How Do You
Do,
I was studying medicine, I told of a gynecologist who had a poor memory for faces but a good one for perineums. A patient would come in for a checkup. The doctor would at first avoid addressing her by name. But suddenly as he viewed the focal area he would say, "Oh! How do you do, Mrs Jones?" I laughed when I heard the story, but recently I have found that it was not
When
was
so
funny.
About three years ago, to add some leaven to an aging Surgical Editor's loaf, I started work in the ambulatory clinic of a large institution. In the surgical clinic, patients are treated on a walk-in basis, so that one is either almost unoccupied or else too busy. I see between one and 15 patients an hour. It is like a hospital emergency room with far fewer cataclysmic problems. Suddenly, after a period of inactivity, six patients are waiting. My immediate instinct is to move them through the clinic as fast as possible. What corners can I cut? The obvious one, since it has least to do with safety and being sure I don't "miss any¬ thing," is the personal touch, the sympathetic ear and discussion (the things that the majority of the patients need most). The first patient has disabling back pain. I seize the clinical record, enter the room with a perfunctory selfintroduction, and start examining the back that the clinic nurse has
Mrs Jones?
arranged for me while simultaneously asking routine present-illness-type questions. Then, gradually, consterna¬ tion infiltrates as the patient's an¬ swers have begun to tell me that the back is familiar. Or perhaps the patient beats me to it: "Dr Warren, those hot packs and exercises you gave me worked for a while, but this is a new pain." Then I realize that although I may have looked at the patient's face, I haven't seen it, and probably didn't the first time either.
It has been said that in some areas where there is a National Health Service, the average time a practi¬ tioner has with a patient is five minutes.1 As forces in the United States mobilize to keep more patients out of hospitals and as group clinics grow in community practice, we are being faced more with walk-in type of clinic work. Ambulatory surgical clinics by their nature deal with a variety of com¬ plaints of unpredictable severity, many of them acute, most of them minor. But these minor ailments can take more time than the serious ones, and should. Because I am passing the buck of responsibility, the decision and the processing for hospital admis¬ sion is faster than dealing with a patient who will remain an outpatient. I must answer the latter's questions about prognosis and activities al¬ lowed. I must clearly state the details of treatment and also take time to
satisfy myself that the patient under¬
stands them. Where can I get the time to do this? The variety and magnitude of most problems we see render a
possible appointment system imprac¬ ticable except for patients returning for checkup. The only rational answer is an understanding and knowledgeable re¬ ceptionist-type of practitioner who will know the clinic, know the job, know the patient, know the doctors, take care of many of the problems independently, and see to it that the
doctor has the time necessary to shoulder the stickier responsibilities. In some clinics such people naturally emerge in response to the need. In others they are arranged and given titles. These positions should be made part of health planning. Their impor¬ tance must be recognized to the point that pay should eventually become equal to that of the doctor. "Even¬ tually become" is used advisedly, since there must be incentive to remain in the position for enough years to become maximally useful. I would like to be able to look first at Mrs Jones's face. RICHARD WARREN, MD Boston
Reference 1. Robson AM: The British National Health Service and some lessons to be learned from it. N Engl J Med 280:754-761, 1969.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/25/2015
Do,
I was studying medicine, I told of a gynecologist who had a poor memory for faces but a good one for perineums. A patient would come in for a checkup. The doctor would at first avoid addressing her by name. But suddenly as he viewed the focal area he would say, "Oh! How do you do, Mrs Jones?" I laughed when I heard the story, but recently I have found that it was not
When
was
so
funny.
About three years ago, to add some leaven to an aging Surgical Editor's loaf, I started work in the ambulatory clinic of a large institution. In the surgical clinic, patients are treated on a walk-in basis, so that one is either almost unoccupied or else too busy. I see between one and 15 patients an hour. It is like a hospital emergency room with far fewer cataclysmic problems. Suddenly, after a period of inactivity, six patients are waiting. My immediate instinct is to move them through the clinic as fast as possible. What corners can I cut? The obvious one, since it has least to do with safety and being sure I don't "miss any¬ thing," is the personal touch, the sympathetic ear and discussion (the things that the majority of the patients need most). The first patient has disabling back pain. I seize the clinical record, enter the room with a perfunctory selfintroduction, and start examining the back that the clinic nurse has
Mrs Jones?
arranged for me while simultaneously asking routine present-illness-type questions. Then, gradually, consterna¬ tion infiltrates as the patient's an¬ swers have begun to tell me that the back is familiar. Or perhaps the patient beats me to it: "Dr Warren, those hot packs and exercises you gave me worked for a while, but this is a new pain." Then I realize that although I may have looked at the patient's face, I haven't seen it, and probably didn't the first time either.
It has been said that in some areas where there is a National Health Service, the average time a practi¬ tioner has with a patient is five minutes.1 As forces in the United States mobilize to keep more patients out of hospitals and as group clinics grow in community practice, we are being faced more with walk-in type of clinic work. Ambulatory surgical clinics by their nature deal with a variety of com¬ plaints of unpredictable severity, many of them acute, most of them minor. But these minor ailments can take more time than the serious ones, and should. Because I am passing the buck of responsibility, the decision and the processing for hospital admis¬ sion is faster than dealing with a patient who will remain an outpatient. I must answer the latter's questions about prognosis and activities al¬ lowed. I must clearly state the details of treatment and also take time to
satisfy myself that the patient under¬
stands them. Where can I get the time to do this? The variety and magnitude of most problems we see render a
possible appointment system imprac¬ ticable except for patients returning for checkup. The only rational answer is an understanding and knowledgeable re¬ ceptionist-type of practitioner who will know the clinic, know the job, know the patient, know the doctors, take care of many of the problems independently, and see to it that the
doctor has the time necessary to shoulder the stickier responsibilities. In some clinics such people naturally emerge in response to the need. In others they are arranged and given titles. These positions should be made part of health planning. Their impor¬ tance must be recognized to the point that pay should eventually become equal to that of the doctor. "Even¬ tually become" is used advisedly, since there must be incentive to remain in the position for enough years to become maximally useful. I would like to be able to look first at Mrs Jones's face. RICHARD WARREN, MD Boston
Reference 1. Robson AM: The British National Health Service and some lessons to be learned from it. N Engl J Med 280:754-761, 1969.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/25/2015
