Incrementalism
 
            Atul Gawande published an article in The New Yorker in the January 23, 2017, issue called “The Heroism of Incremental Care.”[1] Dr. Gawande trained as a surgeon because he was attracted to the heroism of the dramatic, sometimes life-saving intervention. In this article, though, he gives examples where care improves through careful building of the doctor-patient relationship and where cure may not be possible.
 
            “If an illness is a fire, many of them require months or years to extinguish, or can be reduced only to a low-level smolder. The treatments may have side effects and complications that require yet more attention. Chronic illness has become commonplace, and we have been poorly prepared to deal with it. Much of what ails us requires a more patient kind of skill.”
 
            As he looked into the issue of what exactly is going on in the primary care physician’s practice, he found it difficult to pin down what, from a technical perspective, was taking place. But then he noticed the effect of familiarity—when the doctor and patient knew each other, the dynamic changed. He concluded:
 
            “Studies have established that having a regular source of medical care, from a doctor who knows you, has a powerful effect on your willingness to seek care for severe symptoms. This alone appears to be a significant contributor to lower death rates.
Observing the care, I began to grasp how the commitment to seeing people over time leads primary-care clinicians to take an approach to problem-solving that is very different from that of doctors, like me, who provide mainly episodic care.”
 
            Perhaps the most astute comment he quoted was from Dr. Katherine Rose, who noted:
 
            “For me, as a relatively new primary-care physician, the biggest struggle is trusting that patients will call if they are getting worse.” And they do, she said, because they know her and they know the clinic. ‘“Being able to tolerate the anxiety that
accompanies taking care of people who are sick but not dangerously ill is not a skill I was expecting to need when I decided to become a doctor, but it is one of the ones I have worked hardest to develop.”’
 
            As Dr. Gawande goes on to note, incrementalism is not something that comes naturally to our approach to life, and the compensation system still rewards the physician who takes the heroic approach as opposed to the one whose skill is tolerating uncertainty. Yet the nature of medical practice clearly calls for improving our ability to do incremental care.
            Although his focus was on physicians and their patients, he really did not get into an exploration of Dr. Rose’s comment on “being able to tolerate the anxiety.”  As I have worked with physicians in various specialties and stages of experience, I have concluded this is one of the principal determinants of those who will grow from being doctors to being physicians. Those destined to become physicians, even if they are procedural specialists, come to realize the results of their intervention are every bit as uncertain as the future without their intervention in many cases, and they become comfortable withholding interventions and diagnostic tests and waiting to see what develops.
            Perhaps another way to frame the issue is to contemplate whether, as physicians, we are called to “do” or to “be?” I suspect most of us, like me, are inclined to think about what we do—diagnose, treat, advise, counsel—all active verbs. Certainly this is what attracted me to the study of medicine. But as I have grown old in the practice of medicine, I have come to recognize that a good deal of what patients value most from me is just being there, actively listening, and expressing understanding of what they are trying to tell me.
Of course, I do not achieve this level of communication with every patient or every family. Some just want me to “do” something to make the issues go away. But since I  am rarely able to do that, I now see my task as trying to establish a relationship with the patient so together we can do what we can. So we are really called both to do and to be. It is my hope that we can find ways to teach our medical young the value of being just as much as we teach the value of diagnosing, treating and advising. Perhaps if we did this, more young doctors would value primary care, even if the current system does not.
 
30 January 2017
           


[1] Gawande,  A. The Heroism of Incremental Care. The New Yorker, 23 January 2017. Accessed online 18 January 2017 at http://www.newyorker.com/magazine/2017/01/23/theheroism-of-incremental-care.html.

Further Reading

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Empathy
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More on Physician Work
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Uncertainty
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