Friday Reflection 55: The Wisdom of Colleagues

I don’t tell my colleagues that I appreciate them enough. They are my consultants, my teachers, my therapists, and my friends. The best continuing medical education I get is listening to them teach medical students and residents.

For the last few years, I have been hosting The Clinical Excellence Podcast sponsored by the Bucksbaum Siegler Institute for Clinical Excellence.¹ Although it will never compete with The Joe Rogan Experience or This American Life, I have enjoyed making it. The podcast gives me an excuse to have brief, focused conversations with students, doctors, and patients. This season, I’ve doubled down on discussions about the patient-doctor relationship. Four topics that colleagues have mentioned have gotten me thinking.

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We don’t reflect enough when things go well.

When something goes wrong in medicine, whether it’s somebody’s fault or not, we think about it. Usually, there is no official “root cause analysis” or “incident report”, but we can’t help thinking: Did I do something wrong? Could things have gone better?

When something goes well, we seldom dwell on it.

I was once fortunate enough to work with a clinical coach. Her technique, which I think is how most professional coaches work, was to identify what I did well and then work with me to figure out how I could do those things more frequently or in more circumstances.

Reflecting on clinical successes more frequently would be beneficial. When you make a difficult diagnosis, it would be worth considering what went right in the history taking and testing. How and when did you learn that diagnosis? Why was it accessible to you when you saw the patient? Which consultants were best to collaborate with?

When a relationship with a patient develops in a positive way, turns into a truly therapeutic alliance, what did you do well in the room? Were there things you did during follow-up that could be repeated with other patients?

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The patient-doctor relationship usually includes more than just the people in the room.

We spend a lot of time talking about the patient-doctor relationship. We talk about empathy. We talk about asking open-ended questions. We talk about intentional listening. We seldom talk about a doctor’s relationship with people closely associated with the patient who are not in the exam room. A spouse may be the reason that a patient made an appointment. An adult child who is skeptical of medical recommendations might be at home, influencing a person’s adherence to medications. A partner might be the one suffering the most from a patient’s illness.

I can think of dozens of men who admitted that they only made an appointment because their wives insisted. Many of these men tell me that they will need help explaining why we made the decisions we did.

Usually, I learn about these complexities from patients' insights and candor. How much better would I do if I routinely queried my patients about who else is important in their care and management?

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Do not cheat patients who are there only for your time.

My clinical schedule allows 20 minutes for return patients, 40 minutes for new patients, and 40 minutes for patients over 80 years of age. On any given day, some patients need a 60-minute appointment. They have multiple or complicated concerns. They need a detailed exam or a procedure. They require time to hear and process a diagnosis, a treatment plan, or a prognosis. Other patients only need a 10-minute visit. They require only a blood pressure check, a simple exam, or a “How are you doing? Let’s get you your flu shot and labs.” Making a schedule work means telescoping visits to provide the needed care while keeping everyone satisfied.

Some patients seem to need very little, but in fact need a lot of time. These people do not need a complicated exam, a procedure, or a thoughtful discussion of a diagnostic process. They do not need to be counseled through a life-changing diagnosis. Someone reading the note might wonder why this patient came in at all or why the visit took more than 90 seconds. Many of these patients do well because of attentive “check-ins”. These visits often serve to keep somatic symptoms at bay and health-related anxiety in check. In all the borrowing time from the well to care for the unwell, it is sometimes tempting to give these patients short shrift. We need to remember that for some, time is more therapeutic than the newest biologic.

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Don’t feel proud because you care for a very old patient.

It is hard not to feel proud that there are centenarians in your practice. I have a colleague with whom I jokingly compete. His oldest patient is a few months older than my oldest, but I have more patients in their eleventh decade than he does

Neither of us can, nor should, take credit for these people’s longevity. No matter how long we have cared for these amazing people, it is not us who got them here. What brought them to their advanced age? The same things that enabled them to see the same doctor for 10, 20, or 30 years. These patients have benefited from good fortune, social stability, relatability, genetics favoring longevity, and, often, a positive outlook. They are the right tail of the bell curve. As doctors, we are more fortunate to have them in our practices than they are to have us as their doctors. Our most important contribution is not doing anything stupid.

1. I promise you, this piece is not meant to be a podcast promotion.

Photo Credit: Vitaly Gariev