The Doctor-Patient Relationship.
Canadian physician William Osler is quoted to have said, "Listen to the patient, he is telling you what's wrong with him." My dad, Temple Medical class of '31, never tired of reminding of that quote as recently as a few months before his death at the end of my junior year at Temple Med. We both went to Penn State too but that is a topic for another time.
One of the gifts of the ten years I spent in Plymouth doing primary internal medicine was forming relationships with patients, many of whom had been my dad's, and others of whom were new to my practice. I worked almost entirely with the elderly. Having grown up in Plymouth I'd known many of the people who came into the office most of my life. Perhaps the most anxiety producing patient visits during the first year were former high school teachers and other authority figures from my youth. The tables had turned. I got used to it. I think they did as well.
Listening to a patient entails much more than just the words. One cannot get the same information if an assistant of some sort takes the history or if it is filled out by checking boxes. Check boxes are great for a quick screen or to highlight topics for further discussion, but they are not, should not, and must not, be the sole form of history gathering. Besides listening one must look. An exam should begin from the moment the patient walks into the room to the moment he or she disappears from view. What is the patient's expression while describing the symptoms? Are there any particular movements? Very early during my internist years a patient strode into my office without an appointment (family friend), stood in front of the desk, and said, "Every time I go up the steps I get 'bursitis.'" With that he rubbed his open hand over his shoulder muscles. Bursitis doesn't act that way. Several questions later and a focused exam which revealed no abnormal findings I set him up to see a cardiologist the next day. His complaint along with the motion he made with his hand screamed angina. He had a cardiac catheterization two days later. The disease was so severe he was taken directly from the cath lab to the OR for bypass surgery. Do not pass GO, do not collect $200. It was the listening and the watching that gave the critical clue.
When there is a doctor-patient relationship it is both easier and harder to give bad news, to pronounce someone dead, or to make a diagnosis. There is also a greater degree of joy when the diagnostic test is negative for cancer. Under the best of circumstances, the doc can begin to sense when something is wrong with a given patient that he or she may not realize. I will always remember the day a patient walked into the office. I saw her more or less every two or three months to follow a number of minor problems as well as to assuage her hypochondriacal tendencies. She came in two months after her previous appointment and croaked a greeting with a gravelly voice that sounded nothing at all like her. I'd heard that type of voice before. Severely underactive thyroid. It took a while to get the medication stabilized but her voice came back to normal and remained that way for the following six years that I stayed in the office.
There are many stories like that, some funny and some tragic. All of them emerged from the doctor-patient relationship, a relationship that is seriously impaired by insurance companies, the computerized medical record, the presence of "transcribers" and other factors. A relationship cannot develop in quick visits of six minutes (if the insurance company is being generous). A relationship cannot develop with a cast of physicians that changes daily when a different cardiologist makes rounds on the group's patients each day. Sometimes one learns a lot simply taking the patient's blood pressure while he or she is seated at the desk.
I've been a priest for eleven years. Looking back there were times the office served as a confessional--not a sacramental one to be sure, but a place where the patient could unburden himself or herself. I learned some things about people I wish I'd never had to learn and carry around for the rest of my life. Such is the function of the doctor-patient relationship. Other times the "confessional" dimension allowed us to define some problems and figure out how to work them out.
The New York Times Magazine article attached here gets it mostly right. There is an interesting sentence by the author that summarizes a lot: "On a Monday morning in August 2016, I went on hospital rounds with Krishnamoorthi, as he performed the same duties a hospitalist would with one key difference: He already knew the patients." Significantly, though unmentioned, the patient already knew the physician. Important on both sides.
https://www.nytimes.com/interactive/2018/05/16/magazine/health-issue-reinvention-of-primary-care-delivery.html?smid=fb-share
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Below are some photos I took in Slovenia considering the questions of solitude. Will not comment on each on as per usual. I miss the opportunity to wander around in a city alone at night while carrying expensive camera equipment without a hint of anxiety or fear.
There is no way I would walk around my small home town in northeastern PA at night with a camera. Not too keen about doing it during the day either.
+Fr. Jack, SJ, MD
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