Friday Reflection 4: Days of Leaves, Trees and Forests

RL is a 55-year-old man who comes to clinic for follow-up of his hypertension, diabetes and generalized anxiety disorder.

In the doctor patient relationship, both parties generally have a pretty good sense about how much the relationship benefits the patient. Usually, there is what I’ll call value-realization-concordance (VRC).[i] The doctor feels like she is providing a reasonable standard of care and the patient feels like he is getting adequate medical care. Neither thinks anything extraordinary is going on.

Rarely, there is value-realization-concordance in which both patient and doctor recognize that the care being provided is truly exceptional. In the 21st century, when this happens, it usually shows up in the marketing campaign of a medical center.

As discord is always more interesting than concord, value-realization-discordance (VRD)[ii] is more fun to think about. VRD comes in two flavors: only the doctor knows that something special is happening or only the patient knows. We’ll call these physician-centered-VRD and patient-centered-VRD, respectively.[iii]

The only time I personally experience physician-centered-VRD is when I parsimoniously make an interesting diagnosis. This doesn’t happen often, but it is what we internal medicine doctors live for. I expect surgeons experience physician-centered-VRD when an operation goes off splendidly. The doctor (we hope) does not alert the patient of his or her success and the patient goes on thinking they are getting routine, quality care.

Patient-centered VRD occurs when the care provided by a physician is much more consequential than she realizes. A few times in my career, I have learned that while I thought I was providing hardly notable care, my patient was receiving an outsized benefit. I wrote at length about one such case in a JAMA “Piece of My Mind” essay a few years ago.

(We’ll avoid a discussion of relationships when a physician believes he is providing, or a patient believes he is receiving, exceptional care when he is not. There is probably a medical center award that could, but never will, be given for these cases.)

RL came in for a scheduled visit. It was a Friday afternoon in August, the day before I was heading out of town for vacation. I was managing his hypertension and diabetes, something I do enough to rarely find complicated. I had seen him recently because he and I recognized that frequent visits were the best medicine for his anxiety; anxiety focused mostly on his health. A visit, exam, and some well-placed reassurance every month or so was better, if not less addictive, than any medication.

At RL’s previous visit, his blood pressure and glycosylated hemoglobin (average blood sugar) were normal. He’d been feeling well since that visit; there had been no changes in his medications; his vital signs, taken by the medical assistant, were normal; his weight was unchanged. After 8 minutes I ended the visit and asked him to see me again in six weeks.

“Is that it?” he said, with an edge that I was not accustomed to hearing from him.

We all recognize that we are not quite the same person each day. Our mood, how we slept, how well our morning coffee came out, all affect how we behave. That is no less true for how we, as doctors, do in the office. I’d like to think that the quality of care that I deliver stays constant day to day, but I know that the focus with which I attend to my patients varies enormously.

On my worst days, I see only the leaves. Patients’ issues and, unfortunately, patients themselves, become blood pressures, glycosylated hemoglobins and microalbumin levels. I can feel downright besieged on these days, sometimes thinking, “why is everyone complaining to me?”

On the less harried days, I’m able to look at the issues from a greater distance. On these days, I see the trees. I recognize that the numbers we fuss over are only surrogates. Nobody has ever felt better because their glycosylated hemoglobin was 7% rather than 8%. I’m aware that the goal of our treatments is, ultimately, to improve quality of life. How aggressively should I treat the hypertension in this 80-year-old? Is there really a reason to check a microalbumin level in the patient with well-controlled diabetes mellitus and hypertension who is already receiving an ACE inhibitor?

On the tree days I can observe the patients who trouble me the most in a clinical way. Is there a personality disorder here? Can I use my reaction to this patient diagnostically? Should I approach this interaction differently, using our relationship as a more potent therapeutic tool?

On the days that I consider my best, I see the forest. I see the people I am caring for in all their complexity. In the fifth year of our relationship, a difficult and eccentric gentleman brings his wife to an appointment. The visit not only proves that there really is someone for everyone but also reveals this man's kindness, humor, and charisma—traits that I have overlooked for years. There is the 60-year-old who looks 90 and the 90-year-old who looks 60. We should never forget that, for reasons mostly out of our control, we all age very differently. It is narcissism to believe that longevity is anything more than luck – genetic, societal, fated. These observations are not profound; they are notable only because they go completely overlooked on most days.

On the forest days, I sometimes recognize issues critically important for my relationship with a patient. I see that some people are scarcely affected by near-complete disability, whereas others, even into their latest years, are devastated by any loss in function. The effect of the environment on one’s health also becomes noticeable. How many of this patient's health problems are due to, or exacerbated by, the pollution or poverty in her neighborhood or the stressors or violence in her home? This is when the impact of systemic racism, often debated in the abstract, becomes infuriatingly real.

I imagine that I provide better, more holistic care on those “forest days,” but I wonder whether this is true. I’d love to have evidence of improved patient outcomes or satisfaction on these days. Maybe such data would affect our approach to patient care or encourage us to work toward guaranteeing more of our better days.

How could we ensure more forest days? More time, knowledge and experience would be beneficial. Knowledge and experience make the mundane tasks that occupy us on the “leaf days” automatic, freeing us to consider patients more thoughtfully. Decompressing the physician with more time is the wish of patients and doctors. Longer visits are one answer, but computerized decision-support tools and physician extenders could certainly free up physician time and energy.

Beyond these somewhat concrete interventions, a more behavioral approach might yield positive results. On our worst days, might forcing ourselves to ask the questions that we usually ask only on our best days reset our approach?

“Other than medications, what helps your condition the most?”

“Are there things that negatively affect your health that I don't know about?”

“What do you think is causing your problem?”

“What are you most worried about?”

These are the types of questions that would refocus our attention from the leaves to the forest. Even if we can never show better outcomes, it is hard to imagine that patients would not rather have a doctor who considers them as a person with a unique personality, history and ecology rather than as a list of diseases with associated numerical goals. I’d also expect that a doctor who experiences more forest days would find his or her work to be more rewarding.

A previous version of this essay was published here.

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[i] I realize this is a terrible term. Suggest a better one and I’ll edit this, cite you, and link to the website of your choice!)

[ii] ditto

[iii] I am hoping that Sensible Medicine gives me a bonus for every new term I coin.