Archives for posts with tag: medical education

modern-decor-lucite-giraffe-jonathan-adlerEvery week I precept (teach and supervise) in the residents’ internal medicine clinic at the Outpatient Center of Johns Hopkins Hospital, on Caroline Street in Baltimore. The patients are mostly Baltimoreans, mostly African Americans, though an increasing number are Spanish-speaking immigrants.

I tried something new these past couple of weeks. Whenever a resident presented a patient to me (as is required), I listened to the introduction, smiled, and then let myself interrupt with the following request:

“Please tell me one non-medical thing about the patient.”

You see, most often, the patient is presented this way: “Mr. S. is a 69 year old man with CKD [chronic kidney disease], bipolar [disorder], CAD [coronary artery disease], hypertension and hyperlipidemia, here for followup.” But I was interested in knowing something about the patient as a person, when he’s not in clinic.

The residents’ responses to this request of mine seemed to fall into one of several categories.

There were those who had clearly never thought of such an approach; one said, “The patient is very pleasant. Does that count?” No, I said. A number of residents seemed to recognize that they might indeed ask about, for example, where the patient lives or what they do, but they hadn’t had time.

Still others had asked about such things, but needed to be given permission, so to speak, to talk about such things right up front – to give the patient’s love of crossword puzzles, devoted membership in her church choir, and collection of giraffe figurines the same pride of place as her creatinine and medication adherence.

(There was even one resident who gave a laugh and went right on with her presentation — I’m not sure if she didn’t understand, or was just ignoring me.)

None of the residents gave such personal information about the patient in the lead-in to their presentation before I asked for it. Only certain kinds of knowledge of patients are allowable – their biomedical data, their physiological malfunctions, and (some of) their symptoms. But not their personal lives, not what makes their lives — to them — worth living. Not them as people.

Of course, the criteria of allowable knowledge are transmitted only implicitly in medical school and residency. But they are powerful. They are an atmosphere all around a doctor in clinic – so much so that even I, several rungs above residents in the hierarchy, feel self-conscious asking them to give me one (just one!), apologetically named “non-medical thing,” about a patient. And even then, I must justify it — “It’s about seeing the patient as a whole person.”

What non-medical thing have you asked your patient about, or shared with your doctor?

It’s now about two weeks till the book comes out. As an appetizer, I’ll be writing brief posts almost every day till then about topics relevant to each chapter. Today, it’s chapter 1, where I talk about the most frequent procedure – the medical interview. As usual, this is crossposted.

The conversation between the doctor and the patient is the most common opportunity for the doctor to try and heal. As I point out in the book, there are many ways in which this conversation is often suboptimal, overlooked, and given short shrift in medical education: both in the training of medical students and in the continuing education of medical professionals.

On the way to what we hope will be systematic reform in both professional practice and medical education, which will privilege personal interaction over the quick fix of reflex procedure or lab test, it is – unfortunately – mostly up to the person adrift in our health system to find the doctor it is actually possible to talk to.

Which kind of doctor should that be, though? Ideally, you find a combination of skill, knowledge, personality, and sympathy, someone you can stick with for a while. Like as not, that person does not exist.

But if we stick it out with the imperfect person who inhabits the exam room, perhaps we can train them to be a better doctor (or nurse, or PA). Yes, part of our role is to improve matters even if we are the patient, even in the midst of our pain and illness.

The doctor has to measure up but we have to help them do it.