On Being a Doctor
Annals of Internal Medicine
Of Leaves, Trees, Forests, and Primary Care
W
e all recognize that we are not the same doctor from day to day. Our mood, how well we slept, how our kids are doing in school, and what our chair said to us on the way to clinic all affect us in our clinical setting. Although we like to think that the quality of care that we deliver stays constant, I certainly know that the focus with which I attend to my patients varies enormously. On the days when I feel most besieged, I see only the leaves. Patients’ issues and, unfortunately, patients themselves become blood pressures, hemoglobin A1c and microalbumin levels, and the assorted aches and pains that fill the professional life of a general internist. Also clear on these days is the effect that certain patients have on me. Call it what you like, transference or gut reaction, but just looking over the names on my schedule triggers strong emotions. There are the people I look forward to seeing; those who engender grief and hopelessness; and those who leave me aggravated, aggrieved, and annoyed— even when they are doing well. On the less harried days, I am able to look at the issues from a greater distance. On these days, I see the trees. I see the numbers that we fuss over as the surrogates that they are. (Has anybody ever felt better because their hemoglobin A1c level was 7% instead of 8%?) I am aware of what the goals of treatments really are: to improve quality of life and decrease the likelihood of death associated with the diseases that we treat. How aggressively should I treat the hypertension in this 80-yearold? Is there really a reason to check a microalbumin level in the patient with well-controlled diabetes mellitus and hypertension who is already receiving an ACE inhibitor? I am able to clinically observe those who trouble me, personally, the most. Is there a personality disorder here? Can I use my reaction to this patient diagnostically? Should I approach this interaction differently to use our relationship as a more potent therapeutic tool? On the days that I consider my best (which are sadly too rare), I can see the forest. I am reminded of things that that we all know about people. In the fifth year of our relationship, a difficult and eccentric gentleman brings his wife to an appointment. The visit not only proves that there really is someone for everyone but also reveals this man’s kindness, humor, and charisma—traits that I have overlooked for years. Then, there is the 60-year-old who looks 90 who comes in before the 90-year-old who looks 60. We should never forget that, for reasons mostly out of our control, we all age very differently. The observations on these days are certainly not profound; they are notable only because they go completely overlooked on most days. Often, on these good days, I recognize issues that are critical for the care of a patient— especially the enormous breadth of expectations that people have of their health. Some people are scarcely affected by near-complete disabil-
ity, whereas others, even into their latest years, are devastated by any loss in function. The effect of one’s environment on his or her health also becomes noticeable. How many of this patient’s health problems are exacerbated by the pollution or poverty in her neighborhood or the stressors or violence in her home? I imagine that I provide better, more holistic care on those “forest days,” but I wonder whether this is true. Although hard to measure, evidence of improved outcomes or patient satisfaction on these varying days would show doctors the effect of our approach to patient care. Assuming that this type of care is beneficial, we should make efforts to guarantee more of our best days. As is usually the case, more time, knowledge, and experience would be beneficial. Knowledge and experience make the mundane tasks that occupy us on the “leaf days” automatic, freeing us to consider patient concerns more thoughtfully. Decompressing the physician with more time is the wish of patients and doctors. Longer visits are one answer, but computerized decision-support tools and physician extenders could certainly free up physician time and energy. Beyond these somewhat concrete interventions, a more behavioral approach might yield positive results. On our worst days, might forcing ourselves to ask the questions that we usually ask only on our best days reset our approach? “Apart from the medications that I prescribe, what do you think helps your condition the most?” “Are there things that you think negatively affect your health that I don’t know about?” These are the types of questions that would refocus our attention from the leaves to the forest. Even if we can never show better outcomes, it is hard to imagine that patients would not rather have a doctor who considers them as a person with a personality, individual history, and ecology rather than as a list of diseases with associated numerical goals to achieve. This doctor would probably have more rewarding days and less burnout. Whatever the answer, it makes sense to question the variability that we bring to patient encounters just as we question the variability of Medicare funding across our country. It is worth thinking about how we can be at our best more routinely. Adam Seth Cifu, MD University of Chicago Chicago, Illinois Requests for Single Reprints: Adam Seth Cifu, MD, Professor of Medicine, University of Chicago, 5841 South Maryland Avenue, MC3051, Chicago, IL 60637; e-mail, [email protected].
Ann Intern Med. 2014;160:806.
