The Value of Patients & the Importance of Patience
Artificial intelligence, genuine empathy, and making the most of it.
I’ve written a bit about the use of AI in medicine over the past year, publishing more than 50,000 words and 40 articles on the topic through Substack alone. It occurs to me that it’s quite possible that I’ve written about artificial intelligence in veterinary medicine — and used it in practice— more than anyone else in the world.
This realization also forces me to recall a friend’s challenging comment about a year ago, “What’s stopping you from being the best in the world?” I didn’t have an answer at the time. I still don’t. A solid starting point, it would seem, is to find an intensely specialized niche.
I neither imagine nor claim that I’m the best in the world, but I do suspect that I’ve done more of this very specific thing than anyone else in the world. That time has imparted neither extreme expertise nor superlative skill, but I’ve enjoyed it.
Loafs and Fishes
While my writing and tinkering are largely inspired and informed by technologists, physicians, and researchers, I’ve focused on the utility of large-language models in veterinary medicine. I write about it because I didn’t stop at research, I use it in my clinical practice. These large-language models and their marvelous applications can help to improve our outputs in the face of mounting demands for productivity, they can alleviate our decision and executive function fatigue, and dramatically decrease the amount of time spent on rote tasks. Further, LLMs can take the harsh or heavy emotions out of our communications, lessen the burdens of emotionally demanding communication, and help us translate our technical and jargon-laden explanations into more accessible language.
All of that and more, but it can give us something more important than all of that: time.
Some in the veterinary industry cast the issues facing veterinary medicine as a productivity crisis. They clamor for the cruciality of ridiculous solutions like replacing veterinary care with telemedicine or having technicians perform surgery and unsupervised euthanasia. They undermine the veterinarian-client-patient relationship with lobbying and derogatory advertising. These are the types of folks who spend more hours with spreadsheets than with clients and more minutes worrying over investors than patients. That is to say that they believe they completely understand a job they don’t do and, bizarrely, feel entitled to exploit it.
As one of the 82,704 or so of us in clinical practice, I believe it’s less a crisis and more a matter of time.
And not just “time” in the sense that a finite numerical value is entered into a calculator as part of the measure of the productive, monetary, or rate of tasks completed, but “time” in the sense of focus, commitment, and lack of distraction in examining a patient in person, listening to and communicating with clients, and being not just physically but mentally present in the exam room with your client and patient.
We don’t really have the former version of time, despite the bean-counting, spreadsheet-wielders’ proclamations to that end. The commoditization of time has left us with a pervasive belief that everything we do needs to serve a goal in the future and more is always better. While the latter version of time is a much more important, more valuable, and slipperier commodity that exists only in the present moment.
There’s a parable of sorts about a New York businessman who goes on vacation to Mexico where he meets a fisherman. He asks the fisherman how he spends his days, and the fisherman tells him that it’s a miracle of loafs and fishes. The miracle is that he spends only a few hours fishing, and then spends rest of the day loafing on the beach and playing music with his friends.
The businessman is, of course, horrified. He insists that the fisherman work harder to make bigger profits, invest in a bigger boat, and then a fleet of boats, then building an ever-bigger business, and then once he’s made his millions, he can pay others to do the fishing for him. “And then what would I do?” asks the fisherman.
“Ah,” says the businessman knowingly, “then you could spend your day loafing on the beach and playing music with your friends.”
Some kind of miracle.
Rewards and Fairies
More than a few of us driven, ambitious, high-achieving, intense-as-a-personality-trait types seem to be always busy. There’s an event on the calendar, an appointment in the room, the phone is ringing, the To Do list ever-lengthening and we throw ourselves after the tasks. It’s been known to wear us out, even burn us out, but we don’t stop. Do we like it? Or do we need it? There’s a pleasant buzz about the hurry, an intoxicating thrill of the busyness of business, and it’s no coincidence that the word “rush” means both “to act with urgent haste” and “a strong feeling of exhilaration.”
I am equally guilty of indulging in this sort of behavior as I am of admiring this sort of behavior.
I’m a small business owner, the founder of a hospital. I drank the Kool-Aid of optimistic capitalism and tithed at the altar of the Morally Righteous Work Ethic. There is, delightfully, always something to do. The dopamine reward of a task completed or a problem solved is undeniably intoxicating to the mesocorticolimbic circuit, associated with incentive salience, associative learning, and positively-valenced emotions. Completing a task works on all aspects of the positive feedback loop; on desire, on positive reinforcement, and on the hedonic tone of intrinsic appeal. We never had a chance.
I write with enthusiasm and excitement about a technology that has the potential to help us do even more. It can make us faster! It can make us more accurate! More productive! It can take the human effort out of tasks so well that you’ll barely notice its absence! And I’ve done this more than anyone else in the world!
And I think I very nearly missed the point.
The power of this artificial intelligence, the real importance and real value of it, lies not in its power of removing the human interaction from tasks, but in doing so from those tasks that don’t require our humanity, our focus, our attention, or our time, so that we can give it back to those that do require those qualities. And do so in a way that enhances and enriches our human connections and relationships rather than taxes them. It is a technology that has the potential to demand less of our attention1 rather than more. It can give us the time and focus we need to be attentive to our patients, our clients, and ourselves.
