I am on rounds with the medical team on the floor that has patients with medical problems and psychiatric comorbidities. My presence is not actually needed; however, the social worker who attends regularly usually feels the need for support from her attendings, who do not have the “time” to attend these meetings, so I have attended at least weekly. As I sit in the nursing station where the team meeting begins, I hear the beginning of rounds, usually begun by a senior medical resident:

Resident: “JW, bed 740. Cleared by psych, cleared by neuro, needs nursing home.”

Medical social worker: “OK, paperwork placed.”

Resident: “JB, bed 741, medically cleared, psych cleared. Needs placement.”

The list goes on in this way. I have no idea who any of the patients are. It is even less personal than the usual “45-year-old male, hepatitis in bed 750” that I was used to hearing over the years. Nameless, genderless, faceless, just cleared or not cleared, placed or not placed. All the nursing staff and resident staff are staring at the various computer monitors. No one looks up. No eye contact is made. No discussion is had. This continues until we come upon a patient for whom an ethics consult was placed. The rapid-fire report continues until they say, “awaiting Ethics.” I pipe up and ask what we are waiting for ethics for. The senior resident answers quickly, “physician-assisted suicide,” and is ready to move on. I once again pipe up, “We do not have physician-assisted suicide, so what is the ethical question?” I admire the senior resident, who then continues with the report as if the answer is given and there is no more information. Unable to leave well enough alone, I continue to ask questions: “Why does she want PAS?” But the machinery of the rounds will not be derailed that easily, and the answer comes back out: “pain.” Finally, I blurt out, “This is an incredibly unique case. Isn’t anyone interested in the backstory?” A first-year psychiatry resident takes her eye off her screen, looks up, and smiles. Two social workers nod. The senior resident is caught off guard but stops the staccato announcements. A short discussion ensues. There is some involvement from nursing and social work. The medical residents do not play along, but at least they are now looking up from the computer. In the end, however, the process restarts without change.

I was struck by these meetings over the last few months and have been unable to be comfortable with the approach that we take to many of our patients. I do not want to imply that we do that much better as psychiatrists in today’s climate, but I can remember a different approach to the patient.

Understanding the person was always a central theme in the practice of medicine and psychiatry. In order to provide the best of care, we needed to understand the person, their life, their habits, their origins. We were taught to provide a formulation that includes the biological, the social, and the psychological. Thinking of the patient as one-dimensional was considered inadequate. Understanding the individual allowed us to develop a rapport. It allowed us to be part of what was often a major change in their lives. We became observers, historians, advocates, as well as providers of care.

Understanding the so-called “backstory” was a central part of this process. Who is the person sitting on the examining table, lying in the stretcher, lying in the bed? What was the road taken in their lives that led them here? What part of their life experience can we touch upon to develop strength-based plans that rely on their personal narrative of resilience? In the ethics case mentioned, it would bring into focus some of the guardedness of the patient, understanding and empathizing with the trauma and shame associated, and would allow us to begin meaningful therapeutic work. She may still start off on palliative care, but we can move to something more meaningful and effective.

So why are we as clinicians so reluctant to spend that time understanding this narrative? I believe part of the difficulty comes in the way that we deliver care. We provide care in silos, and the purpose of the care is to move from one silo to the next. The exit becomes central. As the Fat Man in The House of God would say, “Placement comes first”; however, people forget the joy he took in helping people and how the laws of The House of God were meant to help the struggling interns survive the year. And this adage is central to the practice of medicine. No longer do we allow for relaxed diagnostic testing. We are laser-focused on a “problem” and a “solution.” Even the way we develop our treatment plan consists of creating a list of problems that, although they might be part of the same physiological process, are addressed as isolated parts. When my part is complete, off they go to the next stage or silo of care.

We have become volume-based, but pretend to be quality-based by checking off multiple boxes in the EMR. The person is time-consuming. The initials can be rapidly dealt with. All the boxes can be checked off, and so the individual is “cleared.” But is it only about defending census or workflow? Knowing the “backstory” leaves us more vulnerable as providers. It puts the patient’s suffering into clear view, and we cannot hide behind screens or checklists. We must face the vulnerable person in front of us. We must also look to the human behind the initials. The mother, father, daughter, brother, sister, etc. We know this person since we are this person.

We ignore the backstory because it is truly not needed in the way we practice. We are taught the importance of speed. We perform focal examinations. We order the CT scan before the neurologist pulls out their trusty reflex hammer. We order an echo before listening for heart sounds. As the technology has improved, as the knowledge has increased, the desire to know the person lessens. The field of medicine is also more complex than ever before. We have well-studied algorithms that have saved countless lives. We have extended survival. We have improved outcomes across the board, aside from the relationship. And the clinician, despite all these tools and improvements, is still facing high levels of burnout. We do find meaning and satisfaction, but the improvements have often interfered with the relationship between physician and patient, or better yet, have hidden the person from the physician. We still provide care and try to heal. But we focus on the body, which is the part that is the easiest to touch and see.

The ability to express the backstory may not even be that important to the patient. For the most part, they present with a problem that they would like solved as quickly as possible. There is no question that we do this and do it well. Doing a full neurological examination is, of course, an art form, but do I need art when I have imaging, especially when minutes count in the outcome? When I present with a sore throat and fever, is a full history and physical more valuable than a quick strep test?

For the patient, it depends on the setting and the prognosis. If I want to quickly assess my symptoms of stroke and be treated and hopefully reverse the damage done, then a doctor discovering the historical aspects within my life that can lead to a CVA is not important. However, when I am undergoing chronic care for a lymphoma, I believe that I would like to be more than initials. When I am afraid, I would like my physician to know who I am.

Perhaps we need to consider how we balance our humanism while embracing the leaps we have taken as a profession. We might also need to consider who holds the patient’s “humanity” during their lifetime, as opposed to all of us taking on that role.

Constantine Ioannou is a psychiatrist.