Whilst the frontiers of medicine are always advancing the discipline of clinical methods remain unchanged in essentials. Our task as clinicians is to observe accurately and comprehensively, to reason soundly about observations made, to learn the principles and practice of medicine and to appreciate how these can be applied to clinical problems; to approach the sick with a sense of humility and compassion and to help them to the best of our ability.
The student must learn how and what to observe, the need for thoroughness, accuracy, logic and freedom from bias, the significance of these observations and how to reach conclusions from them and to think for himself. He must study the patient as a whole and not merely his disease. He must appreciate that the patient is a person, not merely a case illustrating a disease. When he sees a patient who has a duodenal ulcer, he should think of the whole man and not merely of the hole in the duodenum. Neither should he think of a patient with chronic rheumatic carditis as merely “a case of valve disease.” The wise clinician, while paying particular attention to the site of the disease, will not forget the patient as a whole. Every sick person is an individual problem. Unless this idea is grasped, medicine is liable to be a tedious and uninteresting occupation.
It is not only necessary for the clinician to consider the mind and body of the patient together, but he must have an intelligent idea of the patient’s domestic background, such as as appreciated by the good family doctor of the previous generations. The clinician must understand and evaluate the possible environmental stresses and the patient’s reaction to them, not only at present but in the past and, if possible, the future. He should try and assess all the circumstances, whether environmental, genetic, occupational, or social that may have a bearing on the health of the patient, and through him on the health and happiness of his family and immediate associates. After all, disease is the reaction of the man and all that this term implies, to his environment in its fullest implications.
In order to obtain a good history, the clinician must establish a relationship of mutual trust and respect with the patient. This approach will determine the amount of information obtained and, what is more important, its accuracy and truth. Many medical students seem to be under the impression that all that is required to elicit a complete history “is to fire at the patient in quick succession a large number of questions.” Few students seem to realize that to take a good medical history is one of the most difficult tasks in medicine. It requires not only knowledge but also patience, much time, sympathy and understanding. One must allow the patient to talk freely and one must be a good listener. “Listen carefully and attentively to the history, the patient is telling you the diagnosis.” Let the patient talk, find out the real reason why he decided to seek medical advice. Appraise the problems which affect your patient. Remember that in medicine more errors are made because of hurry and because of not looking, than because of not knowing. Cultivate a sympathetic, unhurried bed-side manner and develop the knack of getting the patient to tell you his history. Remember that if you only ask questions, you will only get answers, but nothing more.
Develop an atmosphere of privacy and trust. Open the interview with the patient by saying, “Please tell me all about yourself.” The attitude and atmosphere at the consultation matters more than any questions or techniques adopted. Time is important and encouraging silences by the doctor stimulates the patient to tell us things which might not be otherwise mentioned. A good rapport or lack of it, explains why one clinician may elicit a significant, true and correct history whilst another fails to obtain clear-cut, vital information from the same patient.
A patient will usually judge a doctor on his first impression so, more than in most human relationships, the first meeting will be of importance to both of them. The doctor is a member of a learned profession and is respected as such by the patient; in order to merit the respect and confidence of the patient, the doctor must earn it by his appearance and manner as well as by his skill. If you think about this, you will understand that kindness, patience and tact are essential in all who care for the sick. There are many intangible but important factors involved in a good doctor-patient relationship, they include the general appearance of the clinician, a kind and considerate approach, a proper professional attitude and humility. A clinician who is negligent about his personal appearance, cleanliness and mode of attire cannot command respect from his patient. The patient is likely to suspect, and often correctly so, that the doctor maybe be equally careless in his diagnosis and treatment. The ill patient is sensitive to these attributes and will be reassured when approached by a neatly dressed, clean-shaved, mild-manner man.
The student should endeavor, at an early stage of his education, to develop a professional attitude. He should remember that medicine is an ancient and respected profession and not just a trade or craft. He should endeavor to develop an attitude of maturity, poise, strength of character, gentleness and humility—all these virtues are essential to a successful doctor-patient relationship.
There is no place for arrogance or superiority in medicine. Humility and a love of all people are necessary qualities of the good physician. Do not assume that the patient is your inferior because he lacks intelligence or education, sometimes he is your superior in commonsense, human understanding and good manners. The good doctor knows that the world is made of all sorts of people and that his task is to heal them and not to judge them. We must be charitable. Good manners must never be forgotten during clinical examination. Always remember the patient’s name when talking to him, and do not address a patient as “you,” “dear,” or “old man.”
When dealing with a patient always be simple, sincere and natural. Always use your eyes when talking to a patient, noting his behavior and personal appearance—otherwise you will miss much valuable information. Never treat your patient as a hostile witness or an infant, you are trying to obtain the whole story as it appears to him. Ask simple questions and listen to the answers. The average patient speaks the truth as he sees it.
It is necessary to establish confidence between the patient and the clinician, without such confidence good results are impossible. It is essential to be on good terms with the patient, to be friendly, kind and sympathetic, otherwise, you will not obtain his cooperation. You must be a good listener, let the patient talk freely, never seem to be in a hurry. You must be tactful if the patient is embarrassed, persuasive if he be taciturn, encouraging if he be afraid. Never let your feelings appear however great your contempt or dislike. The patient may be unhelpful, hostile or aggressive, and in your early clinical care-er you may feel embarrassed and confused. In time you will gain experience of disease, confidence, and you will learn how to deal with people. At the beginning of your career your task as a clinician seems hopeless. You need much experience, humility and the ability to learn from your patients.
When sick, many people often react differently than when in their usual health—they are tense, anxious, apathetic, reticent or argumentative, but behind these various facades there is usually an element of fear or concern. They are frightened for themselves, their family and their future social and economic security.
The nature of the questions asked, the manner in which they are put, your general attitude, demeanor and tone of voice can do a great deal to ease the situation. Frightened people often evade the truth and painful reality. They tend to re-arrange the details of some past events so as to show themselves in as favorable a light as possible. He will remember an attack of pneumonia ten years ago, but forget an attack of gonorrhea two years ago. Genuine kindliness and sympathetic understanding come only from within. Many medical students have, fortunately, some compassion and understanding—they may have been factors which influenced them to take their career. This attitude can be fostered, but on occasions it is forgotten. It takes more than mere scientific ability to make a good clinician, the good doctor must be a student of human nature, capable of appreciating and sympathizing with the personalities and outlook of his patients. Brilliant clinicians may make very poor doctors in the true sense of the word because they consider the disease only and ignore the patient.
More than sixty years ago, Stevenson, who had been a patient of many doctors, passed judgement on our profession with regard to those virtues and qualities which are not taught in our curriculum, but which are as important as our skill, training and technical accomplishments to our patients.
“There are men and classes of men that stand above the common herd; the physician almost as a rule. Generosity he has such as is possible to those who practice an art, never to those who drive a trade; discretion, tested by a hundred secrets; tact, tried in a thousand embarrassments; and what are more important, Herculean cheerfulness and courage. So it is that he brings air and cheer into the sick-room and often enough, though not as often as he wishes, brings healing.”
Eric Baker Bates (ca.1960)