“A technician can be defined as one who knows every aspect of his job—except its ultimate purpose and social consequences.”
—Sir Richard W. Livingston (attrib.)
Yesterday, in clinic, a second-year resident told me about a 59-year-old woman with hypertension and diabetes who is overweight and complained of shortness of breath and fatigue. The patient reported that the symptoms had gotten worse over the last eight months, and that they were relieved by rest. She had smoked a pack a day for ten years when she was in her twenties and thirties. The resident recited a differential that included silent angina, COPD, asthma, congestive heart failure, hypothyroidism, and chronic pulmonary emboli. She ticked off a list of blood tests and imaging studies we would need. As her clinic preceptor I couldn’t disagree with anything I heard, but I felt that something was missing.
A few moments later I met “Ms. Wilson.” She was a short woman with a soft handshake and a polite smile. As we talked, I learned that getting around for her had become increasingly difficult over the years as she had gained weight and used her car for short trips in her neighborhood to avoid the effort of walking. She went on to tell me that she had embarked on an exercise program with a friend a couple years ago, and had started to feel much better. She noted that she had lost considerable weight, was shopping on foot, and enjoyed the exercise. Her mood had improved and she no longer felt short of breath even when exercising. Last year, however, her friend left town to help care for grandchildren following her daughter’s divorce. Since then, Ms. Wilson had lost her motivation to exercise and had fallen back into old sedentary habits.
Ms. Wilson’s story ruled out most of the organic causes for her medical complaints. After all, I knew her problems could be resolved with a bit of exercise and companionship. Thousands of dollars of tests and much inconvenience could be avoided. I told Ms. Wilson that we needed to get her back on an exercise program, and we discussed several options. The biggest problem seemed to be finding someone to replace her friend. We didn’t come up with an entirely satisfactory plan, but agreed to meet again in two weeks while we each explored various options. I think she appreciated that we were in this together.
From the perspective of a clinician–educator, the episode was all too familiar to me. I am coming to appreciate that that “something is missing” feeling is a tip off that a resident has not formed the kind of relationship with their patient that is needed to gain essential information. Instead, like a technician, they are working through a laundry list of questions we all learned in medical school. Paradoxically such a direct approach is inefficient. Since it does not tap into the way in which patients live their lives, the clinical picture that emerges is incomplete. As with Ms. Wilson, so often it is the strands that tie a narrative together that constitute the critical data for an optimal clinical assessment and plan of care. Without an engaged questioner, however, they are often politely omitted.
Those of us in the medical profession often form rich relationships with the people we help. Such relationships are inevitable when our focus is on the person rather than the disease. Through our questions we draw the patient into becoming actively engaged with us, enlisting them as full participants in their care. The challenge we face as educators is to convey how essential this process is to the quality of the service we provide.