When a discharge instruction is overlooked

Suddenly, I think back to the other boy with the ocular injury I saw earlier this evening. I recall that I neglected to mention something very important in my final discharge instructions. I promise myself that this time round I won’t make the same error. more»

Interested readers can now access my latest Art of Medicine column — When a discharge instruction is overlooked — recently published in the Journal of the American Academy of Physician Assistants.

Please note that all of my previously published Humane Medicine pieces can now be accessed here.

Listeners and healers

At the end of a recent afternoon session at the office an informal discussion on the relative merits of the physical examination arose among the members of the clinical staff. The junior PA, an astute practitioner with three years of experience in the field, argued that quality medical care centers on careful physical examination of the patient. “It’s so important to develop your observational skills,” she said. “If you want to clinch the diagnosis, you’ve got to know what you’re looking for, regardless of whether it’s a heart murmur, a deviated eye, an enlarged spleen or a skin lesion.”

“That’s what they tell us in PA school,” the student piped up. “It’s all about learning clinical signs and symptoms.”

One of the older pediatricians had a different take. “So much of what we diagnose is actually brought to our attention by the patients themselves,” he said. “And with our modern technological advances, we can readily detect physical maladies. For instance, much of what we used to refer to as congenital heart disease is now diagnosed by ultrasound in utero. As clinicians, we would do much better to ask a few open-ended questions in the patient interview and then sit back and listen to what the patient has to say.”

This impromptu discussion got me to thinking: What does it mean to care for the patient in our age of accelerated technological practice, where computer driven devices allow us to glean volumes of lab values from minute specimens of body fluids; where sophisticated scans enable us to peer inside the living body and tag its idiosyncratic pathologies; where our modern pharmacological armamentarium allows us to treat previously universally fatal diseases with effective drugs and transplanted tissues and organs? Surely, there has never been a time in the history of medicine where the benefits of diagnosis and treatment have shown greater promise than now.

And yet, as we surge ahead toward more and greater technological expertise, might we be in danger of losing something in the process? Are we in fact overlooking the whole point of the practice of medicine — to cure sometimes, to relieve often, to comfort always? Have we in fact forgotten that first and foremost the art of medicine rests upon our ability to listen to the patient — and thus impart some degree of healing in the process?

A hospitalist colleague e-mailed me his observations on this topic.

“Soon computer capability may exist to diagnose and recommend treatment to a degree unimaginable right now. Such advances may ease the burden on the clinician and improve the quality of care. But without a human connection, such a medical encounter falls short of providing a healing environment.”

Doctors are now debating the relative merits of continuing to teach students the art of cardiac auscultation. In 2012 New York’s Mt. Sinai Hospital provided medical students with hand-held ultrasound devices capable of generating real-time images of the heart at the bedside. Such devices have proven to be superior to the physical examination, nearly doubling the likelihood of accurate cardiac diagnoses. There are those who would have us discard the archaic, inaccurate stethoscope for such sophisticated technological tools.

In a recent New England Journal of Medicine essay Dr. Elazer Edelman writes that “auscultation is a fading art.” Yet he makes a case for continuing to teach clinical medicine at the bedside, albeit by the use of an electronic stethoscope linked to a speaker. The projected sounds allow “everyone in the room to hear and understand what the patient is experiencing.”

“In teaching at the bedside,” Dr. Edelman writes, “explanations of the finer elements of auscultation are less important than what the sounds tell us.”

“Projected sounds … engage our patients, for they hear what we hear (often for the first time), and appreciate what we are doing (also often for the first time), which binds them to us and us to them.”

In the practice of clinical medicine Dr. Edelman opines: “We must in a sense become part of our patients — physically engaging them so that we can feel what they feel, sense how they suffer, and fully comprehend what they are trying to tell us.”

“It is not only the teaching of auscultation that is improved when physician and patient are tethered to one another, but also the teaching of patient care and the practice of clinical medicine.”

Dr. Edelman concludes: “The stethoscope can help us diagnose and teach, but above all it ties us to our patients.”

I agree with much of what Dr. Edelman has to say. When we as clinicians distance ourselves from the patient — either physically or empathetically — something of the caring aspect of the art of medicine is lost. But I would take it one step further.

If we wish to become true healers in our chosen vocation, we must take the time to train ourselves to listen, not only with our ears, but with our hearts as well. For it is only when we listen with the heart that we can truly hope to provide a measure of healing to the patient.

Edelman, ER, Weber, BN. Tenuous Tether. NEJM 2015;373:2199–2201 (December 3, 2015)

Hawk in the wind

While out for a mid-day walk in the biting January cold, I turned the collar of my coat up against the windy gusts that ripped the surface of the river, tore at the branches of the trees and sent dry leaves spinning upwards like whirling dervishes.

Standing on the concrete jetty behind the old mill, I suddenly looked up and chanced to see a red-tailed hawk overhead, struggling in flight, making little headway against the wind.

Buffeted, he braced, buckled, then barrel rolled directly into the wind; veered, braced, then buckled again; momentarily held tight, then was suddenly swept away, cast off into the southwestern sky, pummeled by a sea of pounding air.

