Teachable Moments: A Book Excerpt
The following was excerpted from "Searching for the Best Medicine, The Life and Times of a Doctor and Patient," a 2013 memoir by Arthur Bank, MD, professor emeritus of medicine and of genetics & development at P&S.
My most intensive experiences in medicine occurred while making rounds on the general medical wards of Presbyterian Hospital from 1965 to 2000. Every year, I spent one month on the medical wards, overseeing the care of general medical patients with severe illnesses in all fields of internal medicine.
These rounds involved seeing sick hospitalized patients in a "teaching setting" with house staff' and medical students. I, the "ward attending," was not only a teacher, but also one of the two senior physicians responsible for the care of patients. The house staff wrote the orders, monitored the patients from minute to minute, and were their more immediate physicians, but I felt as personally responsible for the care of every patient I saw on the medical wards as I would have if they were private patients of mine.
There was no course given to me in or after medical school on how to make ward rounds. I had learned to do so through internalizing examples from my own experiences as a house officer at the Boston City Hospital on the Harvard II and IV Medical Service in the early '60s. I continued to learn how to make rounds when I came to PH from people like Ed Leifer.
Most patients I saw on the PH wards were admitted to the hospital after having been seen in the emergency room. These were patients who were deemed to be too sick or too difficult to diagnose and treat as outpatients. On ward rounds, there were usually two to four house officers as well as two to four medical students, the "medical team." The cases were formally presented by a house officer or medical student. On rounds, I tried to create an atmosphere in which everyone—students, interns, residents, and co-attendings—felt free to express their thoughts about the patient and the case. After the formal presentation of the case, and before we discussed the patient's further diagnostic workup and treatment more fully, the whole team went to meet and examine the patient. I preferred not to have the formal presentation of the patient's history, physical findings, lab results, and medical evaluation take place at the patient's bedside, as some other physicians did. I always thought that approach was too invasive of the patient's privacy. The team was a large group of people, largely unknown to the patient. I felt it often either embarrassed or frightened the patient to see us all marching in together. I know that when I was a patient, I would not have appreciated a medical team discussing my case at my bedside.
At the bedside, my co-attending and I were introduced to the patient by the house officer who admitted the patient. I asked the patient questions that I thought were critical to the immediate illness to confirm independently what I had been told. I tried to project the image to patients that I was interested in nothing else in the world at that time but them, no matter how short or long a time I spent at the bedside. I usually did a physical exam to confirm the staff's major positive findings, if any. I would point out any new physical findings I discovered to the students and house staff at the bedside, if I found significant ones; I would not further question the students or house staff or discuss the patient at the bedside.
After seeing and examining a new patient, the entire medical team would retreat to our room or our corner of the hall to review the major points of the cases briefly and then discuss appropriate further tests and treatment, adding to our thinking what we had learned at the bedside.
When the medical team was outside of earshot of the patients, I asked tough questions and did not hesitate to indicate to house staff or medical students when I thought they should have done more or different things in their workup of patients: in taking the history; in doing the physical; in ordering emergency lab tests; in scheduling tests to confirm their diagnostic suspicions; in instituting emergency therapy; in devising a short-term and a long-term plan. I was not a touchy-feely attending. I was there to teach the students and house staff the right way to do medicine. In my world, there was always a right way to do medicine, and I wanted them to be exposed to it. With a young, relatively inexperienced ward team, there were, of course, doctor-patient interactions that had to be monitored and edited whenever necessary.
The PH house staff was generally quite sensitive to patients' feelings. There were only a few egregious things that I remember seeing on my watch at the bedside. Once, our ward team was at the bedside of a patient when one of the residents suddenly began to tell the patient, "Your heart is very flabby. It's like a big bag filled with fluid that isn't pumping well. Your lungs are filling up with fluid and we're giving you medicine to help you. You're very sick." I didn't appreciate this resident's outburst at all and told him so, but not at the bedside, only when we were back in our meeting place afterwards discussing the case. I told him about his lack of sensitivity and his poor judgment. I made sure the house officer knew that he had done his talking to the patient at the wrong time, and in the wrong way. He should not have done it while the team was there at the bedside. And when he was talking with the patient, he should have used a more empathetic explanation, something like: "We've found that your heart isn't working properly (or as strong as it should). It's enlarged. And we're giving you medicines to make it better."
I confronted and, if necessary, admonished students and house officers if I thought their reasoning was defective or their attitude toward patients was inappropriate, although it was sometimes painful for them. I don't think I received very high marks as a house staff or student favorite. I was never trying to become one. I think it is absolutely critical in medical education that house officers and students be aware of when they are wrong in their care of medical patients or in their decorum in medical situations.
I am very proud of the care given to patients at Presbyterian Hospital during my tenure there. I thought the two-attending system used was optimal for patient care, usually combining a private practitioner like Ed Leifer and a full-time Columbia faculty member, an MD doing research in a medical subspecialty, like me. This system gave the attending different views from different physicians. For me, it was a marvelously successful system in which to practice medicine, take care of patients, teach, and learn from others.