Nov. 10, 2008

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The Doctor as Patient, the Patient as Teacher

Graham Ramsay Nicole Martin

He’s one of the most elderly patients I’ve ever cared for. He’s also one of the most accomplished. As a young attending physician, Dr. B. spent more than two years caring for wounded soldiers at English and Irish hospitals during WWII. During the ’50s and ’60s, he served as chief of medicine at a local hospital. He has long since retired, but his mind is no less sharp for it. During his recent hospital course, there was always a book and a newspaper on his bedside table.

Most of our conversation topics on morning rounds were fairly run-of-the-mill. “How are you feeling?” I’d ask, inviting him to voice any concerns. He never complained, but occasionally he’d come up with a retort such as, “I can’t know what I feel like—I just woke up!” He didn’t ask many specific questions about his medications or procedures. But every so often, he’d make a comment demonstrating his medical astuteness. After my attending listened to his lungs one morning, trying to determine if fluid had accumulated after a blood transfusion, he said, “I have a propensity to atelectasis,” or partial collapse of the lungs during bed rest. If I can even remember what atelectasis means when I’m in my late 90s, I’ll be happy, I thought to myself.

When I first learned that my team would be admitting Dr. B., I was a little nervous. Physicians are not exactly the easiest patients, and I can say that because I’m no exception. What’s more, Dr. B. was having a significant GI bleed that had caused a drop in blood pressure and a small heart attack. We were supporting him with fluids and blood transfusions, but he was at risk for arrhythmias, pulmonary edema, and other potentially life-threatening problems. And to top it all off, he was a nonagenarian. In my residency program, we tend to believe that if a patient can make it that far in life, he must be doing something right. My task as Dr. B.’s physician was, therefore, simple: avoid messing up.

I drew back the curtain to the emergency room bay and saw a thin, gray-haired man, lying on the stretcher with the blankets drawn up to his earlobes. My concerns subsided as I realized that despite all his acute and chronic medical problems, he was mentating perfectly well. As I interviewed him about his symptoms, I was struck by his calmness. Not only did he seem unfazed by the bloody stools that had brought him in, but he didn’t bombard me with questions about his lab values or our treatment plan. In fact, his only question was, “May I have water?” I told him that, yes, he could have sips of water until midnight, when he would be made npo (nothing by mouth) in anticipation of upper endoscopy. “You’re the first one who’s acted like a human being!” he exclaimed, smiling broadly.

On my way home from the hospital that night, I marveled at the generation gap between Dr. B. and myself. I figured that he must have gone to medical school in the 1930s, well before endoscopy was in wide use. The now-standard, 12-lead EKG would have been introduced when he was a young physician in the 1940s. The use of blood tests such as creatine kinase and troponin, now standard for the diagnosis of heart attack, hadn’t even been imagined. Interns and residents, unaided by computer order entry and search engines, relied on textbooks and brainpower. They interviewed and examined their patients in great detail and wrote lengthy, erudite admission notes in longhand. As I realized how far medicine has come in the past several decades, I breathed a sigh of relief. I couldn’t envision myself practicing in a data void. Without extensive lab testing, EKGs, and CT scans, we wouldn’t even be able to triage patients from modern-day emergency rooms, let alone make definitive diagnoses and devise appropriate treatments.

As much as I cling to technology, I know that our current health-care system is far from ideal. Wondering how things have changed since Dr. B.’s career, I asked him if there was anything he disliked about modern medicine. “You never get to see the homes of the patients!” he commented. Because he was an internist, house calls had been integral to his practice. Although house calls have come back into vogue in some settings, most American doctors don’t practice outside their hospitals and offices. I visited a patient’s home only once during a patient–doctor course in medical school. In residency, I have relied on case managers and social workers to help me investigate and understand patients’ living environments. While I consider patients’ home situations very seriously in devising treatment plans, I know that my knowledge is imperfect. I also admit that if I could make house calls, I’d forge stronger doctor–patient bonds.

With all the demands on our time—multitudes of diagnostic and therapeutic decisions, mandatory educational activities, and sheer patient volume—we physicians are stressed, overloaded with information, and incapable of knowing everything about our patients. It would be naive of me to think that I can avoid these realities. But if I’ve absorbed even one drop of Dr. B.’s serenity, I’ll be a far better doctor. Not surprisingly, he recovered uneventfully with minimal intervention on our part. He’s reminded me that we don’t have to know everything, explain everything, or fix everything, but we do need to be observant and take the time to listen to our patients. Before he left the hospital, I again saw him with the bedclothes pulled up to his ears. “Are you cold?” I asked. “Old men are always cold,” he said. I simply chuckled.

—Nicole Martin, HMS ’06, is a resident in internal medicine at Massachusetts General Hospital.

The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.

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Copyright 2008 by the President and Fellows of Harvard College