His heroic efforts brought to mind Saint Exupéry’s description of flying into the rushing winds off the coast of Patagonia in the mid 1930s. According to Saint Exupéry’s account, “For three months of the year the speed of these winds at ground level is up to one hundred miles an hour.”

“In the first place, I was standing still. Having banked right in order to correct a sudden drift, I saw the landscape freeze abruptly where it was and remain jiggling in the same spot. I was making no headway. My wings had ceased to nibble into the outline of the earth.

“There was no longer a horizon. I was in the wings of a theatre cluttered up with bits of scenery. Vertical, oblique, horizontal, all of plane geometry was awhirl.

“Whenever I seemed about to take my bearings a new eruption would swing me round in a circle or send me tumbling wing over wing and I would have to try all over again to get clear of all this rubbish.

“I was wrestling with chaos, was wearing myself out in a battle with chaos, struggling to keep in the air a gigantic house of cards that kept collapsing despite all I could do.

“The first blow sent me rolling over and over and the sky became a slippery dome on which I could not find a footing.

“Here where I was, facing west, I was as good as motionless, unable to either advance or retreat….So I let myself drift to the left. I had the feeling, meanwhile, that the wind’s violence had perhaps slackened.”

Saint Exupéry concludes with this observation: “The physical drama itself cannot touch us until someone points out its spiritual sense.”

For me, it was much the same with the hawk.

“The Elements” in Wind, Sand and Stars, pp. 58-68.


Aeolian ice harps

With today’s high just above freezing, I set out on a mid-day jaunt about the village, determined to shake off the winter doldrums and stretch my legs.

A thin veil of snow carpeted the landscape below a brilliant blue sky. Down at the great bend in the river a gaggle of Canada geese sounded spontaneous greetings to others in flight overhead, while a pair of Mallards paddled quietly near the entrance to Pickerel Cove. Further downstream, two Mergansers rode the swift current before rounding up into an eddy swirling by the far bank.

The river had dropped appreciably over the past several days, leaving intricate ice formations on debris along the water’s edge. I snapped these photos of aeolian ice harps poised for an afternoon concert.

On this

On this, the last day of the year,
I arose in a noche oscura,
Wandered out into the fog
And glimpsed the sharp cold light
Of the waning moon
Above the shrouded pines.

On this, the last day of the year,
I fried French toast for my wife—
Breakfast in bed—
Washed the penultimate dishes
And peeled potatoes for a
Ham-and-green-bean supper.

On this, the last day of the year,
I paused before a gnarled tree:
Red berries encased in ice;
Motionless corpuscles frozen
Along arterial branches
Of a neighbor who died
This December.

On this, the last day of the year,
I crushed a block of ice melt
And scattered the remains
Over our front frozen steps
While a small brown bird
Piped his lively call
From a bare branched tree
Across the street.

A pearl on Pearl Harbor Day

Today marks the 74th anniversary of the Japanese aerial attack on the U.S. Navy fleet at Pearl Harbor, Hawaii. Of the 2390 U.S. servicemen and civilians who died on December 7, 1941, 1177 perished on the USS Arizona. Within hours of President Franklin D. Roosevelt’s speech the U. S. Congress declared war on Japan. Like many young men from that era my Uncle Sol was called up to serve.

My Uncle Sol would spend the next 4 years without leave working as a field artillery surveyor in the Pacific theater. During the war American GIs were forbidden by military censors to disclose their whereabouts to family members. In one of his letters home my Uncle Sol asked my grandmother to save the stamp on the envelope for his collection. By the time the letter made it to my grandmother’s hands, the stamp had been removed by military censors, along with the name of the island that my uncle had scrawled beneath it.

Years later my Uncle Sol revealed the name of the island where he had been stationed during the war. He spoke highly of the native people. They had been good to the American GIs, periodically preparing feasts for them garnished with plenty of locally grown fresh fruit. Many photos captured the camaraderie of these gatherings and served as keepsakes of happier times.

In his old age my Uncle Sol developed a number of health problems. He consulted a local physician-surgeon by the name of Suarez. At one of these visits in casual conversation my uncle spoke about his time of military service in the Solomon Islands. The doctor revealed that he had grown up in the same part of the world. My Uncle Sol dug up several photographs from that long-ago time and showed them to the doctor. After scrutinizing one of the black and white pictures, the physician-surgeon identified one of the locals. It was his own mother.

The surgeon-physician has since given up practice in the states and returned to the island where he grew up, the same island whose name my Uncle Sol had hidden beneath a stamp on an envelope that 70-some years ago bore one of his letters home.

When powders and potions won’t do

Practicing good medicine does not always mean prescribing medication. When powders and potions won’t do, sometimes education, a little reassurance — and advocating for the caretaker — go a long way.  more»

Interested readers can now access my latest Art of Medicine column — When powders and potions won’t do — recently published in the Journal of the American Academy of Physician Assistants.

Please note that all of my previously published Humane Medicine pieces can now be accessed here.