“You can observe a lot just by watching.” Yogi Berra

A Sensible Medicine Guest Post

Recently, a patient of mine died. She just had her 100^th birthday. I decided to pay a condolence call to her daughter and the patient’s husband, who was alive and well at 102, and also a patient of mine. It was no big deal. It was Sunday, and I was free, and they only lived one mile from me. A week later, I got a card from the husband and his daughter saying how meaningful my visit was.

There were many other ways that I could have expressed my sympathy. Why did I make the condolence call?

In 1975, in my second year of my Family Medicine residency, I got a call in the middle of the night from one of the residents in the hospital that Mr. R had died. This was my first continuity patient who had died, and I did not know what to do. Fortunately, Mr. R had previously been a patient of my residency director, Donald Kent, and Dr. Kent was on backup call that night. I called Dr Kent. His response was, “Well, Bob, let’s you and me get dressed and go over to Mrs. R’s house to make a condolence call.” We went over at 2 am to be with Mrs. R, and I learned a valuable lesson. In the years to come, I attended many funerals and was always moved by the impact my presence made.

While in solo practice, I made it a practice to accept and care for patients on Medicaid despite the financial drain.

Why did I do that?

In 1976, I did a 4-week outpatient ENT rotation at the office of Arthur Brenner, MD. Once, after I had finished observing him in his office, I said, “I will be back tomorrow”. Dr. Brenner said, “No, you won’t, we will be going into New York City.”

Dr Brenner began his medical career before the advent of Medicare and Medicaid, and it was expected that physicians would give back to the community by volunteering their services. So, every Thursday, he drove into midtown New York to volunteer his services. He did this even though Medicare and Medicaid had come into existence a decade previously.

Unfortunately, not all such lessons are internalized the first time around. In 1973, as a medical student, I did a rotation in Family Medicine with David Sharp in rural Hunterdon County, New Jersey. One day, Dave casually mentioned to me,

“The most important thing a family doctor can do is recognize the sick patient from the not sick patient. Do you see that boy across the waiting room? He looks sick. You need to trust your gut instinct.”

Sure enough, several hours later, the child was in the hospital with urosepsis.

In 1988, I was working a shift in an after-hours facility, and a patient came in with what sounded like musculoskeletal chest wall pain. He was diagnosed the day before with reflux and was told to elevate the head of his bed. While lifting, he felt a sudden snap in his anterior chest followed by sharp chest pain. When he came into the office, he had tenderness in the anterior chest which reproduced his symptoms. I did not do an EKG, but I remember remarking to him that he had a worried look on his face. He answered that he was anxious because his mother was in the hospital. Two hours later, I received a call from the emergency room that he had collapsed and expired from an acute MI.

In 2016, a patient presented to my office, reporting feelings of tiredness. He had no symptoms referable to the cardiovascular system, just fatigue. However, he had that worried expression on his face, which reminded me of my patient from nearly 30 years prior. I decided to do an EKG. It showed ST elevations across his precordial leads. Within an hour, he was in the cath lab and was discharged a few days later.

These lessons are just examples of those I learned from role models. What is consistent is that the teachers were not aware that they were teaching, and I am sure that they had no memory of what they said or did. They were just being themselves. However, these were important and enduring lessons.

Recently, I accompanied my wife to her visit with her family physician. I was in awe. I thought that I would love to shadow her for a day to pick up important tips. Despite 51 years in medicine, I still learn by observing others.

In the 19^th century, physicians were primarily trained through apprenticeships. That stopped with the Flexner report, and for good reason. After Flexner, medical education became standardized with a prescribed curriculum delivered through accredited medical schools. Unfortunately, progressively, we have diminished the opportunities to learn through working with and observing experienced practitioners. There has been increased emphasis on counting procedures performed and using specific patient encounters as a proxy for competency. To be sure, one needs a certain minimum number of “at bats” to achieve competency, particularly in procedural skills. Also, my observation is that current residents have a distaste for “shadowing”.

The most important attributes that patients value are empathy and the ability to engender trust: the art of medicine. However, these are precisely the qualities that are decreasing among physicians in the eyes of patients. While we still get high marks in terms of knowledge and technical expertise, those are the attributes that are most threatened by robots and artificial intelligence.

I do not consider myself naturally endowed with humanism as it pertains to the practice of medicine. Even those elements of humanism that are natural to me needed refinement. This learning came from observing others, formally and informally. I suspect that is the case for almost all physicians.

Nowadays, physicians are increasingly isolated from each other. Thus, there are fewer opportunities to learn from observing others.

How much harm would occur if there were a requirement during residency to spend 2-4 weeks working closely with and observing practitioners in a variety of settings? Trainees could spend time with practitioners who are known for professionalism, compassion, career satisfaction, and other traits that are unlikely to be learned within the constraints of ACGME guidelines.

My hope is that we can achieve and maintain equipoise between the science of medicine and the art of medicine

Robert Eidus, MD is a Family Physician in Walnut Creek, California