{"id":32588,"date":"2014-10-23T16:42:35","date_gmt":"2014-10-23T15:42:35","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmj\/?p=32588"},"modified":"2015-09-22T14:33:52","modified_gmt":"2015-09-22T13:33:52","slug":"william-cayley-social-history-consultations-and-patient-time-vs-patient-time","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmj\/2014\/10\/23\/william-cayley-social-history-consultations-and-patient-time-vs-patient-time\/","title":{"rendered":"William Cayley: Social history consultations and patient time vs patient time"},"content":{"rendered":"

\"bill_cayley_2\"<\/a>Who are you, what do you need, and how do I figure out how to care for you?<\/p>\n

Fundamentally, those are the questions that drive every encounter between a doctor and a patient. A recent article<\/a> in the New England Journal of Medicine<\/em>\u00a0calls for us to expand the \u201csocial history\u201d facet of this to include six domains: individual characteristics, life circumstances, emotional health, perceptions of healthcare, health related behaviors, and access to and utilization of health.<\/p>\n

The authors acknowledge that in primary care such comprehensive information may be \u201cbest obtained over multiple visits,\u201d which is possible in a long term continuous relationship, but this still presents the challenge of how best to gather the history and what to do with it.<\/p>\n

In gathering a social history, it is important to consider whether the primary issue at hand is the information\u00a0that is gathered (e.g. documentation of resuscitation preferences, tobacco use, or marital status), or the conversation\u00a0and relationship\u00a0building. Sometimes, even the most thorough gathering of social history leads to the same amount of essentially flat and affectless note taking as reviewing a medication list. This can lead to both missing the patient\u2019s story, and focusing on what has already happened at the expense of what could be done about it.<\/p>\n

To illustrate:\u00a0when I discuss smoking, to an extent I don\u2019t care exactly how many packs my patient has smoked, I want to talk about how we can make it less. And, to an extent, I don\u2019t care how much a patient drinks (if more than occasionally). For rather than focusing on quantifying the history, I want to engage in a discussion of whether there have been or are likely to be consequences, and again how we can work on cutting back.<\/p>\n

On the other hand, sometimes documentation of the social stuff is important (again, resuscitation wishes, etc). And we need to be clear in our own heads when\u00a0the \u201csocial history\u201d conversation is about documentation, and when it is relational or therapeutic, as they are different types of conversation.<\/p>\n

The other side of this, however, is the issue of time. This is not just \u201cpatient time\u201d versus \u201cpaperwork (or computer) time,\u201d or the oft heard complaints about being expected to \u201cproduce\u201d too much clinical volume to be able to give good clinical primary care. This is about \u201cpatient time\u201d versus \u201cpatient time.\u201d<\/p>\n

I\u2019ve had several visits recently with folks who love to chat\u2014and that\u2019s great\u2014and from at least one of those chats I learned the extent to which the patient\u2019s primary health concern was really about the health of another family member. It\u2019s wonderful to spend a lot of time with folks,\u00a0and to be thought of as \u201cthat patient, caring doctor.\u201d<\/p>\n

Yet we are not simply \u201cprofessional friends,\u201d we are in the profession of caring for the sick, and the sick person who I go in to see 20 minutes late, because of\u00a0wonderful conversations with other patients, does not care how wonderful those conversations were. Setting aside all the (very valid) concerns about whether we are \u201cexpected by the system\u201d to do too much \u201cstuff,\u201d we also need to figure out how to practice (and teach our learners to practice) in a way that gathers useful social information, and builds relationships, while still\u00a0doing this efficiently enough to care for the people waiting in line in the waiting room. We want to provide thoroughly compassionate care, but we care for a population,\u00a0and sometimes other members of that population come in with an acute illness presenting an unexpected need.<\/p>\n

Understanding social context is fundamental to understanding our patients, and exploring that social context can be valuable\u2014not just for the information gleaned, but also for the relational healing connection that comes from compassionate listening. Nevertheless, to care for the sick means being available not only when schedules allow or when it is convenient, and it means that sometimes relational work with one patient may have to be sacrificed to attend to compassionate care for another.<\/p>\n

Thoroughness, care for all our patients, and timeliness:\u00a0all are important, but it is nearly impossible to meet all three goals all of the time.<\/p>\n

William E Cayley Jr<\/strong>\u00a0practices\u00a0at the Augusta Family Medicine Clinic; teaches at the Eau Claire Family Medicine Residency; and is a professor at the University of Wisconsin, Department of Family Medicine.<\/em><\/p>\n

Competing interests: I declare that I have read and understood the BMJ policy on declaration of interests and I have no relevant interests to declare.<\/p>\n","protected":false},"excerpt":{"rendered":"

Who are you, what do you need, and how do I figure out how to care for you? Fundamentally, those are the questions that drive every encounter between a doctor and a patient. A recent article in the New England Journal of Medicine\u00a0calls for us to expand the \u201csocial history\u201d facet of this to include […]<\/p>\n

Read More…<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[1357,14769],"tags":[],"class_list":["post-32588","post","type-post","status-publish","format-standard","hentry","category-us-health-care","category-william-cayley"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmj\/wp-json\/wp\/v2\/posts\/32588","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmj\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmj\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmj\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmj\/wp-json\/wp\/v2\/comments?post=32588"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmj\/wp-json\/wp\/v2\/posts\/32588\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmj\/wp-json\/wp\/v2\/media?parent=32588"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmj\/wp-json\/wp\/v2\/categories?post=32588"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmj\/wp-json\/wp\/v2\/tags?post=32588"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}