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.

Medicine and Nursing: A True Collaboration

Special Post for the end of March: Here is a recent "Ted-Talk" I gave with a friend and colleague Abby Muller of the UVa School of Nursing as part of a Student Ambassador of Resiliency (STAR) Workshop retreat. The talk is thematically based on the ideas of 1). Overuse in Medicine 2). Inter professional Collaboration 3). Mindfulness and Resiliency. The workshop was organized and funded through the Lown Institute and is currently being conducted in similar academic settings between nursing and medical students. Enjoy!

Imagine yourself wearing a white coat, stethoscope around your neck, walking into a patient’s room with a small plastic cup of 2 acetaminophen tablets and a slightly larger cup with a little water. The situation seems fairly routine, the patient rustles from the bed to acknowledge your presence and sees you have brought in some potential relief for the nagging headache that just won’t go away.

Now imagine yourself, wearing a white coat, stethoscope around your neck, walking into a patient’s room with a printed visit summary, some scanned MRI results and a gaggle of other white-coated individuals in toe. The situation also seems fairly benign, and the patient doesn’t appear to be bothered by the herd of people, yet still seems quite content to stay asleep and avoid whatever confrontation is about to follow. Meanwhile the family members in the corner pull out their I-phones to check their messages or direct their attention to the TV, which happens to be showing a re-run of House.

So here’s the question, where is the nurse?

If you said checking in on another patient, charting on EPIC or simply outside of the room at the moment, you would actually be incorrect.

In scenario one, it turns out that the trusty white coat sporting individual was a nurse coming to administer a medication order placed by the doctor a few minutes prior, and in the second, it just so happens that everyone in the gaggle of health care providers: resident, attending, medical student, nurse and nursing student were all wearing white coats

So then it seem the real question should be: What does it mean to wear a white coat?

Not surprisingly, if you ask most patients- white coat=doctor and doctor=the one responsible for making me better. So who do you want to be, a doctor or a nurse, a white coat, or somebody in scrubs? Does appearance and expectation make a difference?

Our perceptive world is so vast and our subconscious and unconscious perceptions practically invisible to our awareness. In pondering this dilemma, we sought to ask a few more probing questions: How do patients view their care in the hospital, is it a team with nurses, doctors, therapists all communicating effectively to bring about healing? Was it a somewhat disconnected, yet still productive system of individuals performing a specific trained task leading to improved wellness? And within the process of healing, did the patient feel like they were being treated as a human being?

While we certainly cannot answer these questions in a 10-minute talk, it took only a short Saturday afternoon of simply being with 7 sets of patients in the UVa Hospital to discover much more than we could have ever imagined.

First, as alluded to in our introduction was the idea that white coat=doctor. Without fail nearly every room we entered was perplexed or had to clarify that Abby, dressed in a her white coat, was indeed a nursing student and I, also dressed in my white coat was a medical student.

Second was the fact that yes ,indeed, there was a student nurse and a student doctor in the room at the same time, engaged in conversation and not simply carrying out separate tasks hoping to achieve a desired outcome.

Everyone would argue that communication is paramount to successful care, and we wondered, did the patients ever see nurses and doctors communicating effectively or even carrying out tasks together in the same room at the same time? While nearly every patient expressed great satisfaction with their care and shared knowledge of great teamwork by the staff, most did not experience nursing and medicine as one, but rather as a cohesive and effective summation of the parts. So while everyone seemed to be happy, and the health care providers were carrying out their duties, couldn’t we still do more, or could there be another way of engaging both nurses and physicians?  Would you be willing to change from the status quo, continuing to search for ways to improve the ultimate goal- proving healing to the patients in need

Third, and perhaps the greatest shock to the patients, was that we were there now not to put a stethoscope on their chests, push on their feet or make them follow our fingers from side to side, but simply to be, to listen and hear how they were doing, what was on their mind, what about the hospital stay was pleasant or unpleasant, did they get enough sleep, was the food any good?

