ACP: Relationships enhance patient care

A guest column by the American College of Physicians, exclusive to

Up until 2001 I practiced medicine in the hospital where I was born. I still work in the hospital that was built to replace it. In our mobile society that is clearly the exception rather than the rule.

I love what I am able to offer my patients as a general internist in a community where my family has deep roots. I have cared for patients who knew my grandparents, who died long before I was born. That connection works well both ways.

That long family connection is a source of trust that helps to convince my patients to do something that is in the best interest of their health. My life is richer for the perspectives they share with me about my family members.

I once convinced a patient with atypical chest pain to undergo immediate cardiac workup. He explained his willingness to undergo testing by mentioning his respect for my father: “I don’t trust doctors. I don’t like doctors, but I know that Fred’s boy would not steer me wrong.” In less than 24 hours he was undergoing emergency coronary artery bypass surgery.

Many physicians have long term relationships with patients. These can be particularly rich and helpful in primary care. We need to remember and foster those relationships as we make modifications to our health care system. Every time I visit one of the state or regional American College of Physicians (ACP) chapters, I am reminded of those bonds between doctor and patients and am saddened when I see people who have to leave or change their practice in such a way that those ties are weakened or lost.

I both enjoyed and was distressed by my recent trip to Kansas. I again heard stories of lengthy medical careers and ways that people were trying to deal with a broken payment and delivery system. One hospitalist recounted frequent weekend handoffs on their service. It was dizzying. If done in full detail, the handoffs would take a substantial percentage of the available time.

But the dedication and high quality of care provided by ACP members there was clear in the program of the ACP Chapter meeting. As in other chapters, I see how many internists are struggling to find a way to carry on that care in a payment world that favors high-tech care over thoughtful, careful diagnosis and effective communication. I sensed a real feeling of frustration from long-time internists.

I am not asking that we go back to all of the old ways but just try to remember relationships that are rewarding to both doctors and patients while enhancing patient care. We can have a team approach that is rooted in a strong longitudinal relationship.

In my own practice we are transitioning toward a patient-centered medical home. Hospitalists see my patients, but any day I am in town I stop by and try to add value to their care.

Recently, I returned after a trip to find a long-standing patient about to be discharged after successful treatment for a COPD exacerbation. The patient was scheduled to see me in two days for follow-up and I told her that I knew she wanted to quit smoking and I would be very proud if she had not started back by the time of her visit with me. The nurse caring for her that day didn’t realize she was still smoking although I am sure one of her colleagues had dutifully recorded that information on one of the many required forms.

I love what I am able to do for my patients, but once I leave the exam room it seems at times that the world is becoming increasingly hostile. I have hope for the future, but only if we all band together in ways that transcend politics as usual and look to more effective ways to deliver care – and to pay for it.

ACP is emphasizing its High Value, Cost Conscious Care Initiative, which has clinical, public policy, and educational components. We need to encourage everyone in our society to keep an open mind on evidence-based ways to improve care and delivery.

I look forward to the day when I can continue to encourage medical students and residents by saying how rewarding the relationship with patients can be, but also remind them that the system now encourages and pays for the right care for the patient at the right time.

Fred Ralston practices internal medicine in Fayetteville, Tennessee, and is the Immediate Past President of the American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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