Taking good care of patients requires openness, curiosity, and honesty about all the dimensions of a patient’s life. This helps us navigate the different, intersecting domains that affect health, and achieve a measure of self-knowledge that motivates our improvement as physicians.
In thinking about what makes good care, I suggest a particular approach to professional development, patients, and the self: Intellect, Integration, and Interaction, and the fourth “I,” self-development.
There is a considerable literature devoted to cognitive biases, how physicians use shortcuts when we shouldn’t, and ignore information which doesn’t fit our preconceptions. But cognitive excellence isn’t enough; we also need wisdom regarding such biases themselves and how frequently they impact patients’ experiences. I can’t ground this in empirical research, but being transparent when talking to patients about how our thought processes are susceptible to bias might help reduce frustration and adjust expectations to meet reality.
We have to operate on many different strata at once: keeping political and social forces in mind; paying attention to local realities, histories, and futures; and, of course, the individual patient.
Whenever I teach residents I encourage them to present the patient to me as a whole person, not a collection of symptoms or systems. I do this to remind myself about the whole patient as well.
Integration means we consider the entire patient at once, from the finest details of biomedical reductionism (what medications are they taking? What is their INR?), to the circumstances of their home life (who’s cooking for them?), to the concrete realities of politics (are they worried about getting deported?) – even to the metaphysical (do they have spiritual needs?).
There is no realm out of bounds. That’s why instead of a 74-year-old man with CKD, CAD, AF, and PNA, I like to hear about the man in his 70s, born in South Carolina, who loves jazz, fixing old cars, and singing in his church choir. The patient and I can talk about religion, politics, or gardening, whatever the patient is open to talking about and grants me entrée into their life.
Good care also needs personal interaction. Meeting someone face to face can provide a different sort of information, vital to the care of the patient, beyond the whole-person integration we just mentioned.
While I have not yet fully integrated this into my practice, I love the question “What can you tell me about what your disease means to you?” Every experience of illness is different, and this question gives the individual patient a chance to tell us what their life is like. How would I know, without asking the question, that my 70-year-old patient values the opportunity to re-enact the Civil War and is an aficionado of historical swordplay, and that his shortness of breath makes it hard to carry the heavy ornamental swords? Thus what is important to him in his life is made difficult perhaps out of proportion to the outward appearance of his symptoms.
Development of the “I”: Self-knowledge
This brings us to the bonus “fourth I,” self-development (development of the “I”). Many others have written about how deepening one’s own virtues is necessary for excellence as a physician. This can be done in many ways, for example, by exploring areas of life outside of the narrowly clinical realm that one finds meaningful. Here I want to talk about another kind of self-development, openness to admitting one’s own ignorance.
Self-knowledge requires honesty about our imperfections and ignorance and willingness to change.
Excellent care requires conscious self-development towards transparency: telling the truth, starting with, “this treatment isn’t as good as they say,”or, “we don’t know what might work for this condition.”
In the course of a visit there are so many exchanges which I used to respond to with half-truths or practiced institution-speak. Now I try to be honest.
“When will I get the specialist referral?” asks the patient, and I respond, “We’ll try as hard as we can, but that’s something we as a system need to work on.”
“Why can’t I get the colonoscopy where I used to?” I say, “Because the institution has financial interest in encouraging certain colonoscopy sites.” Or, “Why do medications cost so much?” “Because our system fails to regulate pharmaceutical prices.”
Fostering trust in our care does not require prevarication about the flaws in our system, the imperfections of our evidence or the mistakes we make. I’d like my patient to be honest with me about what disease means to her life, so I should be honest with her about how the flaws in our system will affect my care of her.
Seeing the patient as a whole person in all the domains of life, understanding their needs face-to-face, being open about what we know, what we don’t, and the imperfections and mistakes of ourselves and our system: these are practical pointers I work on every day. When I manage to get them right, I think patients are more satisfied and I feel better about taking care of them. Maybe this will be true for you too.