Patients Not Puzzles

I remember as an undergraduate sitting with my friends in the library “studying,” discussing what kind of doctors we wanted to be once we were finally out of there and in medical school. Our conversations progressed as we progressed, from “surgeon” or “endocrinologist,” to discussions of empathy and patient care. We heard of the students who became machines, so burned out by their studies that they forgot the humanity of the people they served; we vowed that we would not be one of those students. We imagined that it would come naturally to empathize with patients, that thinking of them as people and not puzzles to be solved would come with little effort or training because we were “good people.” After our first Structure and Function test, I realized just how wrong I was.

Our tests (and USMLE Step 1) are presented largely in the format of clinical vignettes: “a patient presents with…” As such much of our studying is done in that format. We quiz each other, read case files, and think about the real-life applications of all of our new-found knowledge; we do this for 10-12 (or sometimes 15-16) hours a day in the weeks preceding an exam.

The effects of that sort of conditioning on my brain became evident to me after our first exam when I was speaking with my mom on the phone. She was telling me that my grandmother was having problems lifting things with her left arm and that she had seen a doctor. I remember being shocked at myself, because my first thought was “Oh good, a rotator cuff question!” rather than “Oh no, is she going to have to have surgery? Is it causing her pain or just functional problems? That must be so frustrating for her!”

I was astounded that my priority was solving the problem. My mother was also none too pleased (she figured out where my mind was going when I asked what direction of movement grandmother was having trouble with). This was my grandmother, not a problem on a test! If I can’t repress the urge to solve a problem when discussing my own grandmother, how can I possibly expect to repress that urge when dealing with a stranger?

Fortunately, we have more classes than just Structure and Function. These issues of humanity and the blending of puzzles and patients are addressed in both Clinical Diagnosis/Reasoning and Medicine/Society classes. In these classes we discuss the patient history and exam; a process that can solve 85% of cases by itself. However, for it to be that effective, the physician must easily shift between patient-focused and problem-focused lines of questioning. The best history is taken when blending broad patient descriptions with focused physician questions, and a good history will often lead to a puzzle solved.

In addition to class work, there’s also my ongoing EMT work. Every time I get on an ambulance I am confronted with more of the patient than the puzzle. Many cases on the ambulances are spent just talking with the patients, as more information than what we can glean on an ambulance will be required to solve their problems. So we talk. In these conversations, these strangers begin to become more familiar. They take on a persona, a specific personality that transcends their vital signs and chief complaint.

I suspect that it is the balance between pure problem solving and pure conversation that will result in productive, compassionate patient care. I have seen how quickly I can fall into the puzzle perspective, and will call on that memory to keep myself in check in the future. We were not mistaken as undergraduates in our conviction that we would not become heartless automatons; we were just mistaken in our assumption that avoiding it would be easy.

By Kyle Townsend