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The Care of the Patient: Field Notes from a Veteran
Editorial The Care of the Patient: Field Notes from a Veteran Burton J. Kushner, MD - Madison, Wisconsin The day before I was due to retire from 40 years of practice Three: Talking in front of patients with advice from a as an academic pediatric ophthalmologist, I delivered the former mentor keynote address at the graduation of my department’s resiAs an intern, I knew a professor of medicine who was a dents and fellows. I was in transition; they were in transimaster in the art of talking to patients. He stressed that we tion. I wanted to choose my words carefully. What would be physicians talk to patients all day, but for the individual meaningful to these about-to-become colleagues who were patient, seeing us is a singular event. Every word we utter in just beginning their careers? Preparing for that presentation the patient’s presence will be chewed upon, mulled over, offered me an opportunity to review my core values that and repeated. When doctors talk to one another in front of have evolved over my years in practice. I have always patients, the patient may not understand the meaning and thought deeply about each patient’s experience when they importance of what we are discussing. Physicians need to come to see me. Through them, I have learned a lot. At the recognize that we speak a different language than patients. risk of sounding preachy, I elaborated 9 suggestions on Especially in a teaching setting, always try to reframe what patient care. Spoiler alert: Number 9 was the ultimate secret is said in terms that a patient can understand. Patients get about caring for patients. For each of the 9, I invoked some perplexed or distraught when ophthalmologists exclaim, “I wisdom from an outside source (writers, mentors, colthink it’s plus 2,” “no, it’s plus 1,” “do you think there’s an leagues, images, patients, and mythology) to add insight afferent pupil defect,” or other such jargon. If ever I am about the subject at hand. The following is a summary of my discussing findings with residents and fellows in front of a address. patient (I actually prefer not to do this in the patient’s One: On talking to patients with wisdom from Mark presence), I will turn to the patient and say, “Excuse us Twain while we talk shop for a minute. Then I will translate for you I have often likened verbal discourse to a scattering of what we have said.” Then I do exactly that. birds. We speak our words, and Four: The importance of ofthey fly off to their own personal fering hope with reference to What would be meaningful to destiny. What we think we say the drinking glass these about-to-become may not be what is heard. Mark Although no patient wants to Twain once said, “The difference be misled by false hope, there is colleagues who were just between the almost right word usually something hopeful that beginning their careers? and the right word is really a large you can say with every patient matterd“tis the difference beencounter. Always look for and tween the lightning-bug and the lightning.”1 Words embody comment on whatever you can honestly be delighted about. connotative and denotative meaning, each of which has It might be the strabismus is a bit worse but the vision is singular energy and power. Therefore, choose the words you better, or vice versa. Or, you’re delighted the macula is say to patients with care. For example, it is so much better to normal even though the cataracts may have progressed a bit. tell a patient that dilating drops will relax, rather than One of my early mentors would look at an older patient’s paralyze their pupil. Relaxation has good energy; paralysis retina and proclaim, “You have the arteries of a teenager,” sounds ominous. After dilation, tell patients they may be and the patient would leave beaming. Always describe the sensitive to light, rather than bothered by light. If you proverbial drinking glass as half full. Patients do not want to suggest they will be bothered, they probably will be. be deceived, but anything good can offset that which is not. Two: Listening to patients with words from a Zen Five: Understanding patients’ needs and wants with master humor and a clinical pearl from Art Jampolsky, MD From a Zen master, I learned about the importance of We all know the really negative patient. You perform a listening to patients with 5 ears. The 5 ways to listen are for refraction test and ask, “Which is better, 1 or 2?” He replies, (1) the facts, (2) the emotions, (3) the body language, (4) “Neither.” You repeat, “Pick the one that’s better.” He says “None!” Doctor Jampolsky taught me to then ask, “Which is how the conversation is affecting you, and (5) what is not worse.” Voilà, the patient can always pick the worst choice, being said. because he or she loves pointing out the negative. Although Always keep in mind that what the patient most wants to this clinical pearl seems humorous, it actually is effective. tell us is exactly what may remain unverbalized. It is up to But that is not the point. The real message here is to get to us to hear those unspoken words. This is particularly chalknow what the patient needs. There are some patients who lenging since the advent of electronic medical records, need validation or recognition of their suffering. Allowing which require you to spend so much time facing the comthem to focus on the negative meets that need by allowing puter monitor. Ó 2015 by the American Academy of Ophthalmology Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.ophtha.2014.09.005 ISSN 0161-6420/14
