Communicate With the Person in Front of You

June 29, 2011

Often on rounds we see problem lists and the clinical issues first and the patient second.

In day-to-day medical practice we use categories and broad judgments to organize the enormous amounts of data at hand. We routinely use information implicit in a clinical diagnosis to move forward with management despite not knowing too much personal detail about the patient. Standard of care necessitates implementation of treatment based on clinical diagnosis and criteria, as judged appropriate after weighing risks and benefits. Standardization improves clinical outcomes by applying evidence-based methods to patient care. Consequently it is natural for clinicians to see a disease or syndrome when we look at any particular patient. We all know that it is good practice to approach any patient encounter with an active problem list in hand, each component of which should be addressed soon thereafter.

Often on rounds we see problem lists and the clinical issues first and the patient second. We often remember radiograph or MRI findings in better detail than the patient’s own name. However it is this manner of seeing that can become problematic when it comes to communication. I wouldn’t go so far as to say that this way of seeing should be radically changed; evidence-based clinical care is so voluminously complex that we must be meticulous and detailed when it comes to day-to-day care, especially in the hospital.

But in addition to knowing every detail about the patient’s problem list, risk factors, organ function, functional status, etc., we must be able to see through this veneer at the person there in front of us, especially while engaged in the act of communicating. Real communication is almost indescribable; it is the a priori basis upon which the entire human experience is fundamentally built. This basic human-to-human bond in communication is often obscured by the superimposed necessities of language and social setting (not to mention liability risk). Consequently a unique human being experiencing a certain life is inevitably viewed by clinicians as a representative of a particular disease manifestation: the 45-year-old obese diabetic male smoker with lumbar disc disease, a fatty liver, and an 80 percent lesion in the circumflex, etc.

What I am trying to reify here is the necessity of communicating with the person in front of you. Philosophically, the human being in its totality defies linguistic and cultural definition. After all, it is the human being which is the definer of any definitions. Clinically, the human being is the whole organism, a subset of which may be involved in any particular clinical problem, i.e. cardiac disturbance, metabolic derangement, etc. Ironically it is the medical specialties which often come later in the temporal sequence of clinical actions (specialties such as hospice care and palliative care) that are best at viewing the patient as an undivided whole, and not as a sum of these subsets. In an ideal world, primary care would also be holistic in its perspective, but that is a topic for another article.

Now, back to real communication. Real communication involves words and eye contact, but it also involves a mutual understanding, an indefinable sense of "I’m here, and you’re here, and I know you know that I know that you’re here with me."

The fact that clinicians get the privilege of engaging in real communication with absolute strangers in their most critical moments of life is more than a privilege: it is a sacred calling that still gives me a spinal shiver in its mere contemplation. I have to remind myself to communicate in this manner every time my heart sinks at the sight of a patient’s weight (350 lbs), social history (smokes a pack a day), vital signs (systolic blood pressure of 180), and cardiac rhythm (atrial fibrillation).

After I inwardly lambast the socio-cultural doomsday that such a common clinical picture portends, I take a deep breath, look my patient in the eye, and see something completely surprising - a human being, much like myself, trapped in the particular trappings of his life, much like myself, trying to survive … much like myself. When such a perspective opens up within me, my heart then takes over. What my heart does at this point will be subject for another day.

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