To My New Colleagues,
Now that you have made all the necessary introductions, met one another and your significant others, learned the names of a few key faculty, attended a small reception with the nurse managers and administrators, and identified the respective locations of your on-call room, the hospital Cafe and the rest rooms, it is time to get down to the business of your education and acculturation into the tribe of Medicine.
Perhaps I am being too optimistic in thinking that my perspective will be of use to you in your efforts to become good physicians. But over the past 20 years, I have had the privilege of observing the professional activities of a staff numbering more than a thousand. The resulting impressions encompass the very best and the very worst of what we can do in the execution of our responsibilities to the sick. These have mingled with my own introspection about the habits and practices that, in my opinion, conduce to success or failure. If after understanding my methodology you are still interested, by all means, read on.
Let’s begin with Osler, who famously noted:
“He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.”
Since the father of American Medicine wrote those words more than 100 years ago, much has changed (team-based care, an explosive increase in specialization, advanced imaging, the EHR) but much has not. The aphorism references two potential errors, and by inference two important practices for us all. I will take them in reverse order. When he wrote about studying “medicine without patients” he was evoking an image of the trainee spending day and night poring over the great works of Medicine and Surgery as they stood at the end of the 19th century, perhaps by candlelight, but away from the wards and actual contact with patients.
I’m not sure this is a realistic concern nowadays. However, it does happen to be true that house officers spend far more hours in the EMR than at the bedside, and are increasingly likely in their case presentations to jump directly from the chief complaint (“cough and dyspnea of several days’ duration”) to the chest CT interpretation with barely a mention of the history or physical examination. And thus much of the point of seeing actual patients is lost. I am not suggesting that residents needs to report these data with the detail of a Da Vinci portrait; a few well placed brush strokes generally suffice to reflect the relevant positives and negatives of the H&P, suggesting along the way the diagnoses she has considered and discarded on her way to a working hypothesis.
Osler’s first point — that the physician who studies Medicine “without books sails an uncharted sea” — gets too little attention, I think. New physicians will, whether they know it or not, commit themselves to one of two sects. Membership in one of these puts the physician on the path to ongoing improvement, driven by intellectual curiosity, a habit of finding a question in almost every encounter addressed by an efficient query of the literature. Paradoxically, the more knowledgable the physician, the more questions she finds. Members of this sect become ever more knowledgable over time. Critically, they are inclined to abandon previous approaches to diagnosis and (especially) treatment, based on evolving data and expert consensus. Ten years after training they are better physicians than they were at the completion of residency. Members of the only other sect avoid all of these activities. Their practice is moored to the last thing they learned in training, and they will become progressively less effective over time. Paradoxically, they will attach almost religious importance to their “clinical experience” which one commentator has described as the “opportunity to make the same mistakes over and over again with increasing degrees of confidence.”
There is another Osler quote which is at least as relevant:
“The good physician treats the disease; the great physician treats the patient who has the disease.”
Ah, humanism! Of course, you think. We had a course on that. “Fortunately,” you think (and I’m guessing this, because I thought it too) “I’ve got this. I like people. I went into Medicine to help people. And I’m a good communicator.”
Here are the realities. Being empathetic and communicating empathy are entirely different things. When asked (as millions of patients are in federal surveys ) how good their physicians are at being empathetic, making them feel listened to, and explaining their condition and treatment, wide variation is present. And of course, half of all physicians are below average in communication. (Think about it.)
Empathetic, effective communication with our patients is the basis for trust, and trust is critical. Trust is correlated with patient activation and adherence to the plan of care. Trust is therapeutic for the patient and itself relieves suffering. And trusting relationship with patients is nurturing for us as physicians.
What I want you to know about effective physician-patient communication is that it does not take more time, but does require that we learn some skills. The biggest mistake we can make about it is to assume that we can’t get better.
When you first meet your patient, postpone for a moment the impulse to treat him like a puzzle to be solved. Introduce yourself, of course, and cleanse your hands in front of him. Then establish connection by doing what a “civilian” would do — acknowledge his situation. You’re seeing a person in the ED who came with a fever, cough and a little shortness of breath. They’re only there because they became so scared that the idea of not coming to the hospital (and maybe dying at home, alone?) was even more scary than the idea of coming in. Often patients will tell us this.
It has been found that we ignore 90% of “empathy opportunities” — times when patients reach out to us, with words or otherwise, and signal their distress. Maybe we say something — “You look concerned”…or…”you know, most people in your situation would be frustrated”…or maybe we just let it go. Don’t just let it go. At the least, acknowledge the discomfort of being thrust into the role of “patient” — “I’m sorry you’ve had to wait in the ED so long…Are you warm enough? We can get you a blanket.”
Can we talk about jargon?
The embryology of jargon in medical training fascinates me. I have seen a student 6 weeks into medical school address a standardized patient as follows: “Mr Paterson, do you mind if I auscult your precordium?”
What is this about? Several things, I think. First, words have power. Using the language of Medicine identifies us with our tribe. We feel confident. (Watch how the jargon quotient skyrockets when a patient challenges our diagnosis!) Second, jargon is just easier (in the short run). It’s hard to do all this translating!
But this is very important. The use of medical jargon confuses our patients, increases their anxiety and distress, interferes with achieving collaboration about their medications or diet or follow up, and it expresses a lack of caring. (Really, you say? Consider what it takes to detect jargon and avoid it. We have to keep seeing things from the patient’s point of view. And that, of course, is exactly what empathy is.)
When asked, a quarter or more of patients tell us that we don’t always listen to them, or listen well enough. Of course, patients cannot literally know how much we’re listening, since that is an interior mental state. It’s about the signals we send. Do we sit down? How soon do we interrupt their initial story? (Despite our worst fears, studies tell us that patients will only speak for 2 minutes if provided the opportunity to tell us what they feel we need to know.) Finally, the best communicators elicit the patient’s concerns in a way that signals genuine interest in meeting her needs: “What questions do you have?” This is an open-ended question. It is generous in a way that do-you-have-any-questions is not. It’s so simple, but makes so much difference.
Try it now: What Questions Do You Have?
There’s more to communicating well, expressing empathy and “treating the patient who has the disease.” In fact, we have a course here at Northwell on Relationship Centered Communication for all physicians. I hope to see you in class this year, and in our conferences, and of course on the floors!
With warmest wishes that you find meaning, fulfillment and joy in your chosen profession,
Michael B Grosso, MD