1
Ophthalmology
Volume 122, Number 1, January 2015
them to voice their pessimistic world view. Communicating with patients is like a dance. You make an approach, they respond, you respond in turn, and if you hit it right you are in an embrace. It is not the patient’s job to adapt to your way of communicating. It is your job, and it can be difficult, to find what language works for the patient. Whenever I see a new patient, I always include 3 questions in my discussion. I ask (1) What were you anticipating I would recommend? (2) What were you hoping I would suggest? (And I acknowledge that their hopes and anticipation may not be the same.) (3) Is there anything you are afraid of or worrying about? Six: Expand your own horizons with words about Descartes’ Error With his famous statement in 1637, “I think therefore I am,” Descartes drove a wedge between our collective right and left hemispheres. I have previously described why I think the doctor/patient relationship has been suffering the consequences thereof ever since.2 Perhaps more appropriately for physicians, Rousseau reframed Descartes’ pronouncement by declaring, “I feel, therefore I am.” My advice in this regard is to read nonmedical books for pleasure, both fiction and poetry. You may ask, “What does reading fiction and poetry have to do with caring for patients?” I believe that fiction is the best way to understand people’s plights and situations and makes us more empathetic. Nothing made me personally as aware of the turmoil in the life of a disabled person than reading Carson McCullers’ The Heart Is a Lonely Hunter.3 Nothing brought home for me the anguish of losing vision as reading Felix Pollak’s book of poetry, Tunnel Visions,4 which poignantly describes his loss of sight from glaucoma. Lisel Mueller’s poem, Monet Refuses the Operation,5 gives insight as to why a patient might refuse to follow a doctor’s recommendations. Monet preferred to see with soft fuzzy edges that his cataracts created, which was the way he rendered them in his paintings. So reading fiction and poetry has the potential to make you a more caring physician. Besides, it is enjoyable. Seven: Take care of your heart and soul with intervention from a son of the Goddess Aphrodite I hope that at least once in your lifetime, preferably just once, but at least once, you get hit by Cupid’s arrow. If this happens to you, the one important question to ask is if you are a better person as a result of the relationship. Being a more heartfelt or compassionate person will understandably make you a more caring doctor, and your patients will also benefit for all the obvious reasons.
Eight: Get to know your patients as people It really means a lot to patients when you remember personal details about their jobs, family, and accomplishments. Find a way to remind yourself of who the person sitting in front of you is beyond a diagnosis or set of symptoms, and what is meaningful in his or her life. When you succeed in relating to your patients as singular individuals, their behavior toward you will speak to that success. I was deeply touched by one of my 4-year-old patients in whom I performed eye muscle surgery. There she was in the recovery area, weeping and uncomfortable. She beckons to me, “Come here, I have a secret.” My heart is sinking. I think she is going say I misled her when I said she would not be too uncomfortable. I bent forward expecting to be informed of my betrayal. She wants to whisper in my ear. I lean over and hear her say softly, “I have a crush on you.” And she was only 4 years old! Ultimately she must have outgrown her original crush, but recently at the age of 18 years she brought her boyfriend to meet me to seek my approval. Nine: The ultimate secret about caring for patients with teachings from a renowned physician So what is the secret of caring for the patient? It is actually not so secret. Like so many important “discoveries,” if you read old medical literature you will see that someone thought of your discovery earlier. In 1925 the great Harvard physician Francis W. Peabody said, “The secret of the care of the patient is to care for the patient.”6 That’s all there is; it’s that simple. I concluded my talk to the graduates with the advice that they are embarking on a wonderful adventure that will bring them a wagonload of gold. But I was not talking about the precious mineral. The gold is in the ability to deeply and meaningfully touch people’s lives every day they go to work. It is a precious privilege. I wished them safe travels on their journey. References 1. Twain M. Methodsdconscious and unconscious. In: Bainton G, ed. The Art of Authorship: Literary Reminiscences, Methods of Work. New York: D. Appleton and Company; 1891:87–8. 2. Kushner BJ. Descartes’ error. J AAPOS 1998;2:1–2. 3. McCullers C. The Heart Is a Lonely Hunter. Boston, MA: Houghton Mifflin; 1940. 4. Pollak F. Tunnel Visions. Peoria, IL: Spoon River Poetry Press; 1984. 5. Mueller L. Refuses the Operation. In: Alive Together: New and Selected Poems. Baton Rouge, LA: Louisiana State University Press; 1996:186–7. 6. Peabody F. The care of the patient. JAMA 1927;88:877–82.
Footnotes and Financial Disclosures Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. Supported by an unrestricted grant from Research to Prevent Blindness, Inc., New York, New York.
