I believe the greatest challenge in medicine today is keeping the “care” in healthcare. One of the most frustrating aspects of practicing medicine for me had to do with how difficult it had become to incorporate caring into my practice. I am not necessarily talking about the kind of caring associated with having a long-term, close and mutually appreciated association with my patients: if that had motivated me, I would have gone into family practice or oncology instead of emergency medicine. I am referring to the type of caring that led me to make “comfort rounds” on the patients in the ED, finding a pillow to put behind someone’s head (there were never enough around the department), or an extra chair for a family member at the bedside, or cranking up the knees of those thin-mattressed gurneys to take some pressure off the bony sacrums of elderly women.

I’m talking about the kind of caring that requires the extra step to redo that suture to make sure its placed just right, or ensures the patient with the fractured femur gets enough pain meds, or sends you out to find a urinal when there are none left in the exam room and the staff is on break, or prompts you to place follow-up calls to your patients one or two days after their ED visit to see how they’re doing.

Keeping the “care” in healthcare was never an easy thing to do, but it has undoubtedly become more challenging. Physicians have had to adapt to the transition from the practice of medicine to the business of medicine in order to keep the lights on in their offices, or provide for all the uninsured patients in their ED. Its not easy to maintain caring when your hospital insists that if the patient can’t afford their co-pay, they don’t get their prescription. There’s plenty of pressure to maintain patient satisfaction scores, in hospital and in private practice, but there is also pressure to ‘move the meat’ and pack more patients into an hour’s office time; and frankly, everything in our lives has become increasingly transactional. It used to be that a waiter would take your lunch order. Now, an impersonal speaker attached to a porcelain clown in a box blares into your car window, and you have to pay first before you get your food; and many prefer it that way! Already, a host of physicians are communicating with patients over email (is there a caring emoticon?), and how do you project caring to the patient at the end of a robotic surgical arm?

Granted, when it comes to keeping the “care” in healthcare, patients are sometimes their own worst enemy. It strains one’s consignment of compassion when, after spending an hour repairing a patient’s self-inflicted lacerations, you discover that she has pulled a razor blade out of some cheeky hiding place and sliced up the other arm, seemingly out of spite; or when, on a dare, a teenager downs a fifth of vodka, and then vomits on your shoes; or someone with a nasty personality decides to spit in your face when you ask, “how are you feeling?” Caring works both ways: it was a lot easier for physicians to be caring in the days when physicians were universally respected in their community; and the erosion of caring in the profession has undoubtedly undermined that respect.

Some practitioners argue that the threat of malpractice suits also gets in the way of caring, though I’m not really convinced. Granted, I am fortunate in that the only time I have ever been sued was by a patient who I never saw, who was treated in a hospital where I never worked two years after I had retired from clinical practice. My name was dismissed from the suit. Perhaps if I had suffered through the months of self-doubt, the adversarial depositions, the accusations in open court, and all the rest; I might have come away with a significantly diminished capacity to care for my patients. I believe, however, that caring might confer a modicum of immunity from malpractice suits, though pure luck probably has more to do with my escape.

Many physicians now complain about these changes in healthcare, and my sense is that it has affected a lot of them in a very personal, and very discouraging way. All sorts of people go into the profession of medicine, and of course not all of them have caring or compassion or empathy leading them into the fold, any more than all firemen have bravery or policemen the urge to protect guiding their choice of careers. Physicians, however, invest more time and money, and make more sacrifices, than most (though not all) professionals to obtain the privilege of plying their art. They say that medical school is so grueling that it tends to squeeze all the humanity out of young doctors, but in fact a few short years in practice reignites, for most physicians, the spirit of caring that led them to aspire to the white coat in the first place. Caring is its own reward.

Now that I am retired from clinical practice, and older, I am more likely to find myself on the receiving end of healthcare. I hope that my own physicians can find a way to keep the care in the healthcare they administer to me, not because I expect to need a lot of hand-holding, but because I think caring healthcare is better care.

Myles Riner is an emergency physician who blogs at The Fickle Finger.

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