Medicolegal Issues

The New and the Timeless


 

I recently picked up volume 1, number 1 of The Hospitalist, which was edited by John Nelson and Win Whitcomb and published in spring 1997. The Hospitalist was six pages long and had five articles and three job advertisements. The articles included one by Bob Wachter about how hospitalists represent “without a doubt … a bona fide new specialty in American medicine,” and one by Richard Slataper about how hospitalists improve quality of care.

As I compare volume 1, number 1 with the current volume, I marvel at how much things have changed—and how much they have stayed the same. The change is obvious just by looking at The Hospitalist. The similarities are evident by reading the content. We still talk about how hospital medicine is emerging as a new specialty and is taking important strides in that direction. Quality is still the key metric by which we measure our practice.

With this volume, we enter a new, exciting era for The Hospitalist with a new format, new editorial staff leadership, and a new publisher—but the same commitment to excellence and dedication to addressing key issues in the field of hospital medicine. I thank Jim Pile for his outstanding job as the previous editor of The Hospitalist. Jamie Newman assumes the role of physician editor with this issue, and I am excited to have his energy and creative ideas to lead the new phase of this important publication.

It has been said that half of what you learn in medical school is obsolete five years after you graduate. The trouble is you can’t know which half that will be until five years later. I remember being warned as an intern never to give a beta-blocker to a patient with heart failure. We now know that beta-blockers are lifesaving for people with heart failure. We are fortunate to practice in a world where scientific discoveries enhance our ability to help our patients and where the pace of discovery is growing by leaps and bounds. I wish I could list everything we do today that will be obsolete in five years, but my crystal ball is not that clear. Because I cannot predict what will change in medicine, I have instead thought about what does not change. As we celebrate the new with this volume of The Hospitalist I want to remember what is timeless in our profession.

One of my mentors says, “Don’t just do something, sit there.” When I am confused about what is going on with a patient, my best aid in figuring things out is to pull up a chair and have the patient tell me his story from the beginning.

Cornerstones of Diagnosis

With so much technology it is easy to believe that technology makes the diagnosis and heals the patient. But despite all of the new and amazing tests at our disposal, the patient history and physical examination remain the cornerstones of diagnosis.

It has been said that in more than 90% of cases the correct diagnosis appears on the differential after the history and physical. The tests merely help to confirm or rule out diagnoses. As technology races ahead the importance of sitting at the bedside, talking with the patient, and hearing her story stays constant.

One of my mentors says, “Don’t just do something, sit there.” When I’m confused about what is going on with a patient, my best aid in figuring things out is to pull up a chair and have the patient tell me his story from the beginning. What I like so much about being a hospitalist is that I have the ability to spend that kind of time when I need to. Unlike the outpatient setting where patients are scheduled every 15 minutes regardless of the reason for the visit, in the hospital I can be more flexible about how I allocate my time. I can spend time sitting and listening.

There is an apocryphal story I like that says that if you sit down in the patient’s room the patient will experience your visit as having lasted longer than if you stand for the same amount of time. I say apocryphal because I have searched for this study but have never found it; however, I believe it. Patients also like telling their story. There is healing in the telling and in knowing that you have been heard. As so much of medicine changes, sitting with the patient and hearing her story remains timeless.

Reach Out and Touch

Another part of medicine that has not changed over the millennia is the power of touch. During my second year of residency I realized that in many situations the physical examination just didn’t add much to my care of the patient. Perhaps this fact reflected my physical examination skills, but I believe it was more a function of realizing that in the absence of complaints in the chest I was unlikely to discover something on lung exam.

The great symbolism and importance of touching and examining the patient goes beyond discovering the unexpected finding. The laying on of hands creates a physical connection to the patient and can heal. I now make it a point to physically examine every patient every day. I examine patients not just to support billing and not just because there just may be a new finding, but because there is power and healing in touch. I want the patient to benefit from this power and I want to connect to it for myself. As a hospitalist I feel privileged to be able to be at the bedside with patients.

Identify with the Patient

Another timeless part of patient care is empathy. Many patients simply want someone to walk alongside them and understand their experience of illness. Empathy makes this possible.

As I talk with patients I use myself as a guide for understanding the patient’s emotional experience and try to reflect that back. More than simply taking the history or laying my hands on the patient, I try to understand what the patient is feeling and going through. The fear and loneliness of illness can be greatly relieved by knowing that another person understands your experience and is walking with you. Our patients’ need and desire for empathy has not changed despite all of our technological innovations.

As hospitalists we meet people at their sickest and most vulnerable. They enter the foreign world of the hospital where they are often alone and where they have little to no control over what happens to them. Patients typically can’t even dictate the basics of life in the hospital like when or what they can eat. Even if we imagine the ideal hospital of the future built around the patient and that affords maximum control to the patient, the hospital will still be foreign. The power of empathy and the human interaction it represents will remain as important in this ideal hospital as it is today and as it always has been.

Education Never Ends

The other certainty in medicine is that science and technology will advance, bringing new and better ways to diagnose and treat illness. Thus the final constant in medicine is the need to always be learning. As an attending I had to learn that beta-blockers were good for people with heart failure and saved lives. I have learned many more new things since residency and understand the need to continue to learn.

Another wonderful aspect of being a hospitalist is the continuous progress of medical care and the ability to apply it to help patients. Advances in diagnosis and treatment, changes to systems that ensure that all patients receive this care, and attention to patient safety, quality, and palliative care all help ensure that patients receive the best possible care. Hospitalists are at the forefront of all of these activities.

In Conclusion

I delight in the new and celebrate progress that this era for The Hospitalist represents. I’m proud of the The Hospitalist and look forward to it continuing the tradition of quality while it expands and grows in new ways. In the same way I’m excited about medical advances but try always to remember what is timeless. Sitting with patients, listening to them, touching them, and being empathic reap great rewards for patients and for us.

As hospitalists we care for people at their most vulnerable moments. At those times our humanity, our gentle, caring touch, and our empathy matter most. In addition to bringing to bear the best that modern medicine has to offer in medications, diagnostic tests, and interventions let us remember the power to heal that we bring to the bedside when we bring ourselves—open to being with the patient and not just doing something but sitting there. TH

Dr. Pantilat is an associate professor of clinical medicine at the University of California at San Francisco.

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