Treat your patients as people first, then as patients. Don’t be dismissive of their symptoms and pain. Be aware of your implicit biases based on your patient’s age, gender, or race. Remember that the medical experience often frightens and intimidates them.
Those are the lessons that three patients offered to doctors at the closing plenary session — entitled “Our Calling, Our Patients: Reflections on the Patient-Doctor Relationship” — at Learn Serve Lead 2023: The AAMC Annual Meeting, on Tuesday, Nov. 7.
The stories they told, both good and bad, of going through diagnosis and treatment for severe illnesses reinforced the advice delivered to physicians by moderator Abraham Verghese, MD, MACP, a professor at Stanford University School of Medicine and a bestselling author: “Find those things in medicine that are timeless, that are unchanged since antiquity, for which we should get our sustenance. And for me that thing is the patient-physician interaction."
When Suleika Jaouad, MFA, began feeling almost debilitated in her early 20s by extreme fatigue and “a mysterious relentless itch,” a doctor said they had a psychological source and sent her home with a prescription for the antidepressant Lexapro. As symptoms expanded, another doctor diagnosed anemia, explaining that it is “common in young women,” and prescribed iron. As Jaouad grew more ill, doctors recommended one month of medical leave from work.
Eventually, Jaouad was diagnosed with leukemia. She was cured, but the disease recently returned.
“As patients, it is often a struggle to be believed,” Jaouad said. “I know my medical team loves and respects me, but I haven’t always felt listened to or taken seriously. We have a lot of work to do in terms of confronting biases around gender, age, class, and race.”
Maya Feller, MS, RD, a registered dietitian nutritionist, was cruising through her first pregnancy in 2016 when she suddenly started feeling extreme pain. Her gynecologist determined that the pain was caused by a large fibroid that was degenerating; he sent her home with ibuprofen.
Within 24 hours, she was in preterm labor. And 24 hours after that, Feller recalled, “I walked out of a local public hospital empty-handed.” Her newborn son did not survive for a day.
Feller had a renowned gynecologist, but wonders if her race and gender contributed to her doctor minimizing her symptoms.
“Implicit bias is tricky because it’s all around us,” Feller said. “We don’t realize when it’s influencing how we view a patient and how it colors the assumptions we’ve been taught to make based on a patient’s race, gender, and socioeconomic status. … The double burden of being a woman and Black while navigating health care feels like life or death at times.”
Ryan Scoble was enjoying his studies and playing lacrosse at Mercyhurst University in Pennsylvania when, at age 21, he was diagnosed with cardiomyopathy, a disease that makes it harder for the heart to pump blood. As his condition worsened — his heart pounding so hard that it awakened him, his legs too weak for him to walk — doctors decided that he needed a heart transplant.
Not long after surgery, his new heart developed irregularities that disrupted his heartbeat to the point where one doctor determined that Scoble had to return to surgery for a new pacemaker. Scoble thought of this physician as “Dr. Detached,” because when he visited Scoble’s hospital room with residents, he referred to Scoble by his patient number, not his name.
But another physician, who had taken the time to know and bond with Scoble, urged patience. “He knew me. He knew I was young. He said, ‘Let’s monitor the heart’ for a few more hours. My heart was soon kickin’ and no new pacemaker was needed,” Scoble said.
Scoble feels forever indebted to the doctors and nurses who saved his life. But, he noted, “there were many instances in which I was looked at as if I was a car being worked on. I didn't feel that I was always looked at as me, my 21-year-old self, scared in the hospital. When I did have doctors taking that extra effort to acknowledge me and my fear, it helped tremendously.”
Several weeks ago, Verghese spoke with AAMCNews about the erosion of the doctor-patient visit and why he urges doctors to “find their passion in each patient encounter.”
You speak a lot about the importance of doctors and medical students in spending time with patients and finding beauty in the doctor-patient relationship. Yet the trend has been toward more use of technology, tests, and procedures that cost money and consume doctors’ time. Why do you feel a need to talk about this?
The core of medicine is the patient. What we’ve witnessed in the last 20 years is this giant and very expensive health care trough that we’re all feeding from. There are many more financial incentives for relying on technology, testing, processes, efficiency. These are eviscerating the incentives for building the physician-patient relationship. They are robbing time from what a human needs.
We, as humans, when we’re ill — we desperately want human beings being attentive to us, to be caring for us. That’s being threatened.
How? You’ve written about walking into rooms where you saw doctors spending an incredible amount of time looking at monitors and data, while the patients were somewhere nearby but not seeing a doctor. You’ve said that the patients are almost just there to justify the data.
It’s been a great boon for us to have an electronic medical record (EMR). It’s tremendously efficient to be able to view most of our lab results in one place on a screen. But the EMR was not designed with physicians in mind as users. It has taken away from our being at the patient’s bedside.
The nature of our work now revolves around the computer. We’re forced to be, essentially, the highest paid clerical workers in the hospital.
I should point out that when I see residents in front of the computer, I feel immensely guilty. Because we [physicians] allowed this to happen on our watch. We are the ones who silently allowed this kind of electronic creep to happen. It’s not where the residents want to be, it’s not what the patients want.
