The morning began with a page from the emergency department. “I’ve got a complicated diabetic foot infection here,” the emergency physician said over the phone. “I think it may be osteomyelitis and it might require admission.” At the nursing station on the internal medicine unit, 12 floors above the emergency department, our team was already reviewing the patient’s electronic record, gathering her past medical history and reviewing her imaging and bloodwork.
The patient, a 70-year-old woman, had been waiting for several hours by the time our team arrived in the ED. She must have heard our chatter as we approached. The consultant entered her room first, followed by the entourage of residents and medical students. After brief introductions, the consultant said: “Your ears must be burning; we’ve been talking about you all afternoon.” The patient, looking somewhat surprised, listened attentively as we reviewed the details of her case and presented to her the proposed treatment plan.
In modern health care, much of physicians’ work takes place away from the bedside. A typical day on a busy clinical teaching unit in a hospital begins with what is commonly referred to as “running the list.” This process involves discussing each patient’s case (in list form, sorted by location), reviewing results of investigations, identifying the main problems to be addressed, and developing a plan of action for the day. Medical trainees spend more than 60 percent of their time scrolling through electronic health records, entering orders, returning telephone calls, reviewing cases and completing documentation. The remaining time is divided between interdisciplinary care meetings, discharge planning, and bedside “rounding,” the last of which consists of brief visits to patients and their families. Trainees may spend as little as 12 percent of their time in direct patient care.
“Rounding” has taken on a new meaning in modern medicine. We have grand rounds, noon rounds, team rounds, and computer rounds, to name a few. Notably, none of these involve bedside interactions with patients, the historical meaning of rounds. Older research suggests that 80 percent of diagnoses are made from the patient’s history alone, and most senior clinicians stand by this statistic. But in most academic centres, bedside rounds have come to be seen as inefficient. Contemporary medicine has witnessed a relative decline in the status of patient narratives. The locus of medical knowledge has shifted from the patient-physician encounter to the computer-physician encounter, with the results of laboratory tests and high-tech imaging all conveniently collated in the patient’s electronic health record.
There are efficiencies in this model of clinical care. It allows us to review results in real time and implement changes in management, while searching the latest evidence and incorporating it into our decision-making. This can contribute to high-level discussion in a teaching setting. Thinking of our patient’s foot infection away from the bedside might raise a host of theoretical questions: What organisms would you consider if the patient had recently travelled to Southeast Asia? What antibiotic(s) would you prescribe in that case? What alternative diagnoses would you consider if this patient had a history of bloody diarrhea? These questions reflect how we approach medical education, and how cases are framed on licensing examinations.
But taken to an extreme, this kind of abstraction can lead us to lose sight of its function. We can forget that medicine is not a science but a practice. While abstraction helps us frame a problem, we ultimately need to apply a solution to each particular patient. A foot infection has a host, the host is a person, and the person has a life beyond the walls of medical care. Context is a crucial factor that shapes how care is provided. How many times have we ordered a course of intravenous antibiotics only to find that our patient has a fear of needles and refuses venous access? How many times have we written a prescription that a patient cannot afford?
Excessive abstraction can also negatively impact how we discuss our patients. The phrase “running the list” dehumanizes an activity that is meant to be about helping people. So does labelling patients by their disease or condition—“the 50-year-old smoker,” “the 65-year-old AIDS patient,” “the diabetic foot infection.” We sometimes hear patients being referred to simply by their location—“Room 12,” “Hallway 8.” A colleague once joked with a nurse who told her that “Bed 7” was having “mobility issues.” “Have you tried replacing the wheels?” she cheekily replied. Pressed for time, when every word counts, we frequently slip into using such phrases. But if so much of our time is spent removed from the bedside, we should at the very least avoid using objectifying terms, which may be a harbinger that we are losing sight of our purpose as physicians and the ethos of our profession.
How do we best remedy this situation? Medical teachers must challenge objectifying language as it arises in the moment to prevent the perception that such terms are acceptable. “You mean the 50-year-woman with diabetes, not the 50-year-old diabetic.” Fundamentally, however, the answer lies in the patient encounter. It is at the bedside that we can begin to initiate a dialogue—to transform our patient’s surprise about our “talking about her” into understanding who she is as a person. Through deliberate instruction, learners can be coached to ask about the impact of their patients’ conditions on their lives, their work, their relationships; things that cannot be captured through reading the electronic medical record but that are of paramount importance in patient care. It is at the bedside that “the diabetic foot infection” rapidly fades into a much richer narrative. It is there that we learn that our patient is a retired accountant and an avid golfer, that she is afraid of losing her leg and the impact this would have on her independence.
Despite all of medicine’s advances, its new technologies, and new models of care, we must continue to rise to the challenge of moving from the abstract to the personal. We must continue to work to bridge the divide between theory and practice, between knowledge and caring. This has always been and will always be at the core of our profession, and remains a central challenge faced by physicians and educators today.
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Along with this, isn’t so sad a high level administrator in Ontario’s health care system has to rely on a cancer patient’s death to bring focus to the Ontario Ministry of Health and Long Term Care and Cancer Care Ontario lack of funding for these situations. So sad for Dr. Ralph Meyer and others in this situation, they are simply automatons without much of a voice at all to the Province of Ontario and their beancounters:
“Laura and her family raised a lot of awareness across the province and the country,” Meyer said. At the time, Ontario Health Minister Eric Hoskins also tweeted his support following a wave of media attention to stem cell treatment access.”