806 © 2014 American College of Physicians
Downloaded From: https://annals.org/pdfaccess.ashx?url=/data/journals/aim/930291/ by a Tufts University User on 07/25/2017
Annals of Internal Medicine
Of Leaves, Trees, Forests, and Primary Care
W
e all recognize that we are not the same doctor from day to day. Our mood, how well we slept, how our kids are doing in school, and what our chair said to us on the way to clinic all affect us in our clinical setting. Although we like to think that the quality of care that we deliver stays constant, I certainly know that the focus with which I attend to my patients varies enormously. On the days when I feel most besieged, I see only the leaves. Patients’ issues and, unfortunately, patients themselves become blood pressures, hemoglobin A1c and microalbumin levels, and the assorted aches and pains that fill the professional life of a general internist. Also clear on these days is the effect that certain patients have on me. Call it what you like, transference or gut reaction, but just looking over the names on my schedule triggers strong emotions. There are the people I look forward to seeing; those who engender grief and hopelessness; and those who leave me aggravated, aggrieved, and annoyed— even when they are doing well. On the less harried days, I am able to look at the issues from a greater distance. On these days, I see the trees. I see the numbers that we fuss over as the surrogates that they are. (Has anybody ever felt better because their hemoglobin A1c level was 7% instead of 8%?) I am aware of what the goals of treatments really are: to improve quality of life and decrease the likelihood of death associated with the diseases that we treat. How aggressively should I treat the hypertension in this 80-yearold? Is there really a reason to check a microalbumin level in the patient with well-controlled diabetes mellitus and hypertension who is already receiving an ACE inhibitor? I am able to clinically observe those who trouble me, personally, the most. Is there a personality disorder here? Can I use my reaction to this patient diagnostically? Should I approach this interaction differently to use our relationship as a more potent therapeutic tool? On the days that I consider my best (which are sadly too rare), I can see the forest. I am reminded of things that that we all know about people. In the fifth year of our relationship, a difficult and eccentric gentleman brings his wife to an appointment. The visit not only proves that there really is someone for everyone but also reveals this man’s kindness, humor, and charisma—traits that I have overlooked for years. Then, there is the 60-year-old who looks 90 who comes in before the 90-year-old who looks 60. We should never forget that, for reasons mostly out of our control, we all age very differently. The observations on these days are certainly not profound; they are notable only because they go completely overlooked on most days. Often, on these good days, I recognize issues that are critical for the care of a patient— especially the enormous breadth of expectations that people have of their health. Some people are scarcely affected by near-complete disabil-
ity, whereas others, even into their latest years, are devastated by any loss in function. The effect of one’s environment on his or her health also becomes noticeable. How many of this patient’s health problems are exacerbated by the pollution or poverty in her neighborhood or the stressors or violence in her home? I imagine that I provide better, more holistic care on those “forest days,” but I wonder whether this is true. Although hard to measure, evidence of improved outcomes or patient satisfaction on these varying days would show doctors the effect of our approach to patient care. Assuming that this type of care is beneficial, we should make efforts to guarantee more of our best days. As is usually the case, more time, knowledge, and experience would be beneficial. Knowledge and experience make the mundane tasks that occupy us on the “leaf days” automatic, freeing us to consider patient concerns more thoughtfully. Decompressing the physician with more time is the wish of patients and doctors. Longer visits are one answer, but computerized decision-support tools and physician extenders could certainly free up physician time and energy. Beyond these somewhat concrete interventions, a more behavioral approach might yield positive results. On our worst days, might forcing ourselves to ask the questions that we usually ask only on our best days reset our approach? “Apart from the medications that I prescribe, what do you think helps your condition the most?” “Are there things that you think negatively affect your health that I don’t know about?” These are the types of questions that would refocus our attention from the leaves to the forest. Even if we can never show better outcomes, it is hard to imagine that patients would not rather have a doctor who considers them as a person with a personality, individual history, and ecology rather than as a list of diseases with associated numerical goals to achieve. This doctor would probably have more rewarding days and less burnout. Whatever the answer, it makes sense to question the variability that we bring to patient encounters just as we question the variability of Medicare funding across our country. It is worth thinking about how we can be at our best more routinely. Adam Seth Cifu, MD University of Chicago Chicago, Illinois Requests for Single Reprints: Adam Seth Cifu, MD, Professor of Medicine, University of Chicago, 5841 South Maryland Avenue, MC3051, Chicago, IL 60637; e-mail, [email protected].
Ann Intern Med. 2014;160:806.
806 © 2014 American College of Physicians
Downloaded From: https://annals.org/pdfaccess.ashx?url=/data/journals/aim/930291/ by a Tufts University User on 07/25/2017
