Reflections on Medicine - September 2008
Tex Med . 2008;104(9):15-16.
By L. Rodney Rodgers, MD, MACP
The scientific basis of medicine is the essential core of quality medical practice. It is the sine qua non in my opinion. Continuing medical education (CME) was very important to me all of my life. The chief resources were the American College of Physicians, the Texas Club of Internists, grand rounds at medical schools, and journals such as the Annals .
There are several definitions to "the art of medicine." My preference: "The physician is skilled at convincing patients to follow his medical advice."
It is one thing to know the science of disease, but can you sell your patient on your treatment plan? Can you motivate patients to go to the necessary trouble of their time, money, and, often, inconvenience to best benefit from your store of knowledge and your therapy? Of what value is your extensive training if they choose to ignore you?
Being a solo internist enabled me to work at my own pace. In later years, it took me one-and-a-half hours on a new patient, but only one hour for a regular, annual checkup. The consultation call could take a half-hour to explain, in the patient's vocabulary, the results of the study and to sell the therapy.
Patients were aware I had acquired information about them in addition to that about the illness. They felt my advice was, therefore, uniquely tailored for them. Recommendations on healthy changes in lifestyle were routine. These were not sanctimonious, but very practical, based on what I had learned about the patient's lifestyle and personal values.
There is no place for such questions as "What is your value system?" and "What can motivate you medically?" They would waste one's time.
The History and Physical
These are the things I found useful to know about most of my patients. A physician can see values and behavior if one is looking for them.
The history began with the chief complaint question, "What brings you to my office today?" If they mentioned a symptom, they were asked to describe it in their own terms. Their attitude toward the symptom was always important. If anxiety was present, I needed to know why. Commonly, an acquaintance of the patient had had that symptom and been found to have a certain illness. Clearly, that particular disease would have to be ruled in or out in that particular patient. The anxiety would be a clue to their value system and a help in all future visits. Humans tend to repeat their anxieties and need repeated reassurances, no matter how thorough the physician is. If they did not demonstrate anxiety over their complaint, that was interesting. Often a spouse or parent was concerned about them and forced the exam. That meant another person for me to educate and use as an effective ally in treating the patient.
Using their description of their complaint as the foundation, a search was launched into the organ system producing the symptom, followed by a review of systems. General health was important, as was the patient's estimate of it over the years. Their usual weight and changes in it and their energy were invariable items. This was an opportunity to learn what they wanted to weigh and the energy desired for their lifestyle. This was their concept of "normal" and their estimate of their level of responsibility for having it or not.
Discomfort in the chest, if present, was admitted by most, degraded by the stoic, and upgraded by the sensitive.
Did they "eat to live" or "live to eat"? Their answers often helped me deal with their obesity, the toughest of all problems in treatment. Eating habits are ingrained over a lifetime and are not changed by a written diet or a pill.
Urgency and stress incontinence were differentiated. Incomplete emptying was more common in men. Sexual activity was brushed over at this point because the usual answers were vague and inexact. But, I got a clue to the patient's attitude on the subject and came back to it if I suspected sex to be a problem. Then, I was specific, and the patient was more relaxed with answers than the first time the subject was touched upon. Patients knew they could bring the subject back if they chose.
Neuromuscular symptoms became more important with aging because of the disability involved. A detailed account took place if a nerve disorder was in question. Dizziness meant different things to patients and always had to be explored. Headache patterns could involve several questions.
Neuropsychiatric history was often the most important in people younger than 35. Clues as to their attitudes and value systems had already arisen and were now dealt with if they were important. The interrelationships in their lives are essential to understanding the patient. Sibling rivalry was more common than expected. There often is a key individual to be reckoned with, such as a spouse, parent, friend, or boss. Religion was important to older persons and much less so to younger ones. Recognizing God as the supreme power sometimes reduced one's expectations of modern medicine.
Family history dealt with genetic inheritance of their medical problems. Ages were noted for onset of vascular diseases and diabetes. Family personal relationships with the patient's life were carefully noted for the value system code.
Social history dealt with habits, work, and marriage. Tobacco, alcohol, medications, exercise, and play were discussed. Working hours, attitude, and expectations about the job and income were always important. Spouse, friends, and the person who referred them were dealt with.
Most time was spent on the history, which usually makes the diagnosis obvious. The history focused my physical examination. My purpose was to demonstrate thoroughness to the patient, satisfy my compulsive curiosity about the illness, and help sell the therapy.
A physician sees what he or she is trained to see. A patient sees only what he or she is looking for and not what is to be seen. When a physician understands this fact of human behavior, he is ready to learn the art of medicine - successfully applying his science to benefit a given patient intelligently and efficiently. Making use of the discovered knowledge of your patients to increase their vision, then using their value system to motivate them to use your science, is the art of medicine.
Witnessing the present system of medical care with its many flaws inflicted by politicians and their mandates, insurance companies determined to make money off medicine for their stockholders, and businesses shopping for bargains in employee health policies, I understand the many present complaints of patients and physicians. They speak of the good old days.
Art in the practice of medicine is still possible and essential. Certain freedoms of choice are missing. Every freedom has its attendant responsibility. Knowing the freedoms missing now can help us work toward better solutions for the future. There is no quick fix available. Some physician groups and insurance companies will have to make available a different sort of medical care. Their patients will note the contrast and spread the word for us. Begin now.
Dr. Rodgers lives in Houston.
Editor's Note: This is the latest in a continuing series of essays by members of the TMA 50-Year Club .
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