career, so perhaps that is a bias. The reactions that I heard were sadness, but some have expressed apathy: "It is what it is; there is not much we can do about it." Others have reluctantly capitulated, "I have to do meaningful use. I have to do relative value units." There is a certain resignation, but they will try to do the best they can.

Others expressed a certain level of denial. They say, "I am an electrophysiologist; this is what I do, and I do it very well—all that other stuff is not electrophysiology." They have narrowed the definition of what is expected of them as a specialist physician.

Others were overwhelmed, another term for burnout. Being excellent in the current environment may just take too much. Still others were biding their time. These are the older doctors, those who are within 5 or fewer years of finishing their careers, and they are just going to bide their time.

I also heard a lot of suspicion and cynicism, especially with the business leaders of our large healthcare organizations. Most of the physicians I spent time with are employees of the preeminent or premier medical center in their cities, and there was a lot of suspicion that the chief financial officers don't have a real understanding of what occurs between patients and physicians.

I did see some who are hoping to optimize circumstances, trying to resist so that they can be the beginners of change by making a real impact in the care of patients.

Don't Just Feel Something, Do Something

Dr Verghese has provided a valuable resource. Several people have written about or done interviews with Dr Verghese on Medscape, such as Dr Eric Topol's one-on-one interview. My conclusion from his talk here at ACC is that there was a range of emotional responses but limited actual responses. People are experiencing a range of emotions, but I have not heard much in the way of what people are going to do differently.

We should continue to be attentive to keeping the patient in the center of care and be committed to that in any way that we can, such as with shared decision-making. We should make sure that the patient's entire being—including home, family life, and other sources of stress—are addressed. When possible, we should be knowledgeable about initiatives that are being done elsewhere successfully that might be adopted in our own locales and would be very valuable. Hopefully Dr Verghese, as a leader at a major American medical center, will provide some insights on that in the future.

So until next time, with some sadness but with some retained hope, this is Seth Bilazarian from San Diego. Thanks.

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