“So Smart”

2017-07-18T13:19:08+00:00

Last week I was describing shoulder anatomy while examining a patient to reason through what could be causing his pain, when he reported to his wife sounding very impressed, “She’s so smart!”

Somewhat surprised by this compliment, my initial reply came out a bit differently from what I intended: “Well, I’m a doctor!” We three chuckled about that before I went on to explain what I meant is that it is a very basic part of my profession to have the knowledge which seemed to strike him as outstanding. What might have more accurately been unique was that I was doing my thinking out loud, whereas quite frankly — contrary to his impression — I was a bit baffled as to what was actually causing his shoulder pain.

I was recently chatting with a fellow physician about a former colleague of his who notoriously filled his documentation with a highly detailed, evidence-based rationale surrounding his decision-making for the express purpose of avoiding lawsuits. Meanwhile, this young doctor’s approach to patients is also increasingly brusque as he packs his schedule so tightly to maximize revenue that his time spent in the exam room or at bedside is dwindling to barely a few minutes per encounter, leaving minimal if any time to discuss his thought process with the very recipients of his care.

I’ve seen it time and again: doctors who are brimming with book knowledge — likely coming from the top of their class in med school — but struggle to connect with a patient. As a supervising resident on the wards, I vividly recall having an intern training under me whose intelligence outshone my own by eons: every day he schooled me on the latest therapeutic trials and their impact on guidelines. During morning rounds one day, we arrived at the bedside of a sweet 85-year-old retired lunch lady who had come to the hospital with chest pain and was successfully ruled out for having a heart attack. Roger, my intern, proudly reported the good news to her: “Your P-Thal showed no evidence of myocardial ischemia! So you can go home.” The dear little lady looked utterly bewildered, but thanked him politely and asked no questions. After Roger examined her and we prepared to leave the room, I offered a brief translation: “Your stress test was normal. Have a nice day.” Her expression changed to relief, and for that patient that day I felt like my work was done. But for the sake of Roger’s future patients, it was my task as the teacher in that situation to coach him on the art of “patient language.”

You see as doctors, we talk shop to each other regularly, even when we aren’t talking to each other much at all. We write or dictate notes every single time we see a patient meant for the eyes of fellow medical providers, that include the likes of “dyslipidemia,” “hepatic steatosis,” and “THA” to describe someone who has a cholesterol problem, fatty liver and hip replacement. When we aren’t careful and indeed may be in a hurry, it’s easy to talk to patients in “medical-ese” like this, without stopping to make sure they understand what they are being told. And that’s how some people come home from a doctor’s visit with no idea what they are supposed to do to get better or keep themselves from getting sick.

I happen to enjoy teaching, and in my new job I don’t have any students or residents to instruct, at least not yet. So I teach my patients. When they come in with a cold and think they should be getting an antibiotic, I list off the criteria I use to determine that their symptoms are inconsistent with a bacterial infection. When they come in with shoulder pain, I discuss what parts of the shoulder are not likely to be injured based on the exam maneuvers I use. Basically, I do my thinking out loud and in lay terms. If I use a technical term, I immediately explain it. I’m really not particularly knowledgeable at all for being a doctor, but I am thorough and transparent.

Meanwhile, knowledge is what helps patients take ownership for the real work in achieving wellness, which is managing their health day-to-day. My role in that is actually rather small, and would dwindle to essentially nothing if I spend my little bit of time with them telling them things that they don’t understand. A successful visit with a patient then, would be one where the patient walks away a bit smarter about what is going on with their bodies than they were before they came to see me.

That’s why the priority for me is not to be super-smart, but to refine my ability to transmit whatever knowledge I have to the people who come to me for help, so that the information and thus ownership of health-related decision-making become their own. If they read that as me being “so smart,” who am I to correct them? 😉