In the medical field, it is said that July, not April, is the cruelest month. It even has a name, the July Effect. In June, hospitals hum and smoothly operate after a year of working out the kinks. In July, they welcome, or dread, the arrival of new recruits: newly minted physicians and medical students, eager to prove themselves, yet raw and untrained. For me, as a senior resident, it is the best time, when the memories of my intern year meet a desire to teach and to mentor this fledgling group. During a teaching session where the interns are quick to flaunt their knowledge by reciting lists of medical facts, one medical student asks me a striking question: Is this what makes a good doctor?
This question follows me as I head to my clinic. My first patient walks through the door. A 56-year-old gentleman who has high blood pressure, diabetes, and high cholesterol, greets me with a solid handshake and a booming “Hello Dr. Chan!” You can hardly notice that he had a stroke a year ago. The strength in his right leg has returned, and he looks fit after months of physical therapy and exercise. We chat about how life is going. He has returned full time to his job as an air conditioning repairman. It turns out he is also training students. “Sometimes they don’t know the practical aspects of the job” he laments. “But I have a surprise for you doc, I’ve finally quit smoking!” he exclaims, and I look at him, beaming. We had spent many visits talking about his smoking. Based on the results of recently published studies, we adjust the medications that control his blood pressure. I schedule a follow-up visit, and we say goodbye.
My next patient is accompanied by her sister. She is a healthy 35-year-old who is early for her annual visit. She is more restless than how I remember her. “Tell the doctor what you told me,” her sister urges her. She looks down at her feet. “Are you depressed?” I ask. She nods and says she is worried about school, and her job is stressful. From my computer, I see that other patients are beginning to arrive. I interrupt and begin a medicine to help with her mood.
The day becomes rushed as patients stream into clinic. A 58-year-old homeless woman comes because she walks only a few feet and becomes short of breath. A 32-year-old feels like he is walking on needles. A 46-year-old with wheezing. Another has chest pain. As I see more patients, I find myself speaking less, examining less, explaining less. It seems the main interaction at each visit becomes the one I have with my computer and my connection to each patient is slowly eroded. At the end of the day, I return to the medical student’s question, what makes a good doctor?
Increasingly medical schools, hospitals, and the media are asking this question, perhaps because it is becoming more difficult to answer succinctly. As we train doctors in medical school and residencies, we try to prepare them for the modern health care environment. We prioritize efficiency, which occurs at the expense of listening to our patients. We use technology to improve clinical safety and quality, but at times it prevents us from giving patients our full attention. We implement population-based guidelines, which we sometimes follow blindly without regard for the nuances in caring for an individual patient. It is easy to forget in the long course of medical training that the training itself is not the goal, nor is it the creation of the perfect physician. Instead, as Francis Peabody, a Harvard physician and great humanitarian wrote, “Medicine is not a trade to be learned but a profession to be entered. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”
Health care and medical education will constantly evolve, but central to the profession of being a physician still remains the relationship between us and our patients. In this light, everything else that seemed of great importance will begin to grow dim. Armed with this perspective, even as medical practice rapidly changes around us, we will avoid being swept away by the waves of dehumanization. A “good doctor” ultimately understands the humanity the patient and the doctor share together.
During my intern year, one of my patients was a 93-year-old Spanish-speaking lady. Her medical issues consisted of hypertension, hypercholesterolemia, and osteoporosis and she was admitted to our hospital after falling. I knew the list of medications she took at home. Blood tests showed that her heart was not functioning well. During the discussion with the supervising physician, I impressed him with my in-depth assessment of her case, from a molecular level to her current presentation and how we would care for her. We had our diagnosis and with efficiency and precision; we treated her.
I knew her, but I did not know her. When she was brought in, she was transferred from the familiarity of her home, surrounded by family, to the strangeness of our hospital, where an interpreter was needed just to communicate a simple greeting. She had lived 93 years of a full life before this episode, a perspective lost amidst of the medicalization of the patient. I failed to mention or even consider this aspect of her identity. As she lingered in the hospital, she seemed to improve at first, but then unexpectedly died overnight.
She was the first patient to die under my direct care and in my mind, I have recalled this scene many times since. The family, which was composed of many relatives, came to see her, and as I began to speak, they surrounded me in a large semicircle. I tried to deliver the unfortunate news, but my words are like drops of mud on the floor. Her sudden death sparked the realization that I did not truly know her and so, what do you say about someone you do not truly know? I ran out of words and fell silent. The attending physician took over and continued the meeting. Afterwards, I told him my conflicted thoughts, and he reminded me, to truly know a patient is to consider who they are outside of their medical condition.
And this is the lesson that formed the answer I ultimately gave the medical student with the striking question. Never forget the humanity of our patients, I told her, despite it being a difficult task at times, for this is what makes a good doctor.
Isaac S. Chan is a hematology-oncology fellow. He can be reached on Twitter @ithinkichan.
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