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PERS PE C T IV E Asymmetric Thinking about Return on Investment

the same ultimate effect on in- punitive revenue reductions. As Disclosure forms provided by the authors
are available with the full text of this article
vestment income, but they influ- U.S. health care financing begins at NEJM.org.
ence thinking in different ways. again to shift risks to hospitals
From the Perelman School of Medicine
We might encourage greater ef- and physicians through bundled (D.A.A., R.W.M.) and the Wharton School
fort and innovation in keeping payments or readmission penal- (D.A.A., M.V.P.), University of Pennsylvania,
people out of the hospital and ties, the financing of the care for and the Center for Health Equity Research
and Promotion, Philadelphia VA Medical
coordinating care if we reframed our most challenging patients Center (D.A.A.) — both in Philadelphia.
its financing as positive pay- might be better shifted in the DOI: 10.1056/NEJMp1512297
ments for noble work rather than other direction. Copyright © 2016 Massachusetts Medical Society.
Asymmetric Thinking about Return on Investment

The Doctor’s New Dilemma

The Doctor’s New Dilemma


Suzanne Koven, M.D.​​

T he woman sits perched on


the end of my exam table,
leaning forward, blond curls tum-
a limited supply of the medica-
tion and a small staff to admin-
ister it. He can treat only 10 pa-
and risk a time-consuming inter-
action? Or do I accept what she’s
saying at face value and risk miss-
bling over her eyes, her precari- tients at a time and so must ing a chance to truly help her?
ous posture mirroring her emo- decide whose life is most worth Often, the situation is not so
tional state. Though the symptom saving. Other conundrums Shaw dramatic. Say I walk into an
she describes is relatively minor highlights in the play’s lengthy exam room and find a patient
— some diarrhea on and off — prologue are how to prevent doc- waiting for me, reading a book.
she appears distraught. She grips tors from being motivated by fi- Do I ask what book she’s read-
the table as if doing so will hold nancial gain and how to rid the ing? If it’s one I’ve recently read
back her tears. medical profession of charlatans. myself, do I ask whether she, like
A psychiatrist colleague tells In recent years, Shaw’s turn-of- me, enjoyed it but found it a bit
me that such moments, when the-20th-century drama about the longer than it needed to be? We
there’s a clear mismatch between ethics and economics of health might debate that point, and then
what a patient says and the in- care has been seen as prescient, she might start telling me about
tensity of feeling with which he as prefiguring the establishment other novels her book group has
or she says it, are especially ripe of the National Health Service in read, and pretty soon we’d be
for probing. But the psychiatrist Britain and the Affordable Care having — horrors! — a conversa-
sees patients for 45 minutes. I Act in the United States. Even tion. Precious minutes wasted on
have 15, several of which have with these developments, modern useless chitchat.
already passed, in which to ad- Colenso Ridgeons still grapple But is chitchat really useless?
dress and document the woman’s with limited resources, inequality Such conversations can generate
chief symptom: loose stool. I find in access to health care, and un- the trust that, studies have sug-
myself in a quandary: Do I ask scrupulous or incompetent col- gested, improves health outcomes,
the patient why she’s so upset, or leagues. such as control of blood pressure
do I order a culture, prescribe The dilemma I face most often and relief of pain — indeed, that
antidiarrheal medication, type my as a primary care doctor, how- is essential to healing.1 Once,
note, and send her on her way? ever, is not one that Shaw antici- when I was covering for a col-
In 1906, George Bernard pated. The commodities I strug- league, I saw an older woman I’d
Shaw’s The Doctor’s Dilemma first gle to ration are my own time never met before. I pride myself
appeared on the London stage. and emotional energy. Almost on being able to put patients at
The play concerns a physician, every day I see a patient like the ease, being able to establish rap-
Sir Colenso Ridgeon, who’s dis- woman with diarrhea and I find port with almost anyone, but this
covered a cure for tuberculosis. myself at a crossroads: Do I ask woman would have none of it.
Ridgeon’s dilemma is that he has her what’s really bothering her She expressed skepticism about

