Even Hippocrates acknowledged that medicine is not practiced in a vacuum. He didn’t use the word vacuum, of course, as it first came into use in medieval times. But he did speak of the individuals that influence doctor-patient relationships. He called them “the Externals”. I have referred to them as “the ghosts in the exam room”.
In my previous post I wrote about how Medicare is now scripting entire visit types – don’t follow the script for the “Annual Wellness Visit” and risk having to return your payment from Uncle Sam. Medicare is certainly a ghost in every exam room in today’s medicine.
There are other ghosts that whisper threats or temptations in both our patients’ and our own ears as we talk to each other. All insurance companies try to do what Medicare is doing but most of them don’t have the same clout. From drug companies to malpractice courts there are countless external forces that make their presence known in the physician-patient encounter. We are all aware of this and do our best to still provide a private, impartial space for our patients to share their concerns with us.
But not all ghosts in the exam rooms are authority figures that try to promote their own agendas in our patient encounters. We all bring our own private ghosts in the form of, for us physicians, patients we have learned from or whom we have failed – making us more cognizant of our personal and professional limitations. Most of us also carry the spirits of our mentors with us as we close each exam room door and open our senses and our hearts to each of our working day’s fellow human beings in some sort of need.
I often think of those patients who I knew had something dreadfully wrong with them, even if I didn’t at first know exactly what. I think about the High School senior who came in with a rash on her legs a few days before graduation and turned out to have acute leukemia. I think about the woman who wouldn’t let anyone else biopsy the small lymph nodes above her collarbones, which proved to be metastatic lung cancer. I think about the rugged motorcycle-riding deer hunter who blamed his widespread muscle pains on falling out of a tree stand a week or two earlier; he also had lung cancer. I also carry with me the vivid recollections of patients who made their own diagnosis once I let them speak uninterrupted.
In many difficult visits I also call on my mentors. Sometimes when I seem to be treading water, I think of Professor Boström, who sat in the corner of the exam room crushing tongue depressors during my final exam patient interview at the end of my internal medicine course. When I find myself getting flustered or feeling hurried, I think of Bob Gordon, one of the specialists at Cityside, who never seems to be in a hurry and never seems overwhelmed, even though he sees more dramatic cases than I do. And when I feel pulled between the conflicting agendas in today’s health care – when the ghosts in the exam room won’t stop chattering – I think to myself: “What would Osler do?”
Thinking and reading about the great masters throughout the history of medicine is as important as keeping up with the leading medical journals.
Practicing medicine without understanding, or at least respecting, the history of our profession and the changing nature of scientific knowledge is like sailing on the ocean without charts, compass, or GPS for that matter. You will begin to just drift with the prevailing wind.
Remembering that ours is an ancient calling that has existed in many cultures and under many rulers is necessary when so many forces are vying to redefine our profession.
We need to make sure the scary ghosts don’t outnumber the friendly ones. Because it is very obvious these days in our line of work: We are hardly ever alone with our patients.
A Country Doctor Writes: 
