BMJ  2003;327:E169 (4 October), doi:10.1136/bmjusa.02120001 (published 20 March 2003)

BMJ USA: Editor's choice

Can you see caring through pinholes?

From BMJ USA 2002;Dec:644

Doctors in America are now accustomed to being judged by arcane metrics. Depending on who is judging us, we are measured by performance indicators (eg, the average glycohemoglobin level we achieve with diabetics), how we code office visits, the length of stay of our hospitalized patients, whether we use the formulary statin, and any other number of parameters that say little about the quality of the care we provide. Doctors can score well on these metrics and have horrible bedside manner, and vice versa.

The evaluators haven't a clue about our caring, and yet that is what patients value most and find most deficient in today's health care experience. What they resent most is not the omission of a foot exam or a -blocker but the cold absence of basic human caring. In a 2001 survey of US adults conducted by the Commonwealth Fund, only 57% rated their overall medical care as excellent or very good. Consider this finding among patients with less than average income: Only 43-61% rated their doctor as excellent or very good at treating them with dignity, listening carefully, providing all the information they wanted, spending enough time, knowing them, or being accessible.

The BMJ devoted its September 28, 2002 issue to the question on its cover, "What's a good doctor?" No clear answer jumped from the pages, other than the obvious: The goodness of doctors encompasses not just technical knowledge but also—if not more so—skills in empathy, communication, sensitivity, and delicacy in relationships.

This issue of BMJ USA features several articles from that issue, on such topics as the importance of communication (BMJ USA p 653) and of considering patient preferences (BMJ USA p 652). New articles from American authors also speak to the elements of caring. McCormally reminds us to be insightful, to not let technology—in this case electronic devices to locate wandering patients—distract us from the search for root causes (BMJ USA p 692). MacCorquodale takes us back 50 years to a time when patients dropped by the house with a catch of fish, house calls were routine, and doctors had the wisdom to recognize the anxiety of terminal illness and treat it with coffee and conversation rather than drugs (BMJ USA p 677).

In contrast, today's doctors curtail their speech with patients for lack of time. We fear too much talk will put us behind, an unfounded fear if two European studies (BMJ USA p 667 and p 675) are to be believed. In fact, if Pollock and Grime are correct, patients with depression might be helping us with our time constraints more than we would want.

If today's metrics are a pinhole for examining caring, direct observation might be the wider-angle lens. Observers' field notes, content analysis of video- or audiotaped encounters, and standardized patients (which a study in this issue examines ÜBMJ USA p 674ü shed more light on what really happens in clinical encounters. Researchers use them, but evaluators continue to look through pinholes.

Articles cited in Editor's choice are listed below, beginning with their BMJ USA page number

BMJ USA p 653: Communication and emotions (Buckman), http://bmj.com/cgi/content/full/325/7366/672

BMJ USA p 652: Patients' views of the good doctor (Coulter), http://bmj.com/cgi/content/full/325/7366/668

BMJ USA p 692: Commentary (McCormally), http://bmj.com/cgi/doi/10.1136/bmjusa.02120004

BMJ USA p 677: The man who was afraid to die (MacCorquodale), http://bmj.com/cgi/doi/10.1136/bmjusa.02120005

BMJ USA p 667: Patients' perceptions of entitlement to time in general practice consultations for depression: qualitative study (Pollock, Grime), http://bmj.com/cgi/content/full/325/7366/687

BMJ USA p 675: Spontaneous talking time at start of consultation in outpatient clinic: cohort study (Langewitz et al) http://bmj.com/cgi/content/full/325/7366/682

BMJ USA p 674: Using standardised patients to measure physicians' practice: validation study using audio recordings (Luck, Peabody) http://bmj.com/cgi/content/abstract/325/7366/679

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