Friday Jun 27, 2014
What You Didn't Learn in Medical School: Prescribing a Dose of Yourself
I sat on the edge of her bed in the nursing home and listened patiently. I would ask a question or clarify her statements occasionally, guiding her through her medical history and learning about her life to this point.
A stroke had affected J.L.'s ability to communicate. Her speech was clear enough, but she had expressive aphasia; she literally couldn't find the words.
Although she had been in this condition for some time, I could tell it was as frustrating for her as if it had started yesterday. Both the hospice nurse, who knew her well, and I would occasionally help her complete her thoughts; a sort of real-life Mad Lib. Near the end of this discourse, J.L. began to get emotional. Her lip quivered and her eyes welled up with tears, but she still had a satisfied smile on her face. I was perplexed, but the hospice nurse smiled at her, gripped her hand and said, "This is the first time someone took the time to have a conversation with you, isn’t it?"
J.L. nodded, and after a concentrated pause said, "Yes."
The day-to-day life of a physician can easily slip into a rut, especially in many of today's practices where encounters with patients are compartmentalized into 10- to 15-minute slots. The clock can be an unforgiving master as the morning or afternoon dwindles away. We start to feel the strain of every extra minute spent in a room, realizing we will pay for it by working through lunch, suffering the irritated glare of the next waiting patient or staying late to finish documentation.
I have found myself making the diagnosis shortly after entering the room, and the rest of the visit becomes a rushed formality.
It is easy to forget that although the process of diagnosing and treating a simple condition may seem straightforward to us, to our patients, it can remain an enigma. I have found that it is possible to prescribe the appropriate treatment and still have a sick patient. Other times, I might make the wrong diagnosis, but the patient feels better anyway. For most patients, it is the unknown or the feeling of isolation that makes the condition unbearable more than the symptoms themselves.
So what's the cure for that? The answer is deceptively simple: It's you. In my earlier training as an occupational therapist (in a former life), we called this "therapeutic use of self," and it is the most important skill I didn't learn in medical school.
For some, this talent seems virtually innate, but fear not; it can be learned, or rather, remembered. I would be willing to bet that for most of us it was a reason why we started on this road in the first place. Before we understood the pathophysiology of cystic fibrosis or the risks indicated by specific genetic markers in breast cancer, we only knew that we wanted to, and could, help people.
Then medical school came along and taught us that the best way to help the patient was to make the right diagnosis -- most times by ordering a slew of tests that often entail discomfort, at the very least -- and start treatment as expeditiously as possible.
I agree wholeheartedly that this approach can help the patient, but what about the person? To make the person well, we need to give of ourselves. Sit at the edge of the patient's bed in the hospital. Let her tell her story. Make eye contact and use open body language. Ask him something about his life that has nothing to do with his diagnosis but may have everything to do with who he is as a person. Don't be afraid to touch her knee, squeeze her hand, or even give her a hug.
Reassure the patient that if he has a question or a problem, you will be there for him. And finally, it is OK to cry in front of your patients.
Therapeutic use of self moves us from influencing the condition from the outside to becoming more involved. When you partner with the patient in the process, rather than acting merely as a consultant, that person realizes that you are willing to listen and to try to understand. This alleviates the patient's fear and anxiety and reduces his or her isolation. It also will build a more rewarding and fruitful partnership between you and your patient, and in some instances, our humanity will begin to heal what science could not.
The clock will always tick away sternly, and I still try to be as efficient as I can. But my efficiency has a purpose: It allows me to spend those few precious moments with my patients when what they really need can't be scribbled on a piece of paper.
G.B. was pregnant and well into her second trimester. She developed a right-sided abdominal and flank pain. She was in significant discomfort and worried about her baby. She went to the local ER and was transferred to the obstetrical unit in a tertiary care center.
Everything with the baby looked fine, and they could not find an explanation for her pain. She was discharged and followed up with me the following day in clinic. I sat with her and her mother and reviewed the hospital lab work and notes, going over them with her and listening to her history. I completed a thorough and careful physical exam.
When I had finished synthesizing all the information, I had a few theories but no firm diagnosis. I reassured her that although her problem was painful, I was sure it posed no acute threat to her infant's health or her own. She saw her obstetrician the next day, and I called her to follow up after that visit. Although she was still in significant discomfort, the pain and fear had disappeared from her voice.
"You know what's strange about the whole thing?" she asked. "Through all that, you were the only one who examined me."
The secret lies in remembering that our patients are people, not diagnoses, and sometimes the best medicine is not a medicine at all.
Peter Rippey, M.D., is a board-certified family physician who maintains a private practice in rural Missouri. He enjoys a full spectrum practice with a focus on community and collegiate athletic coverage.
Posted at 04:58PM Jun 27, 2014 by Peter Rippey, M.D.