At a medical society gathering last year, I was asked to share my thoughts on a half-century of medical practice. This article—my chef-d'oeuvre, of sorts—is a compilation of those remarks.
The practice, art, and science of medicine have been my life. My grandfather practiced general medicine in a small town in Michigan. As a boy, I often visited his home, which also served as his office. After entering through the front door, patients turned to the left to the exam room; the parlor and family quarters were to the right. During meal times, patients frequently came around to the right side of the house and rapped on the dining room window. The old man would fume, but he always got up to attend to them.
When I was older, I accompanied my father, an orthopaedic surgeon, on his rounds at St. Mary's Hospital in Huntington, W. Va. The Pallottine Missionary Sisters, who established the hospital, would inquire with heavy German accents, "Vill you make a doctor like your fater?" To this heritage, I offer reflections on my own life experience.
Today's world attempts to delineate between the so-called "learned" and "caring" professions. Law and medicine are assigned to the former, and a myriad of social service categories to the latter. Nothing dangles in-between. I believe that the recipient of these attentions is best served if the provider is well-grounded in both arenas. So intertwined are the human soma and psyche, it is foolish to divide this responsibility. In my 52 years of private practice, every aspect of health care has changed except one—the patient.
The ability to aid one's patients is based on a knowledge of normal health, disease, and the reaction of a patient's body and mind to both health and illness. However, physicians can do many things to benefit their patients above and beyond their scientific knowledge.
Healers from all cultures share common traits. They aim to establish personal relationships with their patients, within the context of the patient's culture and experience. In this sense, both allopathic and osteopathic medical practitioners are probably only a half-step removed from our ancient forebearers and cousins in healing, such as medicine men, priests, or spiritualists.
The three As in patient care are Ability, Affability, and Availability—although not necessarily in that order of importance. And perhaps the finest placebo is a thorough history and careful physical examination, because they reassure both the patient and the physician that if no pathology can be identified, a satisfactory outcome can be anticipated.
When taking a history, physicians should avoid towering over their patients; sit down and stay at eye level. The act of sitting implies plenty of time to listen to the patient's complaints. Try not to interrupt patients. In my experience, even the most verbose patient cannot continue to talk longer than 3 or 4 minutes without pausing for breath.
There is something cleansing—a therapeutic catharsis—for patients to detail in their own words the duration, nature, and extent of their problems. By telling their stories, patients can share and, perhaps to some degree, transfer their apprehensions and concerns to the physician. At some point the physician will want to direct specific questions to the patient, but the physician should try not to lead the interview, especially during the opening phase. Physicians should also listen to what is not said. Omission is as important as inclusion.
A certain amount of information can be gleaned by observing the patient during the walk from the reception area to the examining room. During the orthopaedic physical examination, it is useful to ask patients to perform certain activities, such as climbing stairs, jumping, hopping, or picking up an object from the floor. This shows patients that they may be capable of more effort than they originally assumed. If the patient is a child, observed performance is also helpful in educating parents on their child's ability to function.
As people mature and develop physical problems, the need for a caring physician becomes paramount. Accepting the impact of aging can be easier with an understanding physician who interprets signs and symptoms and is supportive during the resolution of problems. Aside from manifestations of the aging process, most human complaints and/or symptoms are self-limiting. For example, of 800 consecutive patients who came to our practice complaining of low back pain, only 5 percent eventually had surgery.
Physicians learn from observing their patients. The more time we spend observing, the greater will be our fount of knowledge, as well as our understanding of our fellow man. My staff used to question why I put my own casts on follow-up patients rather than permitting them to. This was my attempt to extend the contact time with the patient.
A friend of mine, also a third-generation physician, always personally takes the patient's blood pressure. When queried, he merely states it ensures that he will have physical contact with his patient because he believes in a correlation between the amount of physical contact and the outcome of the encounter.
A pediatrician once told me that I would learn more about a patient in one visit to his home than during five office visits. My experience supports this observation. If physicians have the time, inclination, and opportunity, by all means they should avail themselves of this chance to learn more about the patient.
In the hospital setting, consider this option: After attending to routine concerns, questions, and physical findings, sit down for a moment and ask an open-ended question about the patient's thoughts, feelings, and concerns. This transfers the visit from the physician's "making rounds" into a person-to-person encounter. It levels the playing field.
I would urge surgeons never to embark on an elective surgical procedure during that period following the death of a spouse; the period of bereavement and grief is a poor time to introduce further physical and emotional stress.
I continue to wrestle with how to communicate the genuine receptiveness that permits patients to articulate their troubles. A combination of visual, verbal, and tactile contact by the physician conveys understanding, caring, and, yes, healing. I used to think this skill was instinctive. It is not. Over the years I have seen my partners struggle to acquire this skill, as I once did. Basic human communication and interaction can be learned and is much easier to acquire if one has a good role model.
Today, forces in medicine may work against caring for the patient. The electronic medical record (EMR) may ensure—in theory at least—that information cannot be misplaced or lost. Templating and recording trivia, however, detracts from concise documentation of vital information that may lead to a diagnosis and appropriate treatment planning. The next phase of compulsory diagnostic coding may, in my opinion, lead us into further minutiae and a spending of untold time and energy akin to determining the number of angels that can dance on the head of the pin.
During the interview process I urge physicians to turn their backs on the computer and squarely face patients while listening to their stories; nothing is more important to either of you. There's time later to record immortal thoughts. Don't allow the inherent impersonality imposed by processing data in EMRs to compromise the ability and need to connect with patients in a meaningful way. Connections are necessary to improving the quality of their lives.
Much emphasis is placed on the "team approach" to medical care. Allied health personnel and alternative practitioners unquestionably add much to patient care. However, disease and its effect on the patient is personal. Emotionally, I believe, the patient yearns for the individual, one-on-one relationship with the physician to achieve relief. As orthopaedists, we must accept and assume this special responsibility. Our patients will be the better for it.
Thomas F. Scott, MD, is an emeritus fellow of the AAOS, who continues to serve as a consultant at Scott Orthopedic Center in Huntington, W. Va.