Abraham Verghese’s research while affiliated with Stanford University and other places

According to that old story, a local giving directions to a lost traveler says, “If I wanted to get there, I wouldn’t start from here.” Medicine finds itself far from the bedside,¹,2 seeking a way back, unsure where to begin.

My first glimpse into the craft of physician-writers did not come through Anton Chekhov, Walker Percy, or William Carlos Williams, whose works I only came to after medical school. As a schoolboy, I loved W. Somerset Maugham, although he never practiced medicine, and his craft had little to do with his medical degree. My introduction to physicians as writers came through my textbooks. Boyd’s Pathology made me aware of literary voice, the ability of authors to place themselves in the text, let their personality come through, and subtly become a character in the reading experience.¹ On the topic of defining the moment of death, Boyd in his single-author text wrote, “It was the author of the book of Ecclesiastes who said, ‘There is a time to be born, and a time to die.’ Fortunately it is the clinician, not the pathologist, who has to make this difficult decision. Sometimes, however, the kindly doctor may find himself murmuring those moving lines from the last act of King Lear: O let him pass! He hates him/That would upon the rack of this tough world/Stretch him out longer.”

Background: Human connection is at the heart of medical care, but questions remain as to the effectiveness of interpersonal interventions. The purpose of this review was to characterize the associations between patient-provider interpersonal interventions and the quadruple aim outcomes (population health, patient experience, cost, and provider experience). Methods: We sourced data from PubMed, EMBASE, and PsycInfo (January 1997-August 2017). Selected studies included randomized controlled trials and controlled observational studies that examined the association between patient-provider interpersonal interventions and at least one outcome measure of the quadruple aim. Two abstractors independently extracted information about study design, methods, and quality. We characterized evidence related to the objective of the intervention, type and duration of intervention training, target recipient (provider-only vs. provider-patient dyad), and quadruple aim outcomes. Results: Seventy-three out of 21,835 studies met the design and outcome inclusion criteria. The methodological quality of research was moderate to high for most included studies; 67% of interventions targeted the provider. Most studies measured impact on patient experience; improvements in experience (e.g., satisfaction, patient-centeredness, reduced unmet needs) often corresponded with a positive impact on other patient health outcomes (e.g., quality of life, depression, adherence). Enhanced interpersonal interactions improved provider well-being, burnout, stress, and confidence in communicating with difficult patients. Roughly a quarter of studies evaluated cost, but the majority reported no significant differences between intervention and control groups. Among studies that measured time in the clinical encounter, intervention effects varied. Interventions with lower demands on provider time and effort were often as effective as those with higher demands. Discussion: Simple, low-demand patient-provider interpersonal interventions may have the potential to improve patient health and patient and provider experience, but there is limited evidence that these interventions influence cost-related outcomes.

Importance Time constraints, technology, and administrative demands of modern medicine often impede the human connection that is central to clinical care, contributing to physician and patient dissatisfaction. Objective To identify evidence and narrative-based practices that promote clinician presence, a state of awareness, focus, and attention with the intent to understand patients. Evidence Review Preliminary practices were derived through a systematic literature review (from January 1997 to August 2017, with a subsequent bridge search to September 2019) of effective interpersonal interventions; observations of primary care encounters in 3 diverse clinics (n = 27 encounters); and qualitative interviews with physicians (n = 10), patients (n = 27), and nonmedical professionals whose occupations involve intense interpersonal interactions (eg, firefighter, chaplain, social worker; n = 30). After evidence synthesis, promising practices were reviewed in a 3-round modified Delphi process by a panel of 14 researchers, clinicians, patients, caregivers, and health system leaders. Panelists rated each practice using 9-point Likert scales (−4 to +4) that reflected the potential effect on patient and clinician experience and feasibility of implementation; after the third round, panelists selected their “top 5” practices from among those with median ratings of at least +2 for all 3 criteria. Final recommendations incorporate elements from all highly rated practices and emphasize the practices with the greatest number of panelist votes. Findings The systematic literature review (n = 73 studies) and qualitative research activities yielded 31 preliminary practices. Following evidence synthesis, 13 distinct practices were reviewed by the Delphi panel, 8 of which met criteria for inclusion and were combined into a final set of 5 recommendations: (1) prepare with intention (take a moment to prepare and focus before greeting a patient); (2) listen intently and completely (sit down, lean forward, avoid interruptions); (3) agree on what matters most (find out what the patient cares about and incorporate these priorities into the visit agenda); (4) connect with the patient’s story (consider life circumstances that influence the patient’s health; acknowledge positive efforts; celebrate successes); and (5) explore emotional cues (notice, name, and validate the patient’s emotions). Conclusions and Relevance This mixed-methods study identified 5 practices that have the potential to enhance physician presence and meaningful connection with patients in the clinical encounter. Evaluation and validation of the outcomes associated with implementing the 5 practices is needed, along with system-level interventions to create a supportive environment for implementation.

