Thoughts on time constraints and bedside skills.

TIME CONSTRAINTS AND BEDSIDE SKILLS A letter to the editor of this journal authored by one of us (GWM) this year, “The Importance of Time and Bedside Skills” [1], stimulated a re-examination of an article co-authored by two of us (LJB, AIR) published in this journal 10 years ago, “The Three-Legged Stool: A Model for the Practicing Clinical Gastroenterologist” [2]. We have been, and remain, concerned that clinical practice productivity, often measured today in terms of the numbers of income-generating endoscopic procedures performed per unit time would soon dominate the day-to-day practice activities of the community-based clinical gastroenterologist. We believe this approach is eroding overall clinical competence and bedside skills (e.g., patient bonding, history taking and physical examination, data-gathering, and problemsolving), all of which seem to have been relegated to a less useful and cost-ineffective status. In this opinion piece, we address these concerns further [3]. THE WELL-BALANCED THREE-LEGGED STOOL: A RE-EXAMINATION When we were program directors, we emphasized the value of the information obtained from a skillfully performed, history and physical examination as the basis for efficient, rapid and riskaverse problem-solving as well as the rational selection of costeffective diagnostic tests. We attempted to place the performance of costly, invasive, sometimes risky, technically challenging and time-consuming endoscopic procedures into the “proper” perspective. To that end, we proposed a hypothetical model for the practicing clinical gastroenterologist who would “sit” on a wellbalanced, metaphorical three-legged stool supported by legs of equal length, and strength (internist, clinical gastroenterologist, proceduralist) and from which position s/he would be able to demonstrate equally high levels of competence in data-gathering, problem-solving, and technical skills [2]. Over the past decade, we have all borne witness to the significant advances made in endoscopic technology and the increasing number of diagnostic and therapeutic endoscopic procedures available to gastroenterologists. We now realize that it has become imperative to redefine “proper perspective” and to revisit the concept of the metaphorical three-legged, ideally balanced stool model. The urgency to do so is driven further by the changes in the way GI healthcare is being delivered and compensated and how the clinician's time at work is apportioned to adjust to these changes. Do today's practicing clinical gastroenterologists have the time, or, for that matter, the interest to utilize the non-procedural skills they acquired in order to become American Board of Internal Medicine (ABIM) board certified in internal medicine and gastroenterology? The metaphorical stool now wobbles with two relatively short internist and clinical gastroenterologist legs and one much longer proceduralist leg. Are these changes challenging program directors to re-examine their training programs’ objectives, educational curricula, and the time management of their trainees, to better prepare for the realities of communitybased clinical practice that lie ahead? The fact that the answer to these questions is unknown does not denigrate their importance. THE UNBALANCED THREE-LEGGED STOOL: WHO HAS TIME TO SIT? Changing times have altered the way clinical gastroenterology is practiced, and there is very little that dinosaurs like us can or should do to turn back the clock; we just want the clock to keep perfect time. The ideal clinical practice model that we proposed 10 years ago has become dated. Admittedly, today's clinical gastroenterologists have neither the time nor interest to sit on a stool of any number of legs, because the balance they seek to achieve is in running against a ticking clock, only stopping to check all the required boxes on their electronic medical record (EMR). Nevertheless, we feel it is important that the well-trained and ABIM-boarded internist/practicing clinical gastroenterologist consciously avoid designating their non-procedural clinical skill sets as cost-ineffective and of limited usefulness. To the contrary, we urge that such patient care-related skills be used as frequently as necessary to assure that high quality healthcare is being delivered, and that patient satisfaction is achieved. A CLARION CALL TO TRAINING PROGRAM DIRECTORS More and more time is being devoted by the practicing clinical gastroenterologist, whether institution-based or communitybased, to the performance of income-generating endoscopic procedures; the evidence for this is irrefutable. Advances in endoscopic technology and technique have done much to enhance the quality of care we provide, but it is our impression that patient care-related “complications” (e.g., lack of bonding, errors in judgment, misdiagnoses, biased conclusions, patient dissatisfaction) are lower, and that overall patient care delivery is higher when internist and clinical gastroenterology skills are included along with procedural skills in the patient care delivery process. To assure that these important “bedside” skills remain an integral part of any clinical encounter, the best we can hope for at this time is that GI trainees receive sufficient exposure to clinical faculty members who still know the importance of physician/patient bonding by obtaining a detailed medical history and performing a focused physical examination; obtaining or reviewing already performed radiologic and laboratory studies; and utilizing the gathered data as the basis for undertaking the challenge of problem-solving the presenting complaint(s) and selecting the appropriate endoscopic procedure(s), if indicated. OUR MAJOR CONCERN Our major concern is that the need to generate income and increase productivity as measured by number of patients seen or number of endoscopic procedures performed risks the erosion of basic bedside diagnostic skills with one or several of the following results: The decision to perform a procedure when one is not indicated; Performing two procedures when one would have sufficed; Selecting the wrong procedure because an inadequate history was obtained and/or a superficial physical exam; or no physical exam was performed; Studies and/or procedures performed elsewhere were not reviewed thoroughly and did not need to be repeated; and An increase in patient care-related “complications”. TIME CONSTRAINTS DEMAND CREATIVE SOLUTIONS The dearth of face-to-face time spent between the patient and physician in the practice setting, whether institution or community-based, is a reality which needs remediation. There are no easy answers to this dilemma and no way of squeezing 20–30 min of time or more into a 15-min office visit without compromising quality. Physicians today spend less than 10 min in face-to-face encounters with patients and the vast amount of their time staring at a computer screen, and checking boxes on standardized EMRs so that maximum reimbursement for services provided will be paid. Physician extenders can ease the time constraint pressures on the clinical gastroenterologist-proceduralist [3]. We believe that the patient care-related responsibilities of the practicing clinical gastroenterologist can best be achieved when a bond of trust is established by making eye contact and listening without interruption; by conveying to the patient sufficient information about them to convince them that you understand their problem; and, most importantly, by the laying on of hands [4]. These internal medicine acquired skills are fundamental to establishing a trusting physician-patient relationship. CT imaging is superior to physical examination at least for detecting abnormalities within the abdomen and pelvis, although not for superficial causes of abdominal pain such as neuropathy. However, the effect that touching has on the patient and the patient-physician bond should not be underestimated; patients like to be touched and touching has a healing effect [4, 5]. Accomplished efficiently without outside interruption, these responsibilities can be fulfilled in 15 min; practice makes perfect. INTERNIST, GASTROENTEROLOGIST, OR PROCEDURALIST? WHY NOT ALL THREE? Envision a future in which advances in non-invasive technology might supplant the need to perform many currently popular, high income-generating, time-consuming, invasive endoscopic procedures; or a time when independently functioning nonphysicians are taught endoscopic procedural skills and acquire technical proficiency equally to that of today's GI proceduralist. Our fear, should time give way to realization, is that in the interim, gastroenterologists risk losing, through disuse, their “bedside” diagnostic skills as reliance on income-generating endoscopic procedures has become the dominant activity in day-to-day patient encounters. We fear that if our young colleagues lose these basic skills that in the future they may lose their place in healthcare. It is as important to enhance pre-sedation bonding with the patient, complete data-gathering, and problem-solving and listening skills as it is to artfully perform an appropriate endoscopic procedure [6].