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What is to be accomplished is not mastery over disease and death but mastery over fear.

The patient is afraid, and subject to behavior not coherent with reason.  The clinician in training is subject to terror that pride will deny and to dangerous nonsense in the guise of knowledge.  What in the life of the healthiest and most integrated patient cannot easily be accepted or managed leaves even the most sensitive and talented student confused and afraid, ungrounded, unanchored.

Today as much as ever the student of clinical science is likely to be motivated by sincere altruism.  His callous acts come not from a callous heart, but from not yet having mastered the comprehending of the whole patient, the whole situation.

My pompous words may be validated by a humble anecdote:

When I was a medical student serving in a rural hospital I was called to the emergency room to examine a man who had fallen on the ice outside a tavern at closing time.  The patient, an old rodeo cowboy, told me in animated and slurred language he had broken his leg, not in the fall but at landing.  A blizzard was building, but the radiology technician drove through driving snow from his farm to take the pictures at my request.  I ordered x-ray pictures of his hip, where the pain was.  My serious and careful study of the films showed me no fracture.  I called the real doctor at home, told him of the patient's pain and that he was convinced his leg was broken, but that I could not see a fracture.

Despite the vicious weather I had vague misgivings about admitting the man to the hospital just because he was hurt (and later remembered the foreboding fleeting image of the hospital administrator had crossed my mind).  I thought I was straining toward generosity when I interpreted to the man that no bone was broken, that he suffered pain from muscle spasm, and in view of the weather I encouraged him to spend the night on the sofa of the hospital lobby, offering to attend him through the night.  He declined, tolerantly disgusted that I had not concurred with his diagnosis, and explaining that his horse was at home alone, asked me to help him get there.  My car small, and he not ambulating, I imposed on the sheriff to take him home, giving him medicines for the pain and good wishes.

Next morning early I was awakened by a call from the doctor who had walked through knee-deep snow to the hospital, the roads now not passable in a blizzard not matched in 20 years.  "You said it was his leg that wasn’t broken.  The fracture of the femoral neck is impacted--that's why you saw no fracture.  Why didn't you take the contralateral?  Then you would have seen the shortening."  I thought of telling him that I had thought of asking for the other picture, but that the technician was already on his way home again through the snow.

Despite the snow I made my car go to the edge of town, and found the patient lying on the floor drinking coffee a friend had come to fix.  The horse was fine.  I told him candidly as I could how honestly I had been wrong about his leg, walked three blocks to a phone to call the ambulance to return him to the hospital where he belonged.  When I came back to wait with him he told me, "Doc, that was the damnedest muscle spasm I ever had."

This is how practical lessons are learned, cheaply for me--just one restless night, some shame, and all these years of moral agony. You need not spend that much.  Just remember these valid aphorisms:

1.  Don't discount a person's worth or pain because he's drunk.
2.  Get a picture of the left side, if it hurts, and of the right side too.
3.  Be exact in what you say. Use Latin words or Greek if they make more clear the part or process you mean to describe.  (The doctor told me, "Say ‘thigh’ or ‘hip’.  Do not say ‘leg’.  When you say there is no fracture of the leg I believe not even you can miss it.  Had you said ‘hip’ I would have known the femur’s neck was cracked, im­pacted." )
4.  Put completely out of mind the fiscal sensitivities of bureaucrats when caring for a patient.
5.  If a rodeo cowboy tells you he has a broken bone, believe him.  You don' t need an x-ray.  He has broken each and every bone before.

The Metamorphosis:  Its Processes, Goals, Obstacles, and Outcomes

You must learn not only facts but also how to accept realities.  Learning overwhelming data is self-centered.  Performing well in the face of demanding residents, supervisors, and attending physicians merely shows your loyalty to or fear of them.  Comprehending the experience only the patient can have had, which only he or she can tell you, perceiving carefully with your eyes and ears and fingers what is real only in the patient's body's shape and workings, interpreting realistically the shadows and abstract numbers which reflect only indirectly what is so within him--these are your tasks in loyalty to the patient.  This loyalty to the patient is the obligation also of the resident, the supervisor, the attending physician, and the administrator.

It is only by being anchored firmly in loyalty to the patient that we can function.  Without the patient's experiences, wishes, and welfare being our central focus, we have at best partial and unreliable goals.

It is easy to discount self-interest as a valid goal for the clinician.  Each of us could have an easier life and larger income some other way.  If we wish to wallow in our pride and power, we eventually will lose our power and have no cause for pride.

If we intend to be scientists, curious for the sake of ourselves and for the benefit of humanity, we will find our individual curiosities more satisfied by Doctor Doyle's Mister Holmes, and we will find our contributions will never have succeeded in relieving all human suffering and death.

In the tight four walls of the hospital, working 36 hours a day, it is easy to become the prisoner of a world without sunlight, where frantic activity drives itself (not without reason).  As in any prison, authorities take on massive aspects, and we tend to direct our efforts toward them, toward pleasing, eluding, or defying them.  When we focus on charge nurses, staff physicians, or administrators, we distract ourselves from the simple task (not easy, but simple, i.e., not complex) of understanding the patient.  You have nothing to lose by concentrating on the patient and you should never have to lose the approval of supervisors, scientific accomplishments, or self-respect by doing so.  If you seem to be losing, hang on--your patient's successful resolution of terrifying and confusing problems will be your reward eventually. 

Confidence and competence in clinical behavior come only by experience.  The willingness to focus on and work for the welfare of another may come with the student to his studies, but the self-centeredness which comes with the effort to understand complex voluminous data, reinforced by the egotism which has been accomplished by one's teachers, will tend to separate the student from the patient emotionally.  Identification with the patient, relying on the altruism the student has brought to her studies, will lead to defiance of teachers and rejection of data.  A balance which (for lack of a better term) might be called "empathetic objectivity" can only be approximated by practice, and by keeping painfully in memory real experiences and imperfect performances.

I have implied that the goal of clinical training is a synthesis which comes from the dialectic tension between altruism and its antithesis, egotism; the willingness to serve another humbly and the antithesis, voracious assimilation of knowledge and power.  Perverted results can generally be characterized by either extreme:  emotional over-identification with the patient, which does not make the clinician ignorant, but which tends to make him act ignorantly; or over-intellectual narrowness which tends to make the clinician impose abstractions on unique individual patients, helping the physician to miss communication with the patient.  To formulate realistic evaluations and recommendations for the patient, and to communicate them effectively, can reliably come only from the balance and the synthesis.


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