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Teaching and Learning Moments

Vaishnava, Prashant, MD

doi: 10.1097/ACM.0b013e318248d827
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Dr. Vaishnava is a fellow in cardiology, Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Medical Center, New York, New York; e-mail:

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PPQRST Revisited

In this very column in November of 2003, I reflected on the Longitudinal Patient-Centered Experience at the Michigan State University College of Human Medicine, suggesting the use of an additional P to denote person in the trusted mnemonic categorizing the characteristics of a patient's chief complaint—PPQRST, or palliative, provocative, quality, radiation, severity, and timing.

Now, nearly a decade later, I am a fellow in cardiology at Mount Sinai Medical Center in New York City and a faculty preceptor to two wonderful students, who remind me of myself as a medical student—enthusiastic and untainted. Like I did, they have the good fortune of attending a medical school that believes strongly in teaching about chronic illness and longitudinal patient-centered relationships. My students have followed one of my sickest patients, a chronically ill gentleman whom I met over a year ago after he was admitted to our hospital with a storm of ventricular tachycardia. Since then, I've seen him through heart failure exacerbations, life-threatening gastrointestinal bleeds, good times, brushes with near death, firings of his implantable cardioverter–defibrillator (ICD), lower extremity vascular bypass surgery, toe amputations, and recurrent Clostridium difficile colitis, although the list could unfortunately go on for much longer.

Through all of this, my students have not been spectators. They have participated in his care, learning along the way how to manage a chronically ill patient. The students also completed a life history assignment, writing about my patient—his reputation as the class clown as a child; his best friends; his frustrations with his recent trip to Aruba, where he found himself unable to do much at all; his concerns about his fading memory.

I must concede that much of this information was new to me. My attention has been so focused on minimizing the firings of his ICD or keeping his INR in range, lest he develop another gastrointestinal bleed. At times, I have, perhaps, forgotten my own lesson about that additional P, person. The students' life history assignments were a gentle reminder about good doctoring, particularly for a patient whose illness is so advanced that devices or a cardiac transplant are simply not feasible options. The most realistic option is to optimize his medical care, based on his preferences. If his fading memory is his most prominent concern, then I should address it, even at the expense of doing away with some medications that may be optimizing his cardiovascular status.

That P is here to stay.

© 2012 Association of American Medical Colleges