608 n engl j med 374;7  nejm.org  February 18, 2016

The New England Journal of Medicine


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Copyright © 2016 Massachusetts Medical Society. All rights reserved.
PE R S PE C T IV E The Doctor’s New Dilemma

everything I said. Finally, she hidden beneath layers of baggy the pastry, we fall hopelessly be-
pulled a pen out of her purse to clothing, vague symptoms, and hind in administrative tasks and
write down my diagnosis, clearly stacks of results of tests ordered feel more burned out. If we don’t
intending to look it up later and by exasperated doctors. The turn- ask about the pastry, we avoid the
marvel at my foolishness in pro- ing point comes when Weinberg, kind of intimacy that not only
posing it. an avid cook but inexpert baker, helps the patient, but also nour-
“What a beautiful pen!” I asks the woman, who works in ishes us and keeps us from feel-
blurted out. And it was: a lovely her family’s bakery, about making ing burned out.
tortoiseshell implement with a pastry. As the woman expounds The woman with the blond
shiny gold nib. The woman’s on the art of producing a perfect curls can keep back her tears no
hostility melted. She told me that Napoleon, Weinberg observes, longer. She gestures to her mid-
fountain pens were a great pas- “For the first time her eyes came section and sobs, “I can’t hold
sion of hers. She collected and alive.” on to anything!”
traded them. She’d been to pen This moment of connection I am struck by her choice of
shows and pen shops all over the leads, over time, to the woman’s words, by the metaphorical power
world. I told her that I liked confiding in Weinberg a painful of her cry. In the past, she’s told
fountain pens too, that in fact secret. In regular meetings, which me of her difficulty maintaining
my husband had just bought me Weinberg schedules at the end of relationships, of her loneliness.
one for my birthday, at a shop in his clinic sessions, they sit and I’ve recommended psychotherapy,
Dublin. Of course she knew the talk. Weinberg is uncomfortable but she’s declined. I consider
shop. “What make of pen?” she playing the role of psychiatrist, pointing that out to her, suggest-
inquired. I confessed I didn’t re- but the patient will speak only ing that her diarrhea might be
member, so she asked me to de- with him. Gradually, she emerges an eloquent manifestation of her
scribe it. Thick . . . natural wood from her shell, and her symptoms psychological pain. But 25 min-
shaft, chrome cap . . . “A Faber- resolve. utes have passed, and there just
Castell!” she pronounced, beam- At first it’s not obvious how isn’t time to open that door.
ing. “That’s it!” I shouted, my “Communion” relates to modern I order the cultures, prescribe
grin matching hers. She put her medical practice. Weinberg may an antidiarrheal drug and some
pen away without recording my have had meaningful conversa- dietary modifications, briefly
diagnosis. She believed in me. tions, but he didn’t have “mean- mention psychotherapy again, and
As part of a new writer-in-resi- ingful use.” In 1985, free from leave the room. Then I sit at my
dence program in the internal the shackles of the computer workstation to document and bill
medicine division of my hospital, screen, Weinberg faces only one for our encounter, perched at the
I’ve been meeting with groups of obstacle in engaging the troubled edge of my seat, on the verge of
doctors and nurses to discuss young woman: his own willing- despair.
brief works of literature relevant ness to do so. His leisurely con- Disclosure forms provided by the author
to clinical practice. Before these versations with her seem as quaint are available with the full text of this article
at NEJM.org.
meetings, I always ask whether to us now as black bags and
there’s a particular theme they’d glass hypodermics. From Massachusetts General Hospital,
like to address, and the answer, Still, the moment when Wein- Boston.
alas, is always the same: burnout. berg takes the plunge, when he
1. Kelley JM, Kraft-Todd G, Schapira L,
For several groups, I’ve selected asks the woman about pastry, Kossowsky J, Riess H. The influence of the
“Communion,” an essay published seems very familiar. It’s a mo- patient-clinician relationship on healthcare
20 years ago in which Richard ment we have all inhabited and, outcomes: a systematic review and meta-
analysis of randomized controlled trials.
Weinberg, a gastroenterologist, all too often, pulled back from PLoS One 2014;​9(4):​e94207.
recounts his interaction with a — a threshold we fear crossing. 2. Weinberg RB. Communion. Ann Intern
young woman who suffers from We imagine ourselves, now, in Med 1995;​123:​804-5.
chronic abdominal pain.2 At first, Weinberg’s place, and we recog- DOI: 10.1056/NEJMp1513708
Weinberg finds it difficult to nize a double bind, a new doc- Copyright © 2016 Massachusetts Medical Society.
The Doctor’s New Dilemma

reach the woman, who seems tor’s dilemma: if we ask about

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The New England Journal of Medicine
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Copyright © 2016 Massachusetts Medical Society. All rights reserved.