Thursday, September 6, 2012

The Art (i.e. Human Side) of Medicine

     It has often been said that medicine is an art in addition to being a science, in that it is based, in part, on human-to-human interaction, with all the dynamics and pitfalls inherent in this process. There are qualities that  make a warm, interactive, "human" doctor, and we try to instill them in our medical students and residents both by lecture and by example. Below I will try to list some of the qualities and actions of which we try to make the students aware; some are actions to imitate and assimilate and some to avoid. This list is by no means complete, and the order in which it is presented does not correspond to the relative importance of the topics.
     Try to maintain eye contact. Patients complain that many of their doctors, especially referred-to specialists, spend most of their time entering data and looking at their computer screens.

     Always touch the patient at every visit, even if it is only to feel the pulse.

     Always sit down when you talk to the patient, so the patient doesn't feel hurried.

     Remember that ALL patients are anxious when in the presence of a doctor, and their anxiety increases sharply as the physical exam commences.

     If the patient has a chronic disease, there is probably also an element of depression.

     One of the most challenging problems in medicine is to help a patient with irritable bowel syndrome to realize that the symptoms and complaints are functional in nature.

     If the patient comes in with a cough, and you diagnose diabetes, the patient will feel untreated because you didn't "solve" the presenting problem.

     Always ask the patient what he/she thinks is wrong.

     Remember that the patient does not see and interact with you per se, but with Doctor You, so you are being viewed through colored glasses.

     Try to understand the patient's mental model of disease and acceptable treatment, or else your advice will not be fully followed, and possibly not followed at all.

     Roughly speaking, 25% of patients never fill the doctor's prescription, of those who fill it 25% never take it at all,  and of those who take it only 25% take it as frequently as prescribed.

     Always ask the patient which medicines their friends and relatives have given them to try.

     All patients have unspoken assumptions about their doctors, based in part on their prior interaction with authority figures as well as  with adults of the doctor's age and sex, and they will ascribe qualities to you that you do not possess.

     Please remember that no matter how intelligent your patient is, almost no patient has an accurate idea of how the body works, and is woefully ignorant of basic human physiology. (If I had my way, a year course of human physiology would be mandatory in every high school in the United States----I think that this would produce healthier patients.)

     Part of a doctor's responsibility is to define "normalcy" for the patient. Remember the old saying that an alcoholic is a patient who drinks more than his/her doctor does.

     Patients will emphasize and de-emphasize if not totally omit or forget parts of their medical history, in part due to the stress of seeing a doctor,  so I find it useful to repeat some questions during the patient's examination. In the hospital it is very common that the history I obtain from the patient on my morning rounds is different from the history the intern recorded in the medical chart the previous evening.

     In general, only a fraction of what you tell the patient will be remembered, and only some of your advice will be acted on.

     If the patient has a chronic illness, then the spouse is also under stress, and this stress is often ignored or not thought about by the patient's physician.

     I often call the patient the next day to see if further thoughts have occurred to the patient, or if any other questions have occurred to him/her, as well as just to "touch base", and I invite the patient to call me if new symptoms or questions occur.

     All my patients were told that if they called my office with a problem before 10 AM then I would fit them in that same day.

     If I had important instructions for the patient, I would type them out on carbonless carbon paper, with the note mailed to the patient and the copy placed in the chart, so that we each knew what the plan was.





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