Monday, June 4, 2018

Curiosity and family medicine

I have never been invited to give a commencement address. The closest I came was my own high school graduation, when I was the unofficial valedictorian. Since my school did not have a tradition of the highest-ranked student addressing the class on graduation day, though, I didn't get the chance. Our commencement speaker, a television news anchor and former graduate, delivered a great speech that I still remember more vividly than the addresses by bigger names at my college, medical school, and public health graduation ceremonies.

Obviously, I have not had the good fortune of hearing Dr. Atul Gawande speak at a commencement. (Atul, if you're reading this, Georgetown University School of Medicine would be delighted to have you address a future graduating class.) Instead, three days ago he delivered a profoundly insightful address at UCLA that has been going viral on social media. It's worth reading in its entirety, but the point he drove home is that in a time when discrimination and unequal treatment have become as socially acceptable in some circles as in the pre-American Civil Rights era, it remains the sacred calling of medicine to recognize that all lives have equal worth, and that doctors and patients share a "common core of humanity":

Without being open to their humanity, it is impossible to provide good care to people—to insure, for instance, that you’ve given them enough anesthetic before doing a procedure. To see their humanity, you must put yourself in their shoes. That requires a willingness to ask people what it’s like in those shoes. It requires curiosity about others and the world beyond your boarding zone.

Curiosity. If medicine were only about the science of the human body in health and disease, I would never have become a family doctor. Fortunately, that isn't so; in fact, after years of practice I often feel that the science has become incidental to doctoring. Yes, the knowledge base for medicine is always expanding, but as I tell students, regardless of what field of medicine you choose, the technical aspects eventually become routine. Even emergency and family physicians, who encounter the largest variety of symptoms and diagnoses, get acclimated to bread-and-butter encounters: back pain, chest pain, respiratory infections, the management of common chronic conditions under or out of control.

What keeps my work meaningful is learning about the details of my patients' lives that aren't strictly medical. As Dr. Faith Fitzgerald wrote in a classic article nearly two decades ago:

What does curiosity have to do with the humanistic practice of medicine? ... I believe that it is curiosity that converts strangers (the objects of analysis) into people we can empathize with. To participate in the feelings and ideas of one’s patients—to empathize—one must be curious enough to know the patients: their characters, cultures, spiritual and physical responses, hopes, past, and social surrounds. Truly curious people go beyond science into art, history, literature, and language as part of the practice of medicine.

Then, as now, pressures to be efficient in evaluating patients threatened to suppress natural curiosity. Dr. Fitzgerald bemoaned an educational system that produces medical students who were too un-curious to ask a patient how he had been bitten in the groin by a snake ("How could one not ask?"), or to question the "BKA (below-knee amputation) times two" description in the chart of a patient who obviously had legs. Finally, she mentioned one patient who had been deemed by the housestaff to be the "dullest" (least interesting) on the service: an old woman who (upon further inquiry) turned out to have survived the sinking of the Titanic.

2018 graduates, I wish that more of you were entering family medicine, but regardless of the medical specialty you've chosen, don't ever stop being curious - especially about the most "difficult" patients and the ones you least understand. It is that skill, more than any other, that will sustain you in your work and that separates the merely competent doctors from the truly great ones.

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