Treating fear itself in the clinical setting

It’s been a tough evening at the after-hours care center. It’s the middle of the cough and cold season, patients are showing up in droves, and I’m the only clinician available to see them. I pick up a clipboard with the next patient’s encounter form attached, take a deep breath and let it out slowly as I step across the threshold into the examination room where a family waits. more»

Interested readers can now access my latest Art of Medicine column — Treating fear itself in the clinical setting — 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.

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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)

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.

Rhetorical persuasion in the clinical setting

It is Friday evening in the after-hours care center. All the scheduled patients have been processed. Each one has departed with a prescription in hand, their precious ticket to procuring a portion of the magic potion they imagine will make them better. more»

Interested readers can now access my latest Art of Medicine column — Rhetorical persuasion in the clinical setting — 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.

Plato and Aristotle

Tightrope

Like a small performance on the high wire, there’s an art to tightrope walking in clinical practice. more»

Interested readers can now access my latest Art of Medicine column — Tightrope — 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.

Philippe Petit on the wire

Lessons learned from the brute beast

Before he chose a career in writing, James Joyce was a medical student. He kept a model of the human fetus in the womb on his desk while he crafted the “Oxen of the Sun” episode in Ulysses. We can surmise that the theme of gestational development was constantly before his eyes and in his thoughts as he wrote. more»

Interested readers can now access my latest Art of Medicine column — Lessons learned from the brute beast — 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.

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