The Price of 30 Minutes at the Bedside

A Case Against Efficiency

As usual, I arrived to work at the VA hospital in Boston one morning, having inherited a few new patients from the night shift. One of them had a concerningly high glucose level. It turned out he had declined to take his long-acting insulin before bed. Surely that explained it. We were able to get his glucose under control, and it felt like a small victory for my intern self. But he had the same problem the next morning. I glanced at the nursing notes from overnight, and one stated: "Patient refuses meds. MD Aware." 

He was missing not only his nightly insulin but also his clozapine, an atypical antipsychotic we use to treat schizophrenia when all other medications fail. The psychiatry consultant brought to my attention that missing one-too-many doses of clozapine meant we'd need to restart at the lowest dose, risking an acute psychotic episode in this patient. But simply telling him to take his medications or leaving them by his bedside did not work for him. 

I went to his bedside in the afternoon and sat at the foot of his bed. First, he only gave me one-word answers. I could pick up on his Caribbean accent. So, I told him a little bit about the Trinidadian and Jamaican friends I made in college. That might have opened him up. I was able to coax him into taking his most important medications and allowing us to draw the day’s labs. But it took no less than a 30-minute conversation. This became a daily routine.  It was no easy feat, but I felt immense pride in being the intern that could manage a patient most would think of  as “difficult.”

It is very unusual to spend 30 minutes at one patient's bedside every day. Sure, every once in a while, for family meetings or serious illness conversations. But my day-to-day as a medical intern consisted of going through what felt like a never-ending list of tasks: following up with consultants, entering orders, and loads of documentation, all interrupted by the frequent screeching sound of my pager, usually from a nurse on the ward, asking for some clarification, or alerting me of a patient's worsening status, or reminding me to put in that order for magnesium or potassium repletion. When my attendings told patients, "We'll be here all day if you need anything," I chuckled a little internally, knowing that while we're here "all day," we spend much of our work time away from the patient. 

Working in a lean- and efficient-to-be healthcare system as an intern made me feel like I was a cog in a wheel, moving people along an admission-to-discharge conveyor belt. But doing what was "extra"—and perhaps sometimes perceived as a barrier to being my most efficient self, like teaching belly breathing to an anxious patient hospitalized for heart failure—gave the work more meaning. It made me feel less like a cog in a wheel and more like an accompagnateur to my patients on their brief hospital journeys. 

The concept of accompaniment was often invoked and taught by the late Paul Farmer. It has many meanings in French, including going somewhere (on a journey) with someone, leading someone or a group on a journey, being present, or being there for someone. 

As he taught, accompaniment as policy varies by context. When I first became acquainted with his teachings, his application of accompaniment to healthcare felt intuitive. Growing up in Cameroon, "Accompagne-moi, s'il te plait!" is a phrase I used frequently. To ask an elder for a ride somewhere, or a friend or cousin to go on a short journey with me, just to have their company. --The English translation “come with me please” doesn’t do the term’s dynamism enough justice.-- In providing medical care, being a patient's accompagnateur means being there for them to the fullest and following their lead in manifesting what they need. It also means that the patient gets to say when the accompaniment is done, like my patients, who might tell me to leave their room and come back later.  

However, advancing patient care in the modern US hospital usually means spending a lot of time in front of a computer or on the phone. This is universally true for medical interns. A carefully done study found that interns spend, on average, only 13% of their time engaging in "direct patient care" (i.e., interacting with patients) compared to over two-thirds of their time on indirect patient care, such as calling consultants, following up on results, and writing notes.

But as so many patients need someone to accompany them, I gladly took on that role. I loved teaching one patient about belly breathing for anxiety and breaking through schizophrenic men's paranoia and justified mistrust of the medical system. They reinvigorated my commitment to being more than a cog in a wheel, doing the bare, medically indicated minimum.

Many would argue that accompaniment may not be sustainable. It certainly felt that way when my senior resident and I stayed at work three or four hours late, trying to figure out how our patient would access a critical but expensive medication before we could discharge her. Each time I had patients with severe mental health disorders requiring more TLC than average, I felt that I was drowning. (I imagine my nursing colleagues may feel similarly.) I was drowning because we deliver care in a system meant to be efficient, and we're not always best equipped to respond to patients' needs when the system requires more redundancy. There are never enough hours in a day. Perhaps the most emblematic of the harms of efficiency-driven healthcare is that when providers are stretched thin, we are more at risk of using shortcuts. Such is the case with the overuse of sedating medications with elderly patients who are agitated. And beyond feeling overwhelmed due to system demands and being cognizant of how deeply unequal our society is, I often have felt a sense of despair because once our patients leave the hospital, I fear they lack the social support necessary to keep them from worsening again.

In his 2018 Harvard Gazette interview, Paul Farmer said cries around sustainability were failures of imagination. He argued that many well-meaning people are socialized to think of scarcity as normal, but always on behalf of others: “But scarcity for ourselves? No. Scarcity for our mom? No. For our own kids? No. We’re socialized for scarcity for other people, and they’re usually Black or brown or poor.”

I agree. We can and should fight for healthcare that isn't driven by efficiency as much, and instead of accepting scarcity as a matter of fact, fight for abundance. After all, abundance is what we have, to an extent, for the wealthy. This manifests in the form of VIP care, including special hospital units with relatively luxurious amenities at an extra cost and special treatment such as more expedited care, sometimes at the expense of the poor within the same health system. But even though disease, illness, and injury make a preferential option for the poor, our for-profit healthcare system doesn’t. 

A healthcare system that embraces abundance would, for instance, preferentially provide one-to-one nursing care to medical patients who also have severe mental illnesses. And, of course, no, it isn't "cost-effective" to do so. But it feels like the right thing to do: deliver the best care. It also doesn't seem realistic or achievable soon, but like with every patient, we try our hardest. And because we may fall short of those ideals, being my patients' accompagnateur does not stop at the end of their hospitalization or clinic visit. It also means, for instance, supporting nursing unions' pleas for better staffing ratios, doing research and advocacy work that bears the promise of helping improve people's material, living conditions, and their access to the best care there is. Accompaniment is, after all, as Paul Farmer would say, elastic.

This essay was originally published in Peste Magazine, a literary magazine about health journalism, advocacy, and the arts.