 Without any previous knowledge of any of the patients’ medical conditions, we encouraged them to talk about their family, friends or spiritual faith and not about the history of their present illness. Quickly you could see a light shining in most people eyes as they realized, we were just 2 students checking in to see that they were doing all right and that it was okay to talk about something other than their recent surgery or upcoming chemo treatments. What was even more of a shock to many, was that fact that we were visiting on a Saturday just because we wanted to be with patients and not because of any school obligation. In all the cases, family was close by and engaged in the conversation, often even to a greater degree than the patients themselves. Some even confessed to a starvation for talking about anything that came to mind, avoiding any topics related to their illness or current hospital condition. It was like they needed some IV fluids in the form of 2 pairs of receptive ears, and 2 hearts willing to engage in a healing, compassionate interaction.

While we can never discount the benefits of modern medicine to heal such devastating diseases, there comes a time when we must understand that patients are human, and humans desire more than anything to be reminded that we are human, and more importantly that we are loved. It is often joked that one should treat a headache with Advil because one has a deficiency of ibuprofen. What if instead of treating illness with only procedures and drugs, we could write prescriptions for meditation, yoga, time spent with family, walking in the outdoors, and human conversation with a therapist/doctor/nurse? What if we could order a 15 minute conversation regarding your hopes upon leaving the hospital just as easily as another 2 L’s of Normal Saline?

You can see that for all the answers we found in this 3-hour adventure, we came up with even more questions that are well worth some deeper thought. And while it may not seem fair to give a talk where you end up asking more of your audience than you provide, we challenge you to see that in the end, becoming a resilient healer isn’t about how many questions you can answer, but instead about how many people you can reach to start asking the right questions. And most importantly, from the wisdom of Dr. Abraham Verghese, author of Cutting For Stone how can we connect with the spiritual heart of our patients, and through the ritual of the healer/patient relationship establish a place where our own self awareness and the patient’s being are one.

Lose Your Fears: Part III, Fear of Being Uncomfortable

              It has been a while since my last post, as I have been spending most of my time with patients in the hospital and reflecting upon my first month of clinical rotations, but I am back now with some hopefully, helpful wisdom. To finish the series, I prefaced the need to lose our fear of uncertainty and our fear of failure with the idea that the final connection would be to lose our fear of being uncomfortable. It seems like everybody likes doing things in three- a three step plan so to speak, but the reality is that these three fears are interconnected and without addressing one you will most likely falter in addressing the others. In the kinetic chain of fears, we are only as strong as our motivation to tackle all three head on.

            So, the fear of being uncomfortable- what does that mean? Well let’s start with the basic premise that being uncomfortable is an undesirable state for most and we have an internal drive to reestablish a state of equilibrium by disturbing the unpleasant sensations back to being more pleasing. Now, the easiest situations of balancing pleasure and pain involve situations in which we have voluntary control. Ask anyone who pursues high intensity interval training or intermittent fasting and they would be lying if they said there was not some degree of discomfort. The fact that we can control, for the most part, how and when we can return to a more balanced state allows us to no longer be fearful of intense exercise or going more than 3 hours without a protein bar. And while I practice both of these principles on a daily and weekly basis, by no means do I feel that this addresses a fear of being uncomfortable- yes I recognized that I may be in some states that are less pleasurable, but there really is no cognitive barrier stopping me from pursuing these practices. So that brings us to the real question, to truly find what you are afraid of doing because of the unpleasant conditions that may develop, you must ask yourself what are the conscious or unconscious barriers stopping me?

            In my personal case, I have found when I lack control of my own schedule or are unable to manage, at least on a rudimentary level, how my day will unfold, I feel uncomfortable. Most of us agree, even the most spontaneous, that we need some semblance of order as well as some free will to dictate how our lives are carried out. While I can say the unpleasant physical sensations during a HIIT session may be more acutely disruptive, the anxiety and mental stress invoked when it comes to the fears I described above are not on the same planet. In yogic traditions it is often said that one pursues a yoga practice not to become some different, enlighten person, but to just become more self aware of the barriers preventing us from living in our true happiness. So in an answer to what are one’s barriers to tackling the fears of being uncomfortable, we must be both aware of when we are in distress AND spend time reflecting on the cognitive distortions from these fears that we internalize and rationalize as being who we are. In letting go to the fear of being uncomfortable, we are allowing ourselves to see that our being is no different in the state of discomfort or in the state of pleasure. It is our thoughts and rationalizations as to why the uncomfortable sensations are actually unpleasant and the ease in which we identify ourselves with these cognitive distortions that ultimately prevents us from stepping outside the box.

