RELATIONSHIP: Which relationships will be impacting depending on the choices he makes right now? His relationship with this patient? Her husband? Her son? All of them? His supervisor? His wife and daughter? In whose best interest does he act? His own? His patients? Her family? His family? His reputation in the health system he works? His supervisors? All of these relationships are now entwined in this short burst of time—reducing his options and multiplying the complexity and sense of threat he is experiencing. His pulse quickens and now there are several beads of sweat as he glances at the door trying to figure out how to conclude this most uncomfortable, threat-inducing time with his patient.
FAIRNESS: What is the fairest way in which to proceed? A justice-focused pathway? A health-focused pathway? Who will judge the fairness of his next steps to address this complex and uncertain situation? Does he have the resources to support going in both directions together? For justice and health? Why does that not feel possible to him right now as he sits nervously with his patient? What resources might he need to very quickly and effectively address the threat and begin to shift into a challenge mind-set? Can he approach a fair and just response with such limited time and limited people resources?
Judges who work in the justice and fairness domain have far more control over time and decisions. When faced with complex demands, a judge might postpone hearings for months to prepare and have dozens of people help prepare—yet a primary care physician like Dr. Jones might find only an MA and a waiting patient as he attempts to address complex and urgent situations like today.
So, how does Dr. Jones begin to shift from the clear sense of threat he experiencing into a more challenging and rewarding mind-set? A lesser physician would shift the threat to the patient and begin to silence her before she says too much—“I have to get to my next patient, please make a follow-up appointment in 1-2 weeks for further discussion, you are bringing up matters that require more time and I don’t have the luxury of time today” without even addressing the mandatory reporting for what was already revealed, perhaps making the patient feel like her problems are not his own to address and can wait.
She might choose not to come back, feeling dismissed and lodge a complaint against the doctor. I suspect that is likely the most common response to such situations in our low-resource Primary Care environment where “productivity” is defined by “number of people seen by doctor” and not “number of people actually helped by doctor or having improved outcomes through visit with doctor.” It is called “productivity” yet it is really “efficiency” a far less impactful measure of the value of time with one’s primary care physician. Regardless of how he proceeds, this will be seen as a “productivity” problem by those who review his care as he has already been in the room for 20 minutes before he swiftly exits without formally addressing the most alarming aspects of the visit.
How might changing the context of care from Individual Physician/Individual Patient toward that of Primary Care Team including the patient begin to help shift Dr. Jones from Threat toward Challenge and Reward mind-set?
