Caring For The Patient

Noticing beauty

As Shug and Celie walk in a field of purple wildflowers on a glorious sun-filled cloudless day, Shug says to Celie, “Don’t you think it pisses God off to walk by the color purple and not even notice?”

This line from the novel The Color Purple, by Alice Walker, captures eloquently the value of noticing beauty and clues in front of us that are often taken for granted.

In my practice, I strive to note the detail in my patient’s lives and in their illness to gain greater insight into my interactions with them and their families. It’s in being cognizant that every patient is unique and beautiful in their own right and that personalized medicine isn’t in the drugs or treatments we recommend, but is the manner that we approach each patient as to where they are and what they need.

Guiding patients down the river

Having chosen a career in cancer medicine, every patient is vulnerable, often scared, and comes to us seeking control over their choices and their life. LIke a whitewater river guide, I’ve guided many down the river of cancer progression. Each ride is different and I must take notice—the quality of the raft, the depth and speed of the water, the strengths and weaknesses of the individual participants and the crew as a whole, as well as my own abilities that day and with each trip down the river. My experience tells me where the rapids are, the bends in the river, and often how long the trip will take. I must notice the changing conditions, what’s different this time down the river. I have to be open to noticing the changes, as every trip is unique. I can warn and inform the riders when there is rough waters ahead and when the ride is near completion. I’m a better guide because of, and with, each trip I make and my satisfaction and reward is providing each passenger with my best guided ride down the river.

Get to know your patient

When I was in medical residency at the University of Colorado, after having a patient history and physical observed by my chief resident, I executed my last H and P done in a traditional fashion with obtaining the history of present illness first. My chief suggested that I obtain all the other information first—the social history, past medical history, medications, then, the history of present illness.

He said, “Get to know your patient first and where they are coming from that brings them to this day,” and so I have from that day on.

I quickly learned that I am the historian for each patient—taking and recording their history, allowing them to tell me who they are. I review the medical records after taking their history, often while they are changing for their physical exam. In this way, I’ve had the opportunity to talk with the patient about what they know and understand with few preconceived notions. I can check the facts and after asking each patient what it is they want to know I’m able to link what they have told me to what the records show to educate them and address their concerns and needs. In subsequent visits and in similar fashion, the focus of each encounter is on the patient’s current status, then I move to the data as it pertains to their questions for each visit.

Consistent with my river guide analogy, I seek to prepare and educate the patient as to what the future may hold—what things we are looking for or signs that I may notice that cause concern and/or a potential need for changing course.  I can prepare them for what scans at the next visit might show, good or bad, and what those results mean and what we may do.

Noticing the color purple in our lives

In many ways I open the door for them to discuss at home what they want to do should outcomes not be what we hope for the next time we meet. Together we discuss hope and how what we are hoping for often changes with time. These real and candid discussions are us (the patient, their family, and me) noticing the color purple in our lives.

I am always taken aback when on rounds the housestaff or fellow is unaware of who a patient lives with or where they live or what they do that gives them meaning. To enhance the living in one’s life and to address medical needs, the medical facts and conditions are not enough.

Although trained as GU medical oncologist/phase 1 clinical trialist, I recognized that I needed additional skills as a clinician that would facilitate my care and improve the outcomes of my patients through to their last days. Good palliative care is intensive care for the patient and their loved ones. I know my patients are not scared to die. They are scared about how they will die.

Addressing fears and concerns

By addressing their fears and concerns, my goal is to reduce pain and suffering and to provide opportunities to my patients and their loved ones the chance to live their life to the end. I know the importance of the work that one needs to do at the end of life. By noticing, by preparing, by addressing hope, my patients benefit as do their surviving loved ones for whom there has been time to say I love you, I forgive you, forgive me, thank you, and goodbye.

As written by Francis Peabody, “the secret of the care of the patient is in caring for the patient.” Through training, practicing, and mentoring, my philosophy and pursuit of clinical excellence is in caring for the patient, being insightful to the needs of each patient, maintaining my skills in a changing medical and therapeutic landscape, and in expanding and teaching the importance of palliative care. As a teacher and a role model for students, residents, fellows, and faculty colleagues, it is a privilege and it is satisfying to continuously strive for clinical excellence.

The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.   

Francis W. Peabody, M.D.  JAMA. 1927;88:877-882.