            How do I put this into practice? Simple, the next time you find yourself dreading an afternoon meeting, procrastinating writing a paper or piling up trash in your room instead of taking a second to clean- ask this question: Am I actually afraid of doing the activity because it is an unpleasurable activity or am I simply afraid of being in a unpleasurable state because my previous experiences performing these tasks were awful and my current emotional and cognitive state tells me it is going to suck. Now realistically, there is probably some truth to the fact that there is some degree of discomfort to cleaning an incredibly dirty room, but what if instead of dreading the dirty socks, you decided to accept the task and actually mindfully notice what it is you feel performing the activity, rather than what your thoughts seem to be telling you even before you start.  While we can all use something distracting to help us through mundane activities- try instead to be mindful one day while you are folding laundry or typing up your final paper. My hunch is that incrementally tackling these states of discomfort with a more mindful awareness will make the activity an entirely new experience. Yes, cleaning your room will not suddenly feel the same as a great family meal at Christmas, but you may find some new satisfaction from finally doing the things you thought you dreaded most. Gaining pleasure from the pain, what a seemingly impossible idea

Lose Your Fears: Part II, Fear of Uncertainty

In Part I of this series on Losing Our Fears, I introduced the concept of eliminating 3 fears from our lives in order be more productive and happier human beings. As I alluded to in the first post, these conclusions have been drawn primarily from my personal experiences in medicine in addition to readings by others within the healthcare field, but by no means are this applicable to only burned-out physicians.

Now with our understanding that it is okay to let go of perfection and relieve some of our fears of failure, what often comes to light is a second, more sinister fear: the fear of uncertainty. So while many of us can begin to lose some attachment to the outcome and reframe our understanding of success and failure, we can easily succumb to the fear of unknowing- will my treatment plan lead to the improvements in quality of life and happiness outlined from my questioning of hopes, goals and dreams with the patient? The bitter reality, despite all of our best intentions and balancing informative shared decision making with paternalistic clinical directing, is that we really cannot be sure that any of our efforts will result in the desired outcomes. Here is where most of us fall back into the failure paradigm and see that if we are not certain to succeed or if we are not entirely certain that we are capable of performing a task without the risk of failure, we will be most likely NOT pursue these endeavors. And thinking back to the ideas presented in the Learning and Praise Series: if we only acknowledge and reward successful outcomes, and we are uncertain that we can achieve this successful outcome, than we will almost assuredly find some other goal to pursue or even worse, cheat to get there. In order to be fully free of the fear of failure, one must also be free of the fear of uncertainty. The two fears are intertwined and if we do not have a willingness to address each fear simultaneously, we will continuously operate with both a fear of uncertainty and a fear of failure.

We can never have all the answers, medicine is so complex that it is a joke to think any one man, let alone any one master computer can be capable of absolute precision when diagnosing and treating the individual. What often keeps MD’s up at night is not the fear of a patient dying, but the fear of will my treatment work, will my patient live another month, are the drugs I’m prescribing actually working? It is the the fear of uncertainty that confines us to operate inside of a box, never stepping out to see a different perspective, adopt a new lifestyle change or begin a meaningful friendship. The sooner one can realize that yes, we do not always have the answers but more importantly, in certain situations- we may not ever have the means to find a definitive answer. Most people cannot fathom living in a world of ambiguity, everything must be yes or no, black or white or resolve in a final outcome. If we spent less time worrying about what we don’t know, and more time engaged in the creative process of realizing that we do not have the answers to a question, then our mental energy can suddenly be diverted into an entirely new field of contemplation. Mindfully attuning to this perceived lack of knowledge, we can search out data and supporting evidence to bring more definitive light to our initial question. Most assuredly this journey to a solution may be difficult and in the end may not even lead to a definitive answer, but engaging in this process will inherently make us more resilient to face our fears of uncertainty and failure. And yes, this mindful engagement will likely be awkward and disturbing to your routine of operating within the box of knowns and guaranteed successes, but guess what, it is within this box of guaranteed successes where we can find and eliminate our final fear: the fear of being uncomfortable.