Time and Intimacy in Healthcare

How can physicians be truly present when office visits are constrained to a mere 15 to 20 minutes or even shorter? Elapsed time might be out of a doctor’s control to some degree, but perceived time can always be created. I teach physicians to sit down while talking with a patient, rather than standing; in a study of surgeons making quick hospital rounds, patients felt that doctors actually spent more time when they sat down, even though the elapsed time was the same as when they stood. A research colleague, Kathy Zoppi, found that parents were more satisfied when they perceived that pediatricians spent more time with them—the true elapsed time didn’t matter as much. Sometimes time is created through silence. As in music, where silences can have the same exquisite beauty as notes, silence can deepen a relationship between a doctor and a patient. It doesn’t take much—a few seconds at most—to reassure a patient that the doctor is there, listening, attending, not rushed. Using silence effectively is even more relevant now that visits—in the hospital and in office practice—are crammed with more administrative imperatives.

Musicians know about presence and its absence. When you’re caught up in your thoughts and just going through the motions, your professional colleagues will say you’re “just phoning it in.” And you’ll think, “I played a good concert. Wish I had been there.” It’s the same in medicine. When you’re being present (or when you’re phoning it in), patients know and you know. My mentor George Engel would say that patients want to know and understand and to feel known and understood. There’s a difference between merely knowing about a patient and knowing the patient as a person. Knowing is much more personal and intimate. During training, supervisors and colleagues warned me of the dangers of becoming too involved with patients. Patients die, and they are ravaged by unspeakable tragedy, depredation, and abuse. Getting too close to the edge of this vortex feels dangerous. You fear that you’ll lose perspective and degenerate into a mass of emotional jelly. Clearly, though, boundary situations require a greater sense of presence—not less. Only with a radically tenacious shared presence can a clinician maintain the sense of intimacy necessary to truly be there with a suffering patient. In medicine, trainees hear little about how to do this. Staying coldly objective seems safer. It also has its perils. While doctors sometimes have to distance themselves emotionally as a survival strategy, making detachment a habit sterilizes clinical care of its richness and meaning. For me, being present means aiming for the sweet spot in which I am emotionally accessible to myself and others in a way that clarifies my vision of the patient, his clinical situation, and our relationship.

Dirk is a 70-year-old man with paranoid schizophrenia whom I have had in my primary care practice for over twenty years. Dirk has spent nearly all of his adult life in mental hospitals and group homes. He’d usually be laconic during our visits: I’d ask questions and he’d answer in a word or two. Over the past year, Dirk has had several episodes of passing out or nearly passing out. His blood pressure was low, likely a side effect of his psychiatric medications. While none of his injuries were serious, I was worried. That day, Dirk was his usual emotionally flat self; I couldn’t tell what he was thinking. He recounted having fallen in a stairwell with the same monotone he’d use if he were reading a list of telephone numbers.

Then I said, “I’m worried,” and waited. To my surprise, Dirk became more talkative. He said that he was worried, too. We talked about the risks and benefits of lowering his medication doses— which might help with the episodes of passing out, but might risk worsening his psychiatric condition. He then talked about how it felt to be different, the stigma of his mental illness. I was speechless; I had completely underestimated his insight.

This brief exchange opened up a new chapter in our long relationship. In the past, I didn’t feel that we had achieved any kind of connection. It took twenty years for that moment to emerge, and I now see him as more of a whole person. It’s reciprocal—I get the sense that now he sees me as a person, not just “the doctor.” Periodically I wonder if I had never given him a chance, that by doing the habitual doctorly things—asking questions, poking, prodding, giving advice—I had inadvertently silenced him. Now we, together, had the opportunity to make a better decision—to lower his medications. I am better able to advocate for him and to address his housing and medication needs and the social activities that give his otherwise impoverished life meaning. Dirk has slowly become more disclosing, sharing more of himself. I have a better understanding of what he fears, what he needs, what he enjoys—and who he is.

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Excerpted with permission from Attending: Medicine, Mindfulness, and Humanity, © 2017, by Ronald Epstein, MD.