Advice for the Bedside
PASSING ON LESSONS LEARNEDThe New Physician
As physicians, we can learn from our trials and tribulations, our successes and failures. I have practiced medicine for more than 30 years and have found that experience is a cruel but effective teacher. I hope the lessons I learned about providing an effective history and physical exam will help you succeed in your practice of medicine.
LESSON 1: Never become too busy to practice good medicine. An adequate history and physical takes time to perform. If you do not take this time, you’re shortchanging your patients, and you’re not doing your job. An overworked, harassed, tired and too busy physician is a dangerous one.
LESSON 2: Communicate with your patients. A physician is analogous to a detective seeking a villain, aka the disease. The detective’s job is to collect information from many sources. To be successful, he must develop good rapport with these information sources; otherwise, he’ll be unable to obtain evidence and will be rendered useless. Patients want to trust and confide in their physicians, and you must be worthy of their confidences. Only then will you be able to gather all the evidence hidden in the history. Communication is essential to being a successful physician.
LESSON 3: Be adaptable. Maimonides, a 13th-century physician, said, “Of the sufferer, show he only the man, neither good or bad, friend or foe, rich or poor.” An effective physician must be able to speak to and treat all social and intellectual classes. You must adapt yourself to the patient, so that patients and their families feel comfortable. One way you can accomplish this is by not using big words; sometimes they only hide your ignorance. Patients who are at ease will tell you more.
LESSON 4: Be a good listener. Always listen to your patients. Enough said.
LESSON 5: Be humble. Nothing destroys the physician–patient relationship faster than a physician’s pride and arrogance. Remember that the patient knows more about his symptoms than you do. It’s your job to extract this information in obtaining an adequate history. The God complex of the white coat syndrome dramatically reduces your effectiveness by placing a barrier between you and the patient. So be aware of this. You have many years of education and training, but with knowledge comes humility. Remember that the human body is the most complicated object on Earth, about which we know little. Today’s wisest physician knows less about medicine than a second-year medical student 100 years from now. Wisdom comes with time; you need to be aware of your ignorance and limitations.
LESSON 6: Read between the lines. Frequently, patients will talk around a symptom rather than openly admit it. For example, depression is common in elderly patients, but most depressed patients will rarely admit this problem. They will merely tell you that they are tired or sleep poorly. In order to collect information, you may need to speak to the patient’s family or caregivers. In some cases, the spouse may know the patient better than the patient knows himself. An intelligent spouse or partner is frequently a patient’s greatest asset, and you’d be wise to make the spouse your ally.
LESSON 7: Take your time. No matter how rushed you are, you cannot appear rushed to your patients. Always try to take time to sit at your patient’s bedside—even if it’s only for a few moments. Patients will appreciate this caring gesture, and this little and seemingly insignificant act conveys empathy and compassion. Without these virtues, a physician is worthless.
LESSON 8: Be organized and methodical. Performing a history and physical exam is an art that is done best in an orderly, methodical and sequential manner. At times, you will be rushed and interrupted. Interruptions can lead to errors and omissions. A methodical technique will help prevent omissions of important information and details.
LESSON 9: Use a quiet and well-lit room. Murmurs, rubs, clicks and gallops disappear in a noisy environment. You’ll waste your time listening for them, because you’ll never hear them. Shut the door, turn off the TV, and keep the room quiet. The exam room should be well-lit, too, preferably with natural light. Fluorescent light may mask cyanosis and jaundice.
LESSON 10: Carry your tools with you. They’re the instruments of your profession and act as an extension of your senses. If you don’t have your tools, you can’t use them. Then you waste your time waiting for someone to obtain them for you. You don’t want to postpone an important part of the physical exam because you don’t have the instruments you need. Your tools are your instruments of good bedside medicine. Use them.
LESSON 11: Ask the right questions. Knowing what to ask is an artful skill firmly rooted in your true understanding of pathophysiology. You can’t merely memorize signs and symptoms of diseases; you must understand why they occur. Although repetition and memorization may be the mother of knowledge, understanding is the beginning of wisdom.
For example, everyone knows that gout occurs most commonly in the foot and ankle, but not everyone knows why. Gout affects these areas because their tissues are more acidic. Tissue pH drops because the products of tissue metabolism accumulate in dependent areas. Lymphatic and venous drainage are poorest here, since they must travel against the force of gravity. Therefore, dependent tissues are more acidic. Uric acid tends to precipitate in an acidic medium. Gout crystals form, inflammation occurs, and the patient complains of sore, warm, red joints. Elevation of the feet will physiologically relieve a patient’s propensity for recurrent gout attacks.
Once you truly understand a disease process, you will remember it, and you’ll be able to ask the right questions.
LESSON 12: Keep an open mind. When examining a patient, always approach him with a free and open mind—a tabula rasa. Your mind must be free, unprejudiced and unpolluted by existing technical information and by the opinions of others in the chart. Your free and open mind is your obligation to your patient. Examine the patient first. Then, examine the chart. Finally, review others’ opinions.
LESSON 13: The patient is the final textbook. The examination of the chart never replaces the examination of the patient. Care of the chart never replaces the care of the patient. The chart never dies; the patient does. Always put patients first.
LESSON 14: Study to learn. True understanding in medicine is vastly more important than high academic grades. In real life, in the care of the sick, your true final exam will not occur on an answer sheet in a classroom. It will occur when you are alone, facing a critically ill patient who has placed his life in your hands. That desperately sick patient’s fate will be the real test of your knowledge; your success or your failure will be your patient’s life or death. Study to learn and understand; study to benefit your ill patients’ welfare rather than a selfish academic grade-point average. Patients are not interested in grades. They’re only interested in your effectiveness as a healer. Your patients’ clinical successes are the benchmarks of your academic knowledge. This is your true final grade-point average.
Frederick H. Roever is a geriatrician and internist at Helen Ellis Memorial Hospital in Tarpon Springs, Florida. He’s also an assistant professor of medicine at the University of South Florida College of Medicine. Have a topic you’d like to see discussed in a future “MedMentor” column? Send it in an e-mail to firstname.lastname@example.org.