This article was originally posted on WBUR’s CommonHealth blog.
A rainbow of thin wires were tangled up in his matted hair, each one connected to a small probe that would measure the electrical activity in his brain. We weren’t sure if Mr. S was having a seizure, or if he was unable to respond to us for some other reason. As he had been for many days, he lay in his hospital bed, frail and slouched, unable to communicate, often asleep with IV lines dutifully carrying his fluids. Standing around his bed with six other doctors, discussing what was looking to be a poor prognosis, I couldn’t help but wonder ― not why Mr. S was so sick ― but who Mr. S had once been.
When I had admitted him to the hospital a few nights prior, he had severe abnormalities in his electrolytes ― ions in our bodies that have many consequences when out of balance ― and had signs of a pneumonia in his lungs. Both of these could explain why he was unwell from a medical perspective, and why he could no longer verbally tell us his story. In scanning his previous notes, I quickly learned that he had a history of cancer that had metastasized to his brain, requiring surgery, and had fallen a few months earlier, resulting in a bleed in his head. But in reading all of this, I had no more of an idea about who he was and how he came to become the patient in front of me.
This is a problem all residents experience on a daily basis. There is a constant struggle between trying to fully understand the disease that demands our expertise, and a more human need to go deeper and understand more than just “Mr. S with pneumonia and potential seizure activity.”
I routinely ask my patients how they are feeling, if they have been able to pass urine, gas and poop, if they have had any concerning symptoms like chest pain or shortness of breath. But I almost never ask questions that are equally, if not more, important: How was life before you were sick? How does your sickness affect how you view your life now? What were things that used to bring you joy? These types of questions reveal critical information about goals of care, the story behind the development of an illness, the patient’s current understanding of their prognosis, and allow the physician to emotionally reflect on a patient’s state of wellness.
I recall one day on morning rounds when an especially thoughtful medical student suggested that she bring one of our patients purple flowers ― a small gesture that reminded the patient of her garden at home. As a resident, between time constraints and pressing medical tasks, I hardly have made time for these seemingly “extra” needs, but I realize now that to the patient, those flowers were just as essential as which medications we prescribed or which procedures we did. In medicine, it is easy to forget that life is far more than just a beating heart or breathing lungs. We are so much more than the basic physiology that keeps us from dying.
Studies have tried to estimate the amount of time that doctors spend with each patient, with most suggesting only a few minutes (one study in Germany found an average of four minutes for hospital encounters). But the exact number is less important than the critical realization that it is far from enough — and the quality of those interactions isn’t always what it should be.
A number of culprits have been discussed in the medical community over the years. Excessively demanding work hours have recently been up for debate again with regard to patient safety and outcomes of care, but studies have failed to examine the effect of these regulations on the physician-patient relationship. Intuitively, one might expect that tired physicians working 28-plus-hour shifts would be less likely to ask about what kind of flowers remind a patient of her garden. This doesn’t mean she needs them any less, however. Increasingly heavy demands of documentation and administrative burden have been implicated as well, with a number of studies suggesting residents spend more time on their computers than with a patient on a given day. Ask any of us and we’ll assure you that typing away at a computer is not what we aspired to do when we chose a career in medicine.
Part of this reality is that medical diagnostics have changed significantly with the advent of advanced imaging and laboratory tests, which are often very accurate in sniffing out signs of disease. For instance, a century ago, a thorough history and physical exam would be needed to determine if someone was developing pneumonia. Today, while we certainly will inquire about sick contacts and other such risk factors, a heavier emphasis is placed on the chest X-ray or CT scan, and laboratory values that indicate infection. We should absolutely use medical technology to its full potential. But in doing so, some older tenets of medical care, like the social history, inevitably move down the ladder of importance.
Recently, in my clinic in a socioeconomically challenged part of Boston, a number of patients have been presenting with vague aches and pains in their stomach and muscles. Upon further inquiry, there often appears to be no clinical explanation. There often are, however, high levels of stress due to losing a home, a job, a family member to violence, and more. These types of diagnoses don’t require thousands of dollars and fancy medical equipment. They do demand a lens that is not fully acquired in medical school alone.
On one of the last days of Mr. S’s care, my co-resident walked into our workroom with tears in her eyes. Moments earlier, Mr. S’s wife had come to see him and left the hospital room crying. This was not the man she had spent her life with ― the man she fell in love with, had children with, traveled with, hoped to grow old with. Mr. S, with wires on his scalp, his head hunched over his shoulder, his arm beginning to swell from clots in his body, his eyes closed and unlikely to open again soon, if ever ― this was the image of him that I had become used to. But this was not who he was. He was a man, like my own father or uncle or friend — a man with a past and people who loved him.
It is hard seeing patients when they are at their sickest, and also realizing that they have a life beyond what we witness as their doctors. It is hard to imagine that the lady who sits quietly in the corner of her room was once happily married; that the man with the skin infection was once walking around completely healthy; that the woman breathing heavily through pursed lips was once a post-office worker, delivering mail without even a cough. It is hard to see very sick patients as people who were once healthy, but if we fail to do so, we will only treat diseases instead of the people who are suffering from them.