I’m giving voice to a universal sentiment amongst physicians. We want more time with patients.
Can you tell us a little bit about the power of conversation with patients? Especially as it relates to the spiritual violation of an illness that you’ve talked about?
Patients have a great need to be listened to. When you have an illness, on the mechanistic level, you know you broke a bone in your hand. But at another level, the human level, you feel a sense of spiritual violation. Why me? Why now?
The spiritual violation can be huge. To use the analogy of your house being robbed: Not only would you have lost your things, but you would feel violated. Even if the police get all your stuff back, you would be “cured” but not healed. The sense of violation might actually make you move from that place.
Physicians can address the spiritual violation of injury and illness by helping to acknowledge what the patient is going through, by locating the illness on their body — not on an X-ray, not on a report, but by examining. Just because our technology has gotten sophisticated, that doesn’t mean that our human needs change. If you listen to patients, you’ll get a lot that you’re not going to get from the chart, and that goes well beyond electronic data. And the physical exam derives information that often can’t be obtained any other way.
Speaking of exams: You’ve talked about the relational and emotional benefits of physical exams, of touch, of thoroughness, and of the benefits for both the physician and the patient for taking that kind of time. Why is that so important?
The potential data that the body presents is huge. For 200 years, physicians have been skilled at reading the body as a text. You can make all kinds of diagnoses through a well-performed examination. One of the drawbacks of imaging and other technology is that you forget that they only go so far. A rash doesn’t show up on the computer. A lesion on the CAT scan of the head tells you nothing about the functional deficit, about what the patient can no longer do. Only the exam gives you that.
Additionally, there’s a tremendous ritual that’s being enacted. Here is someone, a relative stranger, dressed in a white paper gown being examined by another individual in a white coat. The exam room doesn’t look like any room in their house. And the patient tells you things they wouldn’t tell anybody else. Then they disrobe and allow touch. Very few other professions have that great privilege, which comes with it great responsibility.
When we examine a patient well, if we do it in a manner that shows we do this all the time and with ease and confidence, it conveys something important to the patient. If the exam is not done well, patients are immediately onto us, just as you and I are onto the sloppy barista, the sloppy mechanic. We can tell when someone’s doing something very well.
I was fascinated by your story about conducting a physical exam on a patient who was dying of AIDS. You’ve spent a lot of time with AIDS patients in their final days. Why was that experience so important for those patients?
That anecdote [recounted in Health Affairs] helped me understand the importance of the ritual. I was making a house call on a dying patient and I remember feeling absolutely helpless at his bedside. He was hours from his death. He was semiconscious.
Not knowing what else to do, I felt his pulse. Then I pulled on his eyelids to see his pupils. I saw his hands flutter up to unbutton his shirt. I had thought he wasn’t capable of even moving. I realized that he was inviting me to put my stethoscope on him. So this ritual meant something to him.
It was a powerful reminder of the ritual that had characterized our time together and that remained important to him even at the last moments.
How have these insights played out when you’ve worked with students doing rounds?
Everything I learned I learned from modeling and watching the behavior of the people who taught me. We have this sort of disjunction right now, where students are taught physical diagnoses in the first two years. But when they arrive on the wards, they realize that all these instruments [for diagnoses] are not really being used, that everything revolves around the computer. It’s a distressing moment for many of them.
When you can take them around and show them that there is value in this the physical exam and conversation with patients, demonstrate the things that the body can show you, then it’s like doing magic for them, just as it was for me as a student. I will never forget when my attending physician examined a patient’s chest and then accurately drew out what the chest X-ray was going to look like.
If we do the physical exam well and with skill, we then use tests more judiciously and we ask better questions of the tests we order.
I picture doctors and medical students saying, ‘I agree with you, but given the reality, what am I supposed to take away from this? How do I bring this message home?’ What do you hope to convey to the audience?
It pains me that our generation allowed this state of affairs to happen on our watch, where we are chained to the computer. It happened insidiously, one keystroke at a time. What we need is to take back more control so that the major medical decisions about our patients are being made with the blessing, the creativity, and the thought of physicians instead of insurers, the government, Medicaid.
I don’t have the magic answer to solve our present conundrum. But I think we all need to remind ourselves that this is a calling. That it’s a great, great privilege to do what we do, a point we can easily forget when we’re sitting behind computers all day.
My message is that this is a very difficult time, but the pendulum must swing back so we can spend more time with those we serve. Let’s not allow this to get any worse. Already, many physicians are leaving medicine — which is tragic. Burnout is reaching epidemic proportions, despite all our efforts at wellness. We can do our best with wellness initiatives, hand out Starbucks cards and so on, but if we don’t change the fundamental way we physicians work, it isn’t going to get better.
My role is to encourage my colleagues to hang in there, to find their renewal and their energy and their passion in each meaningful patient encounter. To renew our faith through our interactions with like-minded colleagues. We must speak out, advocate for ourselves and the patient, and not be silent.
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