Objective We sought to investigate the concept and practices of ‘clinician presence’, exploring how physicians and professionals create connection, engage in interpersonal interaction, and build trust with individuals across different circumstances and contexts. Design In 2017–2018, we conducted qualitative semistructured interviews with 10 physicians and 30 non-medical professionals from the fields of protective services, business, management, education, art/design/entertainment, social services, and legal/personal services. Setting Physicians were recruited from primary care clinics in an academic medical centre, a Veterans Affairs clinic, and a federally qualified health centre. Participants Participants were 55% men and 45% women; 40% were non-white. Results Qualitative analyses yielded a definition of presence as a purposeful practice of awareness, focus, and attention with the intent to understand and connect with individuals/patients . For both medical and non-medical professionals, creating presence requires managing and considering time and environmental factors; for physicians in particular, this includes managing and integrating technology. Listening was described as central to creating the state of being present. Within a clinic, presence might manifest as a physician listening without interrupting, focusing intentionally on the patient, taking brief re-centering breaks throughout a clinic day, and informing patients when attention must be redirected to administrative or technological demands. Conclusions Clinician presence involves learning to step back, pause, and be prepared to receive a patient’s story. Building on strategies from physicians and non-medical professionals, clinician presence is best enacted through purposeful intention to connect, conscious navigation of time, and proactive management of technology and the environment to focus attention on the patient. Everyday practice or ritual supporting these strategies could support physician self-care as well as physician-patient connection.

In this issue of JAMA, Wynia¹ describes a patient in Colorado with terminal cancer for whom a physician agreed to prescribe aid-in-dying medications in accordance with new state legal guidelines. However, the health care organization that employed the physician objected to her actions, even though by doing so it was violating state law. The patient and physician filed suit against her employer. Chillingly, in a move that should alarm physicians long concerned about erosion of their autonomy, the physician’s dismissal letter chided her for violating the ethical directives of Catholic health care services, which view assisted suicide as “intrinsically immoral” and state that “Patients experiencing suffering that cannot be alleviated should be helped to appreciate the Christian understanding of redemptive suffering.”

BACKGROUND: While barriers to physician wellness have been well detailed, concrete solutions are lacking. OBJECTIVE: We looked to professionals across diversefields whose work requires engagement and interpersonalconnection with clients. The goal was to identify effective strategies from non-medical fields that could be applied to preserve physician wellness. DESIGN: We conducted semi-structured interviews with 30 professionals outside the field of clinical medicine whose work involves fostering effective connections with individuals. PARTICIPANTS: Professionals from diverse professions, including the protective services (e.g., police officer, firefighter), business/finance (e.g., restaurateur, salesperson), management (e.g., CEO, school principal), education, art/design/entertainment (e.g., professional musician, documentary filmmaker), community/social services (e.g., social worker, chaplain), and personal care/services (e.g., massage therapist, yoga instructor). APPROACH: Interviews covered strategies that professionals use to initiate and maintain relationships, practices that cultivate professional fulfillment and preservewellness, and techniques that facilitate emotional pres-ence during interactions. Data were coded using an inductive thematic analysis approach. KEY RESULTS: Professionals identified self-care strategies at both institutional and individual levels that sup-port wellness. Institutional-level strategies include scheduling that allows for self-care, protected time to connect with colleagues, and leadership support for debriefing after traumatic events. Individual strategies include emotionally protective distancing techniques and engagement in a bidirectional exchange that is central to interpersonal connection and professional fulfillment. LIMITATIONS: In this exploratory study, the purposive sampling technique and single representative per occupation could limit the generalizability of findings. CONCLUSION: Across diverse fields, professionals employ common institutional and personal wellness strategies that facilitate meaningful engagement, support collegiality, and encourage processing after intense events. The transdisciplinary nature of these wellness strategies highlights universal underpinnings that support wellbeing in those engaging in people-oriented professions.

If human intelligence is the learned ability to gain from experience and the capacity to handle unfamiliar situations and manipulate abstract concepts while using experience and knowledge to change the world, then the concept of artificial intelligence (AI)—a huge advance in data processing and computing—would not easily compare with true human intelligence. In this Viewpoint, AI broadly encompasses machine learning, natural language processing, expert systems that emulate the decision making and reasoning of human experts, and other related applications.

The privilege of examining a patient is a skill of value beyond its diagnostic utility. A thorough physical examination is an important ritual that benefits patients and physicians. The concept of embodiment helps one understand how illness and pain further define and shape the lived experiences of individuals in the context of their race, gender, sexuality, and socioeconomic status. Understanding ritual in medicine, including the placebo effects of such rituals, reaffirms the centrality of the physical examination to the process of building strong physician-patient relationships.