Time, according to the aphorism, is a great healer. Although primarily referring to affairs of the heart, the saying is also relevant to health. Many illnesses respond to the healing effect of time.
But time is also a major constraint in modern healthcare. In an era where shared decision-making is a priority, and many patients have multiple chronic diseases, time is crucial. But sufficient time is not something that is prioritised in our health system.
Doctors and patients need more time to tease out the best course for each individual’s care. For older patients, there is often a fine line between effective treatment and intolerable side-effects; the only way to get challenging decisions like these right is not to rush them.
The most common barrier to shared decision-making, cited by patients and clinicians, is time. Writing about the issue in a recent viewpoint piece in the Journal of the American Medical Association(JAMA), Dutch and American doctors noted that time can be considered an organising tool that controls what happens and when. “It is a constrained resource that makes caring for patients possible or not. Time starts, becomes available, can be wasted, and runs out. Regardless of whether shared decision-making was planned to take place at a scheduled clinical encounter or needs to be improvised at the bedside when a patient’s condition deteriorates, the shared decision-making clock sometimes starts earlier than expected.”
Ironically, shared decision-making is often most limited during clinical encounters. In general practice, the 10-minute consultation continues as an unattainable goal that leaves doctors running chronically late and patients extremely frustrated. It’s often not much better when seeing a specialist, especially in the public system.
The problem, according to the JAMA authors, is that consultation time is the result of algorithms that prioritise meeting the demand for access to available clinicians over offering enough time for unhurried consultations. Documentation and data entry further eat into consultation time. A hurried doctor then interrupts the conversation with a patient, rather than leaving them complete their story. In doing so, they risk not hearing important elements that would otherwise guide good decision-making.
“When lacking time, clinicians may present information with a complexity or tempo that may easily overwhelm the attention of patients who are ill and worried,” the authors note. “Information is then lost on patients, and time is wasted. Clinicians may not allow for a silent pause and miss key patient disclosures or questions.”
Longer consultations
Evidence shows that more shared decision-making processes are completed during longer consultations. The problem is that shared decision-making remains a “nice-to-have extra” for which new time needs to be found.
How can we achieve this? Clinicians must be curious and appreciate what really matters to patients. They, in turn, cannot assume that clinicians will be aware of their fears without a conversation. And policy makers must understand the trade-offs between access and productivity and then develop policies that allocate meaningful time for care.
I fully agree with the JAMA authors’ conclusion: “Healthcare professionals, patient advocates, healthcare systems, and policy makers need to recognise that time is not simply a resource, its minutes indifferent and interchangeable like dollars or euros. A minute spent in providing information may turn out to be less important than a minute spent waiting silently for patient questions, or a minute responding empathically to angst and loss, or a minute discussing when the plan will be reviewed and revised if necessary. Time for care is precious. The healthcare system must place a much higher value on and invest in innovations that create time and realise the possibility of time for patient care.”
That wise physician Hippocrates said that “healing is a matter of time, but it is sometimes also a matter of opportunity”. That opportunity is now; time must become a central plank in Sláintecare planning.
Finally, last week’s column stated the HSE had failed to consult with cervical cancer patients. In fact, Vicky Phelan was referring to a lack of consultation by civil servants in relation to setting up an ex gratia payment scheme.
mhouston@irishtimes.com