Getting to Know You

I recently read a book called Better by Atul Gawande, a practicing surgeon who authors books, essays, and is a previous National Book Award finalist.  In Better Dr. Gawande strings together a series of essays detailing ways in which clinicians have made big changes in medical quality by launching small initiatives: a cystic fibrosis clinic that made dramatic improvement in success by encouraging parents to play an active role in the treatment of their ill children; third world surgeons who have made do with limited resources but who’ve managed to create remarkable breakthroughs in surgical technique; army doctors who pushed surgical care closer and closer to the battlefield to cut down on deaths among wounded soldiers.

Almost as an aside Dr. Gawande includes in his postscript some recommendations for other doctors who want to improve their medical care.  One suggestion related to our interactions with patients:

“Ours is a job of talking to strangers.  Why not learn something about them?

“On the surface, this seems easy enough.  Then your new patient arrives.  You still have three others to see and two pages to return, and the hour is getting late.  In that instant, all you want is to proceed with the matter at hand.  Where’s the pain, the lump, whatever the trouble is?  How long has it been there?  Does anything make it better or worse?  What are the person’s past medical problems?  Everyone knows the drill.

“But consider, at an appropriate point, taking a moment with your patient.  Make yourself ask an unscripted question: ‘Where did you grow up?’  Or: ‘What made you move to Boston?’  Even: ‘Did you watch last night’s Red Sox game?’  You don’t have to come up with a deep or important question, just one that lets you make a human connection.

“If you ask a question, the machine begins to feel less like a machine.”

I like this advice.

People spend their whole lives establishing their identity: an accountant, a mother, a nurse, a military officer, a truck driver.  A lifetime of accomplishments—whether big or small, momentous or simple—come together to make up a person’s self-image, and it’s generally something they, their family, and their friends recognize and take pride in.

Place that person in a hospital and he or she immediately becomes nothing more than a series of numbers and problems.  A retired schoolteacher, married for decades, who volunteers for her church and can bake a prize-winning pie suddenly becomes the 72-year-old female in room 734 with a UTI, HTN, GERD, and fever.  The retired bank president who is a decorated veteran and father of six is distilled down to a medical record number and billable diagnostic codes.

As a cardiologist I am under no strict obligation to dig any further than a patient’s past medical history, medication and allergy list, and chief complaint.  But if I do that I miss out on what makes a patient more than just a complex series of organs, tissues, and diseases.  Furthermore, I think I owe it to my patients to express as much interest in them as people as I do in them as patients.

Ask your patients what they did (or do) for a living and what they enjoyed about it.  Find out what they do to spend their spare time or if they have any vacations planned for the near future.  Ask about family or pets, what books they read, if they’ve ever traveled overseas.  Learn where they were born or raised, what their parents did for a living, or if they played sports in high school.

Of course it’s not always possible to spend much time ruminating on non-medical issues—we’re all a lot more rushed in clinic than we’d like to be—but in asking one or two of these questions we can at least scratch the surface and find out more than just a list of medical acronyms.

Plus, you might be pleasantly surprised by what you learn.

Just last week I consulted on a gentleman with shortness of breath.  On the surface his case was relatively uncomplicated and as an individual he seemed like any other elderly patient.  In his previously dictated admission note he was described simply as “retired,” but as I questioned him further I learned that he was a professional photographer and learned his trade while serving in the military.  Years ago, as an enlisted army man, he was trained as a staff photographer with a specialty in assessment of intelligence and surveillance imaging.  He was later pulled for special duty as the military photographer attached to the Lyndon Johnson administration and spent a year traveling with the president and his wife.  Lady Bird became quite fond of him and volunteered to intervene when my patient was told he was being deployed on a tour to Viet Nam.  He declined the offer and proceeded overseas.

Another patient of mine recently made the local news for her unusual fitness at a ripe old age.  Mary Skaggs (I use her story with her permission) just turned ninety this week and as I was visiting with her a few weeks ago I asked her to give me an idea on how she spends her time.  She proceeded to list the many things she does on a daily basis—cleaning, walking, spending time with friends, etc—but I had to interrupt her when she said “splits.”  What do you mean by splits? I had to ask.  In a flash she dropped to the floor of the exam room and proceeded to perform a series of splits for which even a stubborn East German judge would give a perfect 10.  Once done she rose to her feet and shuffled out with her cane.  It reminded me of the scene in Star Wars: Attack of the Clones where Yoda hobbles in to face the bad guy, cane in hand, then erupts into a Jackie Chan display of aerial kung fu.

With further probing I discovered that another patient of mine, whom I’ve seen for years, was a bomber pilot in WWII who was shot down, taken prisoner, and escaped to make his way to freedom across occupied France.  One elderly female patient was a nurse at a mobile surgical unit in the Korean War (a little less entertaining than the TV series, she tells me).  Another patient, well into her eighties, spends her time volunteering her services as a driver for other geriatric patients who need trips to doctors’ offices, pharmacies, and grocery stores.

The more we learn about our patients the better care we’ll be able to provide.  And the more we show an interest in what makes them unique the more they’ll trust us when we have to make hard recommendations.

Eventually, like everyone else, I’ll be someone’s patient.  When that time arrives I’d rather not be just the “72-year-old arthritic male here for an annual prostate exam.”  I’d prefer “72-year-old irascible semi-retired doctor with a wife who looks 20 years younger, a daughter who never got in trouble (even during her teen years), and two knees that suffered from way too many years of running and biking (but who keeps plodding along) who is reluctantly here for his annual prostate exam.”