The Abbott Way: The Life History

Part I: Life Story

              Rather than begin the conversation with the prodding question: “What brings you in today? or “Can you describe the pain you are having?” why not start with something different like “Tell me a little about yourself,” or if you are well acquainted already “What have you done since we last talked,” or even “What was it like growing up in…? While some people may look at you and simply say my throat hurts and I need some medication, most people when given the open-ended opportunity to share their life story become quite revealing, honest and overall quite happy. Some may even forget about their discomfort altogether during the recollection of playing capture the flag in elementary school, or sharing the wonders of a recent vacation. A History of Present Illness is overrated, if given the chance to hear a person’s life story first, we can much readily come to realize who and why the patient’s current symptoms are imparting suffering. The reality of illness is that it is entirely a subjective experience, yet we are focused only on objectifying symptoms, quantifying pain or categorizing a collection of symptoms into distinct syndromes. If I cannot understand which symptoms are disruptive to the patient, how the patient’s experience of the symptoms is leading to impaired well-being and most importantly, how a patient’s mental and emotional relationship to his or her current malady is ultimately manifesting as his or her experience of the illness, I will never successfully provide healing, This may come as a shock, but just because Sudafed is used as nasal decongestant, doesn’t mean I should prescribe it or suggest its use to someone presenting with such a complaint. What if an individual’s fundamental issue is spending too much time in a crowded, moldy office building with inadequate ventilation, or the individual has food intolerances to dairy products due to underling intestinal permeability, yet they do not experience overt abdominal bloating or pain, but are exhibiting systemic signs of congestion and inflammation? And what if an individual has had chronic joint pain for the last 20 years and only recently developed a common cold; if you decide to solely target treatment to the osteoarthritis, and provide some degree of relief, yet do nothing for the viral illness, you might find that the patient loves you eternally for their newfound ability to exercise in minimal pain even if there sinuses are still as congested as the Hampton Roads Bridge Tunnel. So instead of taking a formal history with a focus on a chief complaint, start with a life history and you may be surprised to find you may find out about grandma Ida’s heart attack and your patient’s past history of alcohol abuse all the same as if you had asked them in as laundry list. Many current physicians can agree that most illness and disease can be diagnosed by a thorough history in lieu of imaging and laboratory tests. I would argue, however, that without establishing a degree of comfort and trust by obtaining a life story from your patient, who is to say what they tell you is truthful, accurate or complete? Gaining trust is essential to practicing effective medicine, and while a thorough history most certainly can diagnose almost any condition, only by connecting to a patient and elucidating a life story can you most certainly provide a means to heal.

The Abbott Way: A Replacement for the Current Patient/Doctor Interaction

            Practicing medicine is rather simple when you break it down into the relevant tasks a physician is expected to perform. There is taking a complete history of the patient’s current complaints, past medical history, social history including alcohol and drugs, past surgical history, pertinent family history, allergies and current medications. After taking a thorough history, one will usually then conduct a Review of Systems asking straightforward questions for all the body systems in order to elucidate possible issues that the patient may have “forgotten about” due to the pressing nature of the chief complaint. This is then often followed by an assessment of vital signs and finally by the ritualistic physical exam. While this may be the end of the formal patient and doctor encounter, it is by no means the end of a physician’s responsibilities. Following this interaction, a doctor may begin documentation into an electronic health record- if not conducted during the interaction itself, verbal documentation of one’s decision making as part of the “work-up” for the patient’s present complaints, a plan for further diagnostic imaging and laboratory studies to help narrow the list of possible diagnoses, and lastly the development of a final assessment and plan for treatment. When conducted in the academic hospital setting, a formal presentation to other team members regarding the course of therapy is often conducted as well. Following all of these formal processes, the doctor can then return to discuss and initiate a treatment plan with the patient, provide education for self-guided therapy and prescribe drugs or additional medicines. There it is, a doctor’s duties in a paragraph, and yet the process of obtaining the skills to complete all of these tasks effectively takes an entire lifetime. And as I will argue, if one simply follows the template above, I don’t think we will ever reach the ultimate goal of practicing medicine: providing vitality and well-being to all patients who seek our help.

            While I have spent the entirety of this post describing the current formal, medical interaction, I have realized through my training that despite that fact that this framework has provided a reasonable means for treating disease within the Western Medicine system,  and the reality that this type of interaction has been performed for years with relative success, doesn’t mean we can’t improve or even more shockingly, that this method may simply be inadequate for relieving most suffering. While at this point in my training as a third year medical student, I by no means can provide the array of care conducted at the hospital by nurses, residents, attendings, or other staff, but what if we changed the rules of the game and redefined what it meant to treat illness. While my years of practicing medicine upon completion of my training are still years off, I feel obligated to share a different method for approaching the patient encounter to all those currently healing the sick, for as I see it, you cannot change a system, you can only provide a different perspective that allows those around you to choose for themselves what is worth the time and effort. Nothing is more precious than an individual’s time so why not use your 15-minute encounter for something meaningful, even if it means disregarding the ROS, eliminating electronic documentation or completely ignoring medication reconciliation.

             So in a four-part blog series to follow, I will provide a potential substitute for the History, ROS, Physical Exam, and Treatment. For the sake of humor I will call it the Abbott Way: A Life Story, A Nourishing Review, A Healing Touch and A Goal-Directed Acton Plan. While each of these practices can be implemented separately as part of a physician-patient interaction, I whole-heartedly believe and plan to utilize all 4 as part of my normal encounters with people everyday. To be honest, I think I would be doing a disservice if my medical care did not involve all four of these practices. After finishing the series, I hope that you may share this same view.