FESTIVAL DELLA SCIENZA MEDICA

TIME TO CARE
BOLOGNA, 3-6 MAY 2018

No one can reasonably deny that developments in medical science – and the consequent improvement in treatment and prevention – have extended our lives, with life expectancy at birth in several western countries now exceeding 80 years. Yet many of these additional years are spent worrying about our health, receiving treatment, and at times making excessive demands on medical science, not only to give us more years but also to improve the quality of our extended life span.

The corollary of greater life expectancy is more patient care. As more life years have been added, we have become more treatment conscious, more concerned for our health. A Long Life, the theme of the first edition of our Bologna Medical Science Festival, goes hand in hand with Time to Care.

Time, in the sense of the experience of change, a physically measurable but also subjective entity, is an essential factor, or variable, that must be taken into consideration if we are to understand the logic behind the concept of health, both in terms of the risk of falling ill, as well as the judgments and decisions regarding medical procedures and the effectiveness of diagnoses and treatments. This was clearly evidenced in the previous editions, which looked at longevity, individual life cycles, and the way tradition and innovation co-exist in the sphere of scientific and medical practice.

For thousands of years, healers and doctors studied how time impacts disease: not, of course, in terms of the time allocated to patient care, but rather the course, outcome and duration of disease in the individual or an epidemic in the general population. The reason for their concern for time was simple: very few effective treatments were available. Medical men of the past were forced to rely on the psychological effect of communication between healer and patient in the hope of inducing some kind of ‘placebo effect’, even if not known as such. The first doctors to refute the idea of illness as a divine punishment understood that, as a natural phenomenon, every disease has its own particular mode of progression, life cycle and development pattern. They therefore took for granted that understanding the natural cycle and progression of disease over time would allow them to intervene in a timely and effective manner. This knowledge only permitted better prognosis, however – although it did give physicians an aura of experience, and hence reliability in the eyes of patients and their relatives! Later on, the scientific approach to medicine led to discovery of the genetic and physiological basis of disease development, how the course of disease varies from one patient to another, and the length of treatment needed to cure curable conditions.

Yet by providing doctors with increasingly powerful diagnostic and therapeutic tools, scientific medicine has evidenced a new and different dimension of the time for patient care. For centuries following the breakup of the ancient world and before the scientific breakthrough, physicians would dedicate considerable time and attention to collecting data and impressions regarding their patient’s medical history. Physical examinations were not practised, however. Indeed, during the Middle Ages – with the exception of some western and Arab medical schools – doctors almost never laid their hands on their patients. Differential diagnosis was unknown, there being no classification of diseases or any concept of specific etiology. Practices – aptly known as ‘heroic’ – bloodletting, purging, emetics and surgery – were the order of the day. With the modern era, physicians continued to study their patients in depth, investigating their clinical history. Thanks to the anatomo-clinical approach, they became progressively more accurate in their diagnoses and clinical assessments, systematically conducting physical examinations. They were also adept at differential diagnoses. Despite this, however, effective treatments continued to be few until the 1930s. But with the arrival of the most advanced scientific knowledge and sophisticated technologies, doctors – somewhat paradoxically – started developing an impatient approach, taking little time to establish a patient’s clinical history. They also became cursory in their physical examinations, paying much more attention to laboratory data or diagnostic imaging. In fact, physicians today are now on average better at establishing a differential diagnosis; they have an enormous arsenal of treatment protocols thanks to experimental research and clinical trial standards and a formidable array of drugs and interventional technologies. They have better instruments and greater knowledge … yet they seem to be distancing themselves from their patients, dedicating less time to the person.

It could be said in the defence of the medical profession that “it is a waste of time talking with patients and listening to a lot of useless chatter when a diagnosis and subsequent treatment can be arrived at more swiftly and more accurately with objective means”. That would be how Doctor House would justify his attitude. Interestingly though, the physician/patient relationship as part of patient care has been carefully studied in recent years, revealing many surprising facts.

A study carried out in 1984 on how a physician’s behaviour influences information collection during a patient’s visit to a doctor’s surgery showed that in only 23% of the visits examined were patients allowed to complete the presentation of the problem that had brought them to the doctor in the first place. In 63% of cases, the doctor had interrupted the patient after about 18 seconds. From then on, in 94% of these interruption explanations, it was the doctor who had then conducted the interview, the patient no longer being allowed to put his/her point of view. Again, in 70% of the cases of interrupted explanations, the doctor had taken for granted that the first problem described was the key issue. 15 years later, a new study showed that doctors interrupted patients after 23.1 seconds. In addition, the negative consequences in terms of the diagnosis arrived at was also measured as a result of patients not being allow time to explain and doctors not encouraging further information.

The time factor in patient care presents another interesting aspect in the doctor/patient relationship. In February 1997, an article that was to become historic appeared showing that physicians accused of malpractice had certain characteristics in common, one of them being patient visits of less than 15 minutes. Visit duration, along with irony, was seen to be the predictive variable most frequently linked – especially for surgeons – to the risk of a malpractice claim. The study also evidenced a time threshold that considerably reduced the malpractice complaint risk, especially in the case of internists: an average visit of more than 18.3 minutes. Beyond this threshold no malpractice accusations were found.

 

More than any other variable, patient consultation time most affects doctor/patient communication. And since poor communication has been seen to be associated with medical error and patient dissatisfaction, the time factor also influences the quality of care and its results.  The acclaimed Canadian internist, Wendy Levinson, has championed this thesis for more than a decade, conducting empirical sector studies into physician/patient communication, in which the baseline of good communication is ‘active listening’ by the physician. It is a type of listening that takes time. What, however, is the state of affairs on the ground? Although when interviewed, physicians claim they want to spend more time with a patient, a series of perverse incentives oblige them to become operators whose efficiency and productivity are measured against quantity rather than quality parameters, i.e. the number of patients visited in a given time.

Time has an ‘ethical’ significance. Quality time, in other words, ‘sufficient time’ to deliver quality professional service is of ethical importance since it allows for effective physician/patient interchange. When the therapeutic relationship is solid, patient autonomy, i.e. patient involvement in the decision-making process and his/her trust in the doctor, improve. In terms of the benefits derived – another ethical dimension of the clinical relationship – we have already seen how the quantity and quality of the time dedicated to patients positively impacts both clinical results and patient satisfaction. In addition, ‘sufficient time’ also improves the ethical quality of the doctor’s decisions in terms of schedule organization, which in turn implies time allocation according to the principle of fairness and justice.

Historical and social considerations are currently conveying the message to both patients and physicians that insufficient time is spent with the patient. A closer look should therefore be taken at the ethical implications and how the ‘time’ variable influences the quality of the doctor/patient relationship in order to provide ethically justifiable answers to the current perception that the time factor is unsatisfactorily managed by doctors in their clinical practice. 

The philosopher Leibniz aptly noted that: “The present is saturated with the past and pregnant with the future”.  In no other human activity do these words of wisdom hold truer than in the sphere of patient care, an area combining science and experience

Gilberto Corbellini
Scientific Director, Festival della Scienza Medica