Yesterday was a fast day. Which is not to say that it went by quickly, but that, for religious reasons, I did not eat. The prayer that an individual says in the afternoon service on a fast day, within the final hour or two before eating, says, “Be near to our cry.” It quotes a verse from Isaiah 65 where God says, “Before they call, I will answer; while they are still speaking, I will hear.”
If only. If my practice of medicine is based around emulating the Divine qualities of lovingkindness, this is one place where I fall flat. When I look at my style of practice, I am compassionate, thorough, gentle, caring – and completely reactive. I answer when you cry out; I hear when you have spoken. But to be near enough to hear and answer before the sound has been uttered? That’s a tall order.
But when you cry out, when you call, or send a message through the portal, or come in for a visit, it is already too late. You are in the emergency room, or have run out of medicine, or are angry and at wits’ end. Sometimes it is so late that you can no longer cry out yourself, and I am hearing from the police, or a distraught spouse, or the paramedics.
We have built a medical system designed to be episodic, with long periods of silence between episodes that are only broken when you have something to say that can’t wait. We say we are responsive, which really means we only respond to problems, without initiating contact. In fact, there are situations where we are not permitted to initiate contact, lest we be accused of fraudulently trying to generate revenue: in the limited situations where a medical provider can be compensated for their time spent on the phone with a patient, they can only do so if the patient reaches out first.
When we do attempt to be proactive, it is with our technology, not with ourselves. We promote screening tests for cancer, for heart disease, for osteoporosis. The number-needed-to-screen is often enormous; estimates for screening for breast cancer by mammography suggest that it may take as many as 1400 mammograms per year in women over 50 to detect and prevent one fatal case of breast cancer, and generate dozens of false-positive results in the process.
The most ironic comment I have ever heard about screening came from one of my pediatric colleagues. We were discussing the recommendation for universal lead screening in toddlers in Allegheny County, where we have the triple whammy of old housing stock (lead paint), old water mains (lead pipes) and brownfield reclamation (lead in the soil). “Why aren’t we screening houses for lead before they harm children,” they said, “instead of screening children for lead after they’ve already been poisoned so we can fix the house when it’s too late?”
We know where the problems will occur. This is not my first rodeo; I know if you are likely to have problems finding your medicine, or if you are going to have trouble getting to the appointment, or if I may not have explained your plan in a way that made sense to you. Why am I not screening you – not for cancer, but for derailed plans and setbacks that I can see coming before they happen?
In chapter 6 of Healing People, Not Patients, I wrote about a vision of a “medical home” that focused on that kind of pro-active behavior. I likened it to the poem by the medieval Spanish rabbi Judah HaLevi, who wrote, “And in my going out to meet you, I found you coming toward me.” I have a song based on that verse that I sometimes sing at my speaking engagements; it’s about the care that some of the sickest people I work with are hoping they can receive from me.
And then that vision sat, on page 106 of my book or waiting to be performed at the next open mike night. When you are overwhelmed by the people who have already cried out, when primary care doctors have panels of a couple thousand people, it is hard to do anything but scramble to keep up with what is here in front of you, let alone have time to go out seeking the people who have not yet spoken up.
Last week I finally did something about it. After carrying the idea around with me for months or maybe even years, I made a worry list. I opened a spreadsheet to keep track of people for whom I had unfinished tasks to attend to, for whom I could not just trust that things would work themselves out, for whom I was worried that the next step wouldn’t happen unless I personally, repeatedly intervened, or who had simply fallen out of touch despite unresolved problems. Each day I have been adding names, tasks, and reminders of the folks who need me to hear before they cry out – that their paperwork was lost, that their test was cancelled, that their medication was not refilled or that they are not getting better and can’t get in to see me for three more months.
If you are reading this and think you may be on that list, and are wondering why you haven’t heard from me, I offer only this excuse: that I am still learning how to do this well. But I can tell the rest of you that when I have remembered, when I have come toward someone who had not yet gone out to meet me, there was not a number-needed-to-screen of 1400. There is a number-needed-to-screen of one. Reaching out in that way is always helpful, whether to make a person feel cared for, missed, or reassured, or to give them an opportunity to vent out loud about their frustration instead of sitting in silence, or to actually fix a problem instead of letting it fester.
Today one of my colleagues sent a team to do a wellness check on someone whom we had been unable to reach for weeks. We feared the worst, but when the mobile team arrived they were alive and well – and had a broken phone that had only been replaced this morning. “Thank you so much,” they told us, “in three weeks you were the only ones who noticed.”
Maybe we are learning to answer before you call after all. Drop by drop, day by day.