Getting the Tempo Right
A recent study showed patients on dialysis seriously overestimate their prognosis, which impacts negatively on the likelihood of having advance care plans, surrogate decision makers or having stated an explicit goal of therapy. This discordance came as no surprise, having been observed in many other studies, and confirmed by routine practice. For instance, a question on the SF 36 says “I expect my health to be better next year.” In our units, 80% routinely said yes without reservation, even though the best we as clinicians expected is that they would be no worse off than they were today. The authors note:
“Prognostic optimism and uncertainty…reflect a number of different factors. Communication about prognosis is especially challenging for technologies that shift the focus of care away from prognosis to diagnosis and treatment. When dialysis is framed as a necessary life-saving treatment rather than an explicit treatment choice, discussions about life-expectancy…assume a lower priority…estimating life-expectancy in individual patients continues to be fraught with difficulty. Furthermore, payment and incentive structures…may even discourage frank discussions about prognosis.”
A second study from the same group reported a qualitative study of nephrologist experience with delivering only medical management to patients with advanced kidney disease. The authors surveyed 21 nephrologists experienced in caring for patients with advanced CKD who did not opt for dialysis. (I was one of the subjects.) The authors identified two major themes in the interviews. First, dialysis needed to be framed as an explicit choice by the patient, recognizing patient preferences and needs might change over time, not something that was automatic. Second, patients had to be prepared to navigate healthcare systems in which dialysis is the default option.
Finally, I want to describe a “thought piece” from the Mayo Clinic, “Careful and Kind Care Requires Unhurried Conversations.”
“Within unhurried conversations patients and clinicians work together to advance the problematic human situation of patients, to celebrate and to grieve, to establish and renew relationships of care to which they return to regroup after a disappointment…patients and clinicians must be able to have unhurried conversations…in which they can see the patient situation in “high definition”—both content and context, biology and biography—to discover what aspect of that situation demands action and discover together the action that this situation demands.”
The authors note unhurried does not necessarily mean long—rather it means long enough to meet the need of the moment. It also implies there is a rhythm to patient encounters that is developed during the visit.
“Thus, rhythm is not the passing of seconds, or the rate of data exchange per second, but a tempo that the participants create as they converse. The organization of policies, clinical information, teams, and structures can determine the fulfillment of this achievement. Poorly supported, conversations become hurried…Key organizational contributors to rhythm include how much time the system allots for the conversation, how much time that conversation should take, and what participants are required to do during that time…Clinician and patient should feel neither hurried nor that they are wasting the time of the system…or each other. Care has its own tempo, which depends on the nature of the problem, the participants, and what is at stake.”
One of my medical executive friends likes to say: “Every system is perfectly designed to get the results it has.” Today’s production oriented system assumes every patient problem can be standardized and the goal is to maximize “efficiency.” Getting dialysis patients to have a realistic understanding of their dilemma does not promote efficiency. Likewise, talking to someone about foregoing dialysis will cost twice—you can’t bill enough to cover the time spent now, and you forego the monthly capitation fee. Besides, prognosis is uncertain, so shouldn’t dialysis be the default option? Contrast that with the potential individual and system benefits of better educated patients who have more realistic treatment goals, including knowing when it is time to stop treatment. Imagine a system where patients feel their caregivers know them and what they think matters rather than being driven to meet the metrics or the production goals.
The Mayo authors don’t propose a method to get the tempo right but raise it as a system goal. I empirically arrived at slotting new patients for one hour which worked out about right, and for some it was too long. When it was too long, I took the extra time to get paper work done. For rechecks I arrived at 20 minute slots, which was too long for most patients, but gave me 10 minutes or so of “wiggle room” for the “Oh, by the way doc…” moments. (And also gave my staff some time to slot work-ins to keep people out of the ER.) Of course, I set this up when the only person who really cared about my production was me.
In today’s production-oriented system environment, 30 minute new patient slots and 15 minute rechecks are the norm. On the other hand, both patient and provider satisfaction are going down rapidly. While there is no universal answer, getting the tempo right seems to be a key to improving both. The “unhurried conversation” needs to make a comeback. But this requires we acknowledge health care can only be commoditized so far.
18 November 2019
 O’Hare AM, Kurella Tamura M, Lavallee DC, Vig EK, Taylor JS, Hall YN, Katz R, Curtis JR, Engelberg RA. Assessment of Self-Reported Prognostic Expectations of People Undergoing Dialysis:: United States Renal Data System Study of Treatment Preferences. JAMA Intern Med 2019;179(10):1325-1333. doi. 10.1001/jamainternmed.2019.2879.
 Wong SPY, Boyapati S, Engelberg RA, Thorsteinsdottir B, Taylor JS, O’Hare AM. Experiences of US Nephrologists in the Delivery of Conservative Care to Patients with Advanced Kidney Disease: A National Qualitative Study. Am J Kid Dis 27 September 2019. doi. 10.1053/ajkd2019.07.006.
 Montori V, Hargraves IG, Breslin M, Shaw K, Morera L, Branda M, Montori V. Careful and Kind Care Requires Unhurried Conversations. NEJM Catalyst, 29 October 2019. Accessed same day at https://catalyst.nejm.org/kind-care-requires-unhurried-conversations/
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