Every 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?