2
Presented in part as the Keynote Address at: the graduation of residents and fellows of the Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, June 27, 2014.
http://dx.doi.org/10.1016/j.ophtha.2014.09.005 ISSN 0161-6420/14
1
Ophthalmology
Volume 122, Number 1, January 2015
them to voice their pessimistic world view. Communicating with patients is like a dance. You make an approach, they respond, you respond in turn, and if you hit it right you are in an embrace. It is not the patient’s job to adapt to your way of communicating. It is your job, and it can be difficult, to find what language works for the patient. Whenever I see a new patient, I always include 3 questions in my discussion. I ask (1) What were you anticipating I would recommend? (2) What were you hoping I would suggest? (And I acknowledge that their hopes and anticipation may not be the same.) (3) Is there anything you are afraid of or worrying about? Six: Expand your own horizons with words about Descartes’ Error With his famous statement in 1637, “I think therefore I am,” Descartes drove a wedge between our collective right and left hemispheres. I have previously described why I think the doctor/patient relationship has been suffering the consequences thereof ever since.2 Perhaps more appropriately for physicians, Rousseau reframed Descartes’ pronouncement by declaring, “I feel, therefore I am.” My advice in this regard is to read nonmedical books for pleasure, both fiction and poetry. You may ask, “What does reading fiction and poetry have to do with caring for patients?” I believe that fiction is the best way to understand people’s plights and situations and makes us more empathetic. Nothing made me personally as aware of the turmoil in the life of a disabled person than reading Carson McCullers’ The Heart Is a Lonely Hunter.3 Nothing brought home for me the anguish of losing vision as reading Felix Pollak’s book of poetry, Tunnel Visions,4 which poignantly describes his loss of sight from glaucoma. Lisel Mueller’s poem, Monet Refuses the Operation,5 gives insight as to why a patient might refuse to follow a doctor’s recommendations. Monet preferred to see with soft fuzzy edges that his cataracts created, which was the way he rendered them in his paintings. So reading fiction and poetry has the potential to make you a more caring physician. Besides, it is enjoyable. Seven: Take care of your heart and soul with intervention from a son of the Goddess Aphrodite I hope that at least once in your lifetime, preferably just once, but at least once, you get hit by Cupid’s arrow. If this happens to you, the one important question to ask is if you are a better person as a result of the relationship. Being a more heartfelt or compassionate person will understandably make you a more caring doctor, and your patients will also benefit for all the obvious reasons.
Eight: Get to know your patients as people It really means a lot to patients when you remember personal details about their jobs, family, and accomplishments. Find a way to remind yourself of who the person sitting in front of you is beyond a diagnosis or set of symptoms, and what is meaningful in his or her life. When you succeed in relating to your patients as singular individuals, their behavior toward you will speak to that success. I was deeply touched by one of my 4-year-old patients in whom I performed eye muscle surgery. There she was in the recovery area, weeping and uncomfortable. She beckons to me, “Come here, I have a secret.” My heart is sinking. I think she is going say I misled her when I said she would not be too uncomfortable. I bent forward expecting to be informed of my betrayal. She wants to whisper in my ear. I lean over and hear her say softly, “I have a crush on you.” And she was only 4 years old! Ultimately she must have outgrown her original crush, but recently at the age of 18 years she brought her boyfriend to meet me to seek my approval. Nine: The ultimate secret about caring for patients with teachings from a renowned physician So what is the secret of caring for the patient? It is actually not so secret. Like so many important “discoveries,” if you read old medical literature you will see that someone thought of your discovery earlier. In 1925 the great Harvard physician Francis W. Peabody said, “The secret of the care of the patient is to care for the patient.”6 That’s all there is; it’s that simple. I concluded my talk to the graduates with the advice that they are embarking on a wonderful adventure that will bring them a wagonload of gold. But I was not talking about the precious mineral. The gold is in the ability to deeply and meaningfully touch people’s lives every day they go to work. It is a precious privilege. I wished them safe travels on their journey. References 1. Twain M. Methodsdconscious and unconscious. In: Bainton G, ed. The Art of Authorship: Literary Reminiscences, Methods of Work. New York: D. Appleton and Company; 1891:87–8. 2. Kushner BJ. Descartes’ error. J AAPOS 1998;2:1–2. 3. McCullers C. The Heart Is a Lonely Hunter. Boston, MA: Houghton Mifflin; 1940. 4. Pollak F. Tunnel Visions. Peoria, IL: Spoon River Poetry Press; 1984. 5. Mueller L. Refuses the Operation. In: Alive Together: New and Selected Poems. Baton Rouge, LA: Louisiana State University Press; 1996:186–7. 6. Peabody F. The care of the patient. JAMA 1927;88:877–82.
Footnotes and Financial Disclosures Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. Supported by an unrestricted grant from Research to Prevent Blindness, Inc., New York, New York.
2
Presented in part as the Keynote Address at: the graduation of residents and fellows of the Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, June 27, 2014.