I mean why does a patient need to raise awareness to the professionals at the Ontario Ministry of Health and Long Term Care and Cancer Care Ontario? What a ridiculous situation that is when someone like Dr. Meyer is admitting he is basically not much of a voice? Very sad.
https://www.cbc.ca/news/canada/hamilton/laura-hillier-driving-boost-to-stem-cell-treatments-almost-a-year-after-she-died-1.3922341
Thanks for your thoughtful piece! I’m grateful that you’ve brought awareness to this important subject.
Language that reminds practitioners that the person they’re writing about is the point of the note itself can be a powerful way to bring meaning and value to the significant amount of time spent documenting encounters.
How much extra time does it take to spell out someone’s name in place of “pt”? When we actively name the person whose story we’re describing (filtered and retold, as it may be), I think we are given a brief moment to slow down and remind ourselves who we’re writing about and why we’re writing the note in the first place. If we can compose a note with the intention (and hope) of improving the care (and health!) of the person the note is about–with that person actively in our mind’s eye as we describe their story as we see it–there’s a chance everyone can benefit.
Of note, I’m increasingly mindful of the possibly ageist implications of beginning a report with a person’s age. People speak of ageism as a final frontier in reducing discrimination, and I’m reminded of the concept of biological vs. chronological age. How helpful is it, really, to report a person’s chronological age, other than for activating a reader or listener’s assumptions of what that age looks like? What if practitioners didn’t need to set the stage with “___ is an 84-year-old lady from ____,” and instead focused on the person and the reason they’ve sought help?
Ultimately, we all create stories based on the stories we’ve heard already, and it’s impossible to make meaning without calling on what we’ve seen-and-heard in life so far.
As Sherlock Holmes says in “A Study in Scarlet”:
Before turning to those moral and mental aspects of the matter which present the greatest difficulties, let the inquirer begin by mastering those more elementary problems. Let him, on meeting a fellow mortal, learn at a glance to distinguish the history of the man, and the trade or profession to which he belongs. Puerile as such an exercise may seem, it sharpens the faculties of observation, and teaches one where to look and what to look for. By a man’s finger-nails, by his coat-sleeve, by his boots, by his trouser-knees, by the callosities of his forefinger and thumb, by his expression, by his shirt-cuffs—by each of these things a man’s calling is plainly revealed. That all united should fail to enlighten the competent inquirer in any case is almost inconceivable.
While keen deduction (…during clinical rounds, perhaps), can help construct an impression, the risk of losing sight of the person themselves remains present. Assumptions can get us in trouble if the focus is on being clever instead of being curious.
In any event, the value of simply using a person’s name to keep our attention on them can be a potent change in practice.
Thanks again! :)
This is very insightful, after having been with family members who were treated like a number instead of a human I find this very much the way patients are treated at times. Hopefully Educaters will point out that compassion is a real healer of the spirit, helping then with the healing of the body. Thanks for sharing this read.
Well said indeed. Removed from the human context, the exercise is intellectually challenging, but so uni-dimensional. Presumably we enter this profession because we are interested in the human interactions and transactions that are so meaningful and helpful to our patients and thus so satisfying to us.
Interesting, one might ask wether we need to go back to times when the physician “knows it all, sometimes efven already”? Isn’t practice “applied science”? I think both aspects, are crucial: doing a throught analysis in medical terms so as to adhere to medicine insights/values, and interacting/ communicating with the patient to know the patients’ opinioins, context and conditions so as to jointly decide how to apply the medical insights and suggestions. Not to speak indeed about how to bestdo this in the frame of time/costs aspects of medical care. healthcare is devellping and evolving to new formats and staes of care. Let’s take up that challenge?
I am grateful to read this reflection! As a patient advocate, it is my priority to focus on the human aspect of care, of recognizing the multi-dimensional person that is being treated, so this article really resonates with me.
As you so insightfully point out, there may be additional factors that influence the best way to administer treatment to the individual. I consider it the highest form of care when a doctor intentionally seeks out that personal information, and demonstrates they have heard that information by using it to inform the most appropriate treatment. Love to witness occasions when this is put into practice!
“Are you anesthesia?” “No, I’m Mark.” *Awkward pause.* “The appy’s here.”
Great to read that this is front and foremost in the minds of some of our physicians in Canada, very nice. Blends in with what Victor Montori is emphasizing as well albeit with differences between Canadian and American health care structure and culture.
“He wrote his slim and moving book to “see things as they are,” as George Orwell put it, and what he sees is the ways in which the industrialization of health care, rather than making it more efficient, has instead corrupted the mission of medicine. It has turned doctors and nurses into tools of a profit-seeking machine, “care” into a means to fulfill corporate ends. Montori sees a system filled with “unintentional cruelty” where “care happens almost by mistake.”
https://washingtonmonthly.com/magazine/april-may-june-2018/more-heart-than-science/
In an ideal world, the ER would not have been necessary.
The Woman with the infection could have had a Nurse or Doctor visit at her home. What better place to get to know her Greater Biome? BTW , the Nurse who got told by Doctor to replace the wheels will never forget that snipe comment. As a nurse, juggling patients, families, Management and Doctors, if they say bed 15 needs a PT consult, it’s ok to just write the order. In Fact, why Did the Nurse have to tell you what to order, anyway? Didn’t You Observe Your Patient Walk? Even from the Doorway?