“If you can fill the unforgiving minute,” wrote Kipling in his poem IF—,2 “with sixty seconds’ worth of distance run, yours is the Earth and everything that’s in it. And —which is more—you’ll be a Man, my son!” A line I once regarded as gospel from a poem that hangs on my office wall now seems a fantasy. It suddenly has the feel of an idealized notion of productivity, a mantra conceived in the Industrial Revolution and born in Edwardian England, carrying with it the optimism and ambition of the Belle Epoque, which may have some business guiding business but not the rest of one’s life. Unexpectedly, the notion of filling the unforgiving minute with sixty seconds’ worth of distance run has a utility similar to chasing fairies through a meadow.
Patients and Patience
While we pursue the care of patients, we hold little regard for the importance of patience. Physicians waited an average of 18 seconds before interrupting their patient in one study and 36 seconds in another.3 Accountant Terence O’Neil, in a lecture at WVC on behalf of Veterinary Management Group, spoke with enthusiasm about the remarkable profitability of a veterinarian’s “drive-thru” services.4 He also spoke critically of his own veterinarian, who spent six minutes with him talking about baseball and their own families instead of the minimum required two minutes to discuss his pet’s health. While I can complete a physical examination in two minutes, I wonder about its quality. And while I can express my findings almost simultaneously in that timeframe, I might doubt that they’ve been effectively communicated.5
I believe that the argument of efficiency experts more or less amounts to “if you’re more efficient with your time and make more money, you’ll have more time and money to do the things you want to do.” A decent point to make, even in its reductive form, I suppose, but the practice of medicine isn’t something I regard as a chore to be completed with greatest regard to maximizing speed and efficiency, or even as a job I do solely for money.
This profession is my life’s work, a vocation I believe imparts higher purpose to my time and is a vital part of this life I love. This isn’t what I do so I can do the things I want to do, it’s what I do because I want to do it. I’ve done it in barns and in hospitals, examining pets on tailgates, stalls, and exam rooms. I’ve done it in the rain, in the dark, and even, recently, with a baby boy in one arm and an ultrasound probe in the other.6 And even if it wasn’t something I loved to do, so great is the responsibility of caring for animals that I would want to do it as well as I can regardless of any other factors.
We have to be comfortable acknowledging that doing some things properly just takes the time it takes. And, with respect to Mr. O’Neil’s perspective, I believe that most veterinarians believe as I do. We don’t do this just for the money, we do this because we find joy and fulfillment in it. Though, sadly and cynically, I suspect that the veterinarian who finds a way to see twenty patients an hour will inevitably find, among his rewards for productivity, a request to see twenty-one patients an hour.
“There is one fundamental rule that transcends all others, and I’ll tell you what it is,” wrote James Herriot of his mentor Siegfried Farnan’s instructions to him, “YOU MUST ATTEND. That is it and it ought to be written on your soul in letters of fire.”7
Our attention is constantly taxed. We consume the informational equivalent, I’ve read, of nearly 200 newspapers a day. We are commanded to “pay attention,” constantly trying to make withdrawals from a finite account that offers no credit. To our patients, however, there is a debt that remains owed by an immutable mandate, “You must attend.”
You must attend, you must be attentive, you must pay attention. In a world that levies expense after expense on our attention with the genius of miraculous technology engineered by psychologists and behavioralists to command our every blink and moment’s focus, suddenly and in sharp relief, there exists a software that can be used to take it back. And how we choose to spend our time and attention can make all the difference in the world.
In giving that reclaimed attention back to our patients, we give it back to ourselves. In offering it back to our charges and obliging Siegfried’s command, we rediscover our humanity, reforge and strengthen the human-animal bond, and not only do better medicine for our patients but also to create more satisfaction and fulfillment for ourselves.
The dream I want to see fulfilled by the usage and refinement of artificial intelligence in veterinary medicine isn’t to use it so much and write about it so much so as to claim superlative expertise over the field, but rather it is to encourage its adoption in removing the time demands of rote tasks from doctors’ lives so that they can once again find the enjoyment and satisfaction in their practice, that they may attend their patients with all of themselves and in doing so delight in the doing of their life’s work.
I love what I do, and I want the other people who choose to do this to love it too.
I write this line straight-faced and unironically, at 3:12 AM, having awoken to a fussing baby and coughing bulldog, leaving a wife in bed, and deciding to go write this revised essay because I couldn’t get back to sleep.
The wife, baby, and bulldog are all fine. I checked on them before slipping off to write.
Kipling, Rudyard. Rewards and Fairies (p. 74). Kindle Edition.
It’s an interesting study and less damning than it sounds on the face of it. The vast majority of physician interruptions were considered cooperative. There were some interesting gender differences as well, for instance, male physicians were more likely to interrupt, but more likely to do so cooperatively. Male patients were less likely to interrupt. It’s a relatively small study, but it gets the brain churning.
It was a pretty cool use of an unusual space during COVID protocols, honestly.
And I could talk sports with clients all day long. A few of my clients are professional athletes, I’m way more interested in hearing about their jobs than I need to be.
Regarding the level of attention required to an infant, I assert that in that moment he was sleeping and demanded little in the way of attention, but still required the large primate holding him to sway back and forth to ensure he’d remain sleeping. When the large primate stopped swaying, he awoke to give voice to his opinion.
Herriot, James. All Creatures Great and Small (p. 71). Open Road Media. Kindle Edition.