A Good H&P, A Dwindling Skill

Having done medical school in the era (circa early 60’s) before ultrasounds, CT scans, MRIs, tumor markers and the like, I was nevertheless skeptical when our faculty kept assuring us that a good, thorough careful history could elicit an accurate diagnosis 80% of the time and a similarly done physical exam could get the results up to 90%, This would be all without lab or X-ray tests.

I remained on a slow learning curve through the first two decades of practice, never fully  enlisting this sage advice and too often falling back on the investigative crutches. That orientation started to reverse after my first overseas mission tour in the early 80’s.  At a camp of thirty thousand Laotian refugees on the Mekong River in northern Thailand, I was the lead medical officer on the International Rescue Committee’s team. Our lab support provided only hematocrits, dip stick urines and stool microscopy. The hospital in the nearest town (10 klicks away) could do chest and limb skeletal X-rays.

Beyond that a history through an interpreter and as much of a  physical we could do in cramped, crowded quarters underlay all clinical decisions. Remarkably the overall care for the refugees was excellent, all things considered.  Having an excellent medical and nursing staff contributed. Also useful was doing serial, repetitive histories and physicals to confirm and flesh out the diagnoses.

When I returned home after three months the mind set of valuing and relying heavily on good histories and physicals more or less stayed with me. I came to resist the habit of routinely ordering lots of front end technology. The lessons of 1960s medical teaching began finally to make increasing sense. Still, in generalizing  this approach there are some problems.

First, present economics compel changes in medical record keeping and in provider-patient interaction that limit the time for doing a effective history and physical. As well, the training in doing thorough exams are just not taught in medical school, at least compared to my educational experience. I say this from my having taught Intro to Clinical Medicine to 2nd year students for ten years.

See me as a dinosaur, but I firmly believe solid training and ongoing performance of careful, thorough H&P leads to better diagnoses, save money and enlist skills a physican will always have when technology is not there.


The Immeasurable Value of Small Acts of Kindness

The virtue of kindness, however small in occurrence, can have profound impact on relationships and on the quality of life for both givers and recipients. Unfortunately we see many missed opportunities in clinical practice. When it does happen, it stands out like a precious gem and greatly enhances provider-patient relationships, as well as the process of healing.

My most recent experience with kindness happened from the perspective of the patient, or rather, the spouse of a patient. About a year ago my wife Marilyn developed appendicitis. Our odyssey started with a five hour stint in the emergency room, a misdiagnosis, surgery two days later, five days in the hospital and a fortunately uneventful recovery.

In the Emergency Department we were visited by two college age volunteers who came around regularly to ask if we needed anything, update us as best they could on the progress of the work up, find out how we were doing and just providing some emotional support. Thinking back now, for both of us the whole Emergency Department experience was complex and very stressful. Yet the caring presence of this young man and young woman was greatly appreciated and vital to getting us through those five hours.

Later, after surgery as Marilyn was begining to take food, she received a late afternoon call from a hospital kitchen worker informing her that the kitchen would soon close and she had not yet ordered anything for dinner. Marilyn was deeply touched to realize someone had noticed this and cared to take the time to call her. While this experience did not represent crucial clinical events, it was still something she shared with many friends for weeks after her recovery.

Earlier in my medical career, as an Ob-Gyn resident, I was once on rounds with an attending physician who had done emergency surgery on a woman with a ruptured ovarian cyst. As a consequence of the cyst rupture she miscarried a very early pregnancy, about which she had not even yet shared with her husband. When told of the loss by the attending physician, she was devastated and began to cry. Rather than mumbling something to justify a quick exit to the door or even just handing her a box of tissues, this compassionate physician took out a tissue and wiped away her tears. From later experience I know that for the woman the personal impact of this small gesture of kindness was gigantic.

Kindness is so precious and so easy to give. Practicing it does not require the degree of formal training needed to master specific traditional clinical skills. Why this simple message cannot effectively get into medical education is puzzling. For starters It would be effortless for medical school faculty and other mentors to share experiences such as these with students and residents.

As a virtue, to develop it needs to become a habit. Yet, it is a habit easy and gratifying to ingrain in our daily lives and in the practice of medicine.