In my memories, I imagine him slamming my chart closed, and shoving me towards the patient door. This probably didn't happen. What did happen, however, was I tried his advice thoroughly, even after we ended up on different services.
I eventually decided that this advice just didn't work for me. Naive medical histories took longer, sure, but also required meticulous sustained collection of detail in the more complicated patients. I didn't see any gain in the fidelity of information, and actually saw a loss when I had to cover more ground in the same amount of time. Above all, patients could find this practice obnoxious, especially when they have been asked the same questions over and over again. Reading the chart first, I realized, provided a framework for building my patient history, and I could confirm or repeat information as needed.
Recently, I find myself walking into patients' rooms, not as a medical student, but as a researcher. I walk into a patient's room with little more than their name and age. My white coat is left draped over in a corner of the nurses' station, and I've traded my stethoscope for a folder, a notebook, and tape recorder. I'll knock on a door, as I've done hundreds of times, walk in and introduce myself.
Everything is different.
Without the chart, all I see is a person in the room. Diagnoses, lab reports, x-rays, vital signs, numbers and figures used to float through my memory during an initial encounter. Now, my focus is on the balloons in the corner, a meal tray pushed aside, a laptop with a Facebook page, the books in the corner. We sit and we talk, as if new friends or old colleagues.
Others have previously written about the dawn of the iPatient (see Verghese 2008), but I never personally felt the extent to which medicine can dehumanize. I felt like I've always done a good job of keeping the person and the patient in mind, but doing research on the wards has forced a sharp lens onto the process. I meet a person, have them sign a few consent forms, and we chat for a bit. Eventually, I read through their chart, and slowly, they become patients again.
As a third-year medical student, the process was reversed. One of my advisors once suggested that it was important to take the time to check back in with your patients at the end of the day. To just swing by and say hello, he said. You get a very different sense of what goes on in the hospital.
It was during these off-service hours that the patients became persons again. There was something nice about seeing the early evenings in the hospital, when things tended to be a lot calmer. I got to hear about how people's days went, what they were eating for dinner, and how they were anticipating the night. Throughout the rest of my clinical rotations, I ended up trying to do this for as many patients as I could sanely handle-- I would pay for it with a few extra minutes, sometimes at the risk of being "caught" and being dragged into something else. Or, honestly, I would often just go home to get some rest. But on days when I did follow through, those late-day conversations totally made the extra minutes in the hospital worth it.
There was also something oddly powerful about saying "I'm just here to say hello." No physical exam, no procedures, just hearing about how things were going. I sat with one particular elderly patient for a long while once, and listened to her share details about her life as we watched the sun set through her window. "You have a beautiful view," I said.
"That's right," she said. "I do." Her pain was well-controlled, and she was looking forward to going home tomorrow. And so we sat, watching the shadows turn long as the hospital wound itself down towards the evening. Slowly and suddenly, we became human again.
