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.