How to treat patients

Issue: BCMJ, Vol. 52, No. 6, July, August 2010, page(s) 284 Editorials
Timothy C. Rowe, MB, FRCSC, FRCOG

In my regular encounters with medical students during their clinical rotations, I am impressed by their general level of maturity and accomplishment. Like most of my contemporaries, I am extremely grateful that I entered medical school when I did, because today I would have a microscopic chance of making it. By and large I rely on Socratic methods of clinical instruction. That is, I expect that the students with whom I see patients will have a decent understanding of what’s happening, without me having to spell it out. Most of the time that expectation is justified, which impresses me even more—when I was a student, what I seemed to say most often was, “I’m sorry, could you repeat the question?” Maybe it’s the easy access we all have to information, but they certainly seem to know a lot by the time I meet them.

So I have become used to the idea that there isn’t a lot of information that I can impart to these students because they have ready access to better organized resources than me. But what I can do is tell them what I have learned over the years to be important and what is not important. This information comes with qualifiers, of course, because although my clinical experience covers over 40 years, the great bulk of that experience has been in the health care of women—and men are different. But I have insight there as well, so I may be covered. Regardless, here are three general observations that I hope help guide students in their clinical encounters.

Everybody wants to feel healthy
This observation is a vague corollary of the first of Dr Robert Lamberts’ Six Rules Doctors Need to Know (cited in the New York Times): the patient doesn’t want to be in your office in the first place. I would have thought that this was self-evident, but there are nevertheless some patients who seem to enjoy the idea of being unwell. I think that these patients are most likely fulfilling observation number 3. By and large, however, everybody does indeed want to feel healthy—explaining the popularity of alternative care prac­titioners, who peddle the idea that everyone is inherently unhealthy and needs “treatment” to restore “health.” Our job is largely to reassure. How­ever, beyond this we must ensure that, in addition to treating illness, we try to make patients feel well.

Everybody wants to feel safe
This is an expansion of observation number 1. Patients who present with minor symptoms may be apologetic about troubling you with trivial concerns, but in most cases there is a real underlying fear—abdominal bloating is most likely due to poor dietary habits, but it can also be a sinister sign. Is this chest pain due to acid reflux or angina? Patients need to feel secure that you are taking their concerns seriously and can ensure their safety.

Everybody wants to feel special
I am sure this is true, even in the shyest individuals. Hence the importance of spending sufficient time with every patient so that you learn, in poker terms, their “tells”—how they des­cribe positives and negatives—so that you don’t miss critical pieces of information in their history. The challenge inherent in this is to keep relevant details for each patient in your head. Sooner or later we all run into patients in Safeway, and they invariably remember every detail of every discussion you ever had—but do you? Give it your best.

The students with whom I spend time are indeed an impressive group. I am happy to entrust the future of our profession to them—but I will continue to remind them of these observations, because at one time or another we’re all patients. Strangely enough, that doesn’t let us park in the “patients only” section of the hospital car park. Life is so unfair.
—TCR

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