The patient wasn’t grumpy. He was hurting.
—Alan Z. Yang, “Blind Spots” 1
Learning to care for patients takes years. It taps our brains and tugs at our hearts. Learning to care for patients with many complex medical and psychosocial issues takes even more: more thoroughness, more time, more work, more compassion. More tapping, more tugging.
Being more observant and becoming more self-aware are needed, too, as beautifully conveyed in a brief essay 1 in this issue of our journal by Alan Z. Yang, a medical student. Reflecting on his very first encounter with his very first patient, Yang writes, “In hindsight … clues were there the whole time…. Things I saw but did not see.” In his narrative, Yang asks that the skill of clinical observation be given more priority in training than checklists, tasks, and scripts, which can interfere with truly seeing the patient. “Our patients,” he says, “shouldn’t be our blind spots.”
In his gentle way, our early-career colleague is also asking us to truly see this patient. This patient, M, is not unlike others who find themselves on an inpatient unit in an academic teaching hospital. M has many health issues and a long problem list. He has a hard, lonely life, many struggles, few resources, and innumerable disadvantages. M is a patient whose complexity and challenges can teach the most important lessons of an entire medical school curriculum but may also elicit feelings of helplessness, distress, or detachment by his caregivers. 2
“‘You guys must be tired of me,’ [M] groaned.”
“The patient wasn’t grumpy. He was hurting,” writes Yang, rebutting his resident’s preview of M.
This interpretation of the patient’s outward expression and interior experience is elegant. In this way, “Blind Spots” resonates with the message of a classic article 3 published decades ago in the New England Journal of Medicine in which the author emphasized how the behaviors of patients and the corresponding responses of physicians are important clinical data that should not be ignored. These data should instead be appreciated for their importance in caring for patients—and in learning to care for patients.
“Blind Spots” also reminds me a little of one of my first essays 4 about becoming a physician—about what it means to begin to feel like a doctor. In that narrative, I described taking a cross-country train trip with my daughter just before medical school graduation. On a similar journey during college, I had enjoyed looking out of the window and talking with my fellow travelers. “On this recent trip, however, I was surrounded by a world of pathology—a trainload of potential diagnoses and treatments,” I wrote. I had seen people before; now I saw people with surgical scars, developmental delays, addictions, and health risks. “I still saw all of the things that I had before. It was just that many of these observations had somehow translated into evidence with medical significance.” Without quite realizing it, I had begun to see the world differently, to adopt the skills and point of view of a physician. As Yang is.
In “Blind Spots,” our early career colleague describes his aim to become more observant, and he suggests that the skill of clinical observation be given more priority in medical education. As noted by other authors 5,6 whose work has appeared in our journal, more research is needed on how best to teach and evaluate clinical observation attentively and compassionately, tapping our brains and tugging at our hearts. Giving greater priority to clinical observation and interpretation might also prompt us, Dear Reader, to consider what we ourselves see and fail to see. We might consider our own blind spots.
1. Yang AZ. Blind spots. Acad Med. 2022;97:620.
2. McCarty T, Roberts LW. The difficult patient. Rubin, RH, Voss C, Derksen D, Gateley A, Quenzer R, eds. In: Medicine: A Primary Care Approach. Philadelphia, PA: WB Saunders; 1996;395–399.
3. Groves JE. Taking care of the hateful patient. N Engl J Med. 1978;298:883–887.
4. Lane LW. A trained eye. New Physician. 1989;38:11.
5. Rock LK. Communication as a high-stakes clinical skill: “Just-in-time” simulation and vicarious observational learning to promote patient- and family-centered care and to improve trainee skill. Acad Med. 2021;96:1534–1539.
6. Warm EJ, Kinnear B, Lance S, Schauer DP, Brenner J. What behaviors define a good physician? Assessing and communicating about noncognitive skills. Acad Med. 2022;97:193–199.