May 10, 2009

An encounter makes a lasting impression

“Good morning, Mrs. K, I’m Clinton Pong, a third-year medical student,” I said warmly as I swept into the small exam room, shook her hand and pulled up a seat. “I’m here with the doctor today and before she comes in, I’d like to get a chance to hear a little bit about what’s been going on.”

She proceeded to tell me about how often she checks her blood pressure, her struggle with cutting down on shoyu and how she’s been golfing more. I responded in kind with encouragement on her lifestyle changes and reviewed her medications. It was a routine follow-up visit but it was my first time with her, so I spent some time finding out more about her. To my surprise, I realized that I saw her husband earlier in the day (they must have patiently swapped places in the waiting room) and she was the grandmother of one of my classmates! “He just got married, you know,” she said conspiratorially. “WHAT?!?” I exclaimed, “I had no idea!”

Indeed, I would not have known any of these things if I resigned this patient encounter as something mundanely routine and checked off some boxes. One of the things that I love most about Family Medicine is actually stepping away from the medicine from time to time and treating patients like family. I think that’s what Primary Care is all about -- care first and the rest will follow.

I told my friend Brad recently that "one of the hardest things to do with patients is to forget all the medicine." He looked at me strangely and I clarified: "because you really have to put yourself in the place of your patient to understand whats going on for them."

It struck me that this was a kernel of wisdom.

Since I have been following various preceptors over the course of the past 5 months in outpatient clinics, there is a lot of the common things like the cold, the flu, the stomach flu, high blood pressure and high blood sugar check ups that have become entirely routine for me. However, every time I walk into the room, I am impressed by how different each of the cases are. Every patient has a different set of challenges that do not do my patient logs justice when they are reduced to an age bracket, a diagnosis and treatment.

This is especially true in the hospital. Patients are isolated in their rooms, shaken awake at all hours of the night to take their medications, get their blood pressure checked and who knows what fluids or solids need to be put into them or flushed out. When the finally start drifting off, they have a brief encounter with a medical student at 5-6am who rattles off a series of rapid-fire questions: "do you have any complaints/concerns? hows the wound/infection/blood pressure/reason why you are in the hospital doing? are you in any pain? can you walk ok? hows the urine? are you passing gas/having bowel movements/eating ok? any nausea or vomiting? diarrhea or constipation?" And then before they can shake themselves fully awake to ask the questions that matter, like "when can I go home? what's wrong with me?" the doctors are gone. After the flurry of midnight-midmorning activity, the patients are left to twiddle their thumbs.

Too often, this hospital routine forgets that it is NOT A ROUTINE for (these individual) patients to be in the hospital. Healthcare workers take this sort of thing for granted. The rub is that it comes off as cold and uncaring.

Even though I often feel rushed or out of time after going through all of my (mostly irrelevant) questions and pausing for all of my patients (mostly very important) concerns, I always feel a sense of immense gratitude from them. Sometimes, this simple pause with an invitation for questions at the end of an encounter turns it into a lasting impression. It's funny how such a small thing makes such a big difference.


  1. I agree. The patient is there for the medicine but what he perceives is the doctor as a human, not as a scientist.

  2. I heard an interview once on "The People's Pharmacy" with Evan Handler. He read one of his short stories from his book which was about a nurse's morning routine, and his roommate. It was painful to listen to, much less experience.

    Veterinarians have an easier job at least in that area. We can act as scientists once we get the animal to a treatment area without the owner around. But animals don't talk (owners are misleading, and non-compliant) and they bite and scratch.