“Nothing will sustain you more potently than the power to recognize in our humdrum routine… the true poetry of life – the poetry of the commonplace, of the plain, toil-warn woman, with their joys their sorrows and their griefs.” – Sir William Osler
At morning rounds recently I listened as a first year resident presented the case of a young woman admitted to the hospital. As the presentation became more complicated by a curious past history I interrupted and asked, “Who is this person?”
The other residents stared in silence.
I explained that a nurse care coordinator who I had worked with would always pose a similar question when presented with a new case during rounds. If we were discussing an elderly patient who had been admitted with diverticulitis, she would ask, “Does she have anyone who loves her?”
Her question asked if we had identified anyone who helped this person through life. The answer involved finding out about the person, asking questions or “going to where the patient lives.” So the “who” of the patient I was concerned about was a request that the resident delve into the patient’s “narrative,” her life. Was this young woman married, did she have a partner, have kids, go to school, did she work, care for an ill parent, had she gone to college, did she like her job, hate her job? What was her affect? What were her fears? If the patient has obvious impairments who helps her—who loves her?
When I was in medical school a world famous rheumatologist on our faculty would comment on his patients during rounds by first describing them psychiatrically. I can still see him at grand rounds, looming large in front of the crowd of staff and students, cigar in hand describing the personalities of the people he treated. He did so for good reason. He understood how their personalities and psychiatric profiles colored how they cared for their individual chronic illnesses. Some were passive aggressive, some depressive, some outgoing. They were people. They were souls.
No one suffers illness that is not contextualized by who they are and where they stand in the complex social arrangements of their lives. Recently I was rounding with residents who were getting ready to discharge a man in his middle fifties who had had some complications from gall stone pancreatitis following surgery. This was my first encounter with him and I asked him about his life. He had recently lost a job, was divorced with no children, shared a rental apartment with a roommate, had no car and had medical insurance through Medicaid.
As we were walking down the hall I asked the two residents I was working with what they felt about his life and they seemed bewildered.
Given what he told me, I explained that I saw this man’s life as “Precarious.” A lone, unemployed man in middle age with no assets and no social support structure always makes me worry. It should raise their eyebrows as well. They must see the whole patient. There is a lot of “precariousness” going about these days.
The social history should not be just a series of questions. It has been boiled down to questions regarding illicit drug use, smoking and drinking alcohol. The functional pressure of the physician to get the patient processed cannot explode the art of using the history of the patient to guide the treatment and diagnostic course. This pressure is partly due to the transformative effect of the electronic health record in which the clinician role is warped into a data entry job—one seeks out, in communicating with the patient, what one must point and click in the patient note formats. The patient becomes a complaint, a problem list.
I would further argue that many of the work environment demands bearing down on the physician in the hospital (quality metrics, billing metrics, coding metrics, use of order sets metrics, attestations, time metrics for discharge, individualizing physician patient satisfaction scoring, stroke alerts, sepsis alerts) may have negative quality effects on patient care, as they vampirically suck out the physicians’ time. Every moment a physician has to spend feeding the beast with a screen is a moment of patient communication lost. Often a piece of information from the patient or the family, if one has the time and technique to get to it, alters dramatically a course of therapy or diagnostic planning.
Burdens that come from above and onto the shoulders of physicians and nurses arrive without much concern or investigation about whether the clerical or procedural burdens, multiplying each year, can reasonably be born. In many instances their benefits are not very clear.
Black humor abounds regarding the situation, such as the characterization of a physician’s hospital life as a “death by a thousand clicks.”
Perhaps the time for humor is over. Perhaps it’s time for revolt. We have people to care for, souls to assist.