I begin this perspective with an observation by Sir William Osler, a pre-eminent physician and teacher of his day, “The practice of medicine is an art, not a trade; a calling, not a business…Often the best part of your work will have nothing to do with potions and powders…” What, you may ask, is that “best part”? Why, the “art” of the explanation. Allow me to share my perspective.
After medical school comes the post-doctoral training known as Residency. This time can range from as little as one year (rarely done in this day and age) to 10 years or more depending on the chosen track. Newly minted residents universally show up on July 1 of every year begin their post-doc training. ‘Tis a heady experience for most despite the demands, stresses and hours and I was there in the thick of it. Differential diagnoses, therapeutic options, physiologic explanations came rolling (most of the time) off my tongue. I conversed well with my peers and my attendings in our second language, that of medicine. And then I met Miss Mable.
Miss Mable was a sweet, genteel elderly lady from the South, having relocated a few years beforehand to the North. She was hospitalized with pneumonia and, after a few days, was on the mend. I was the intern in charge of her care with oversight by a third year resident, Dr. C. One day while was checking back after formal rounds to see how she was doing she asked, “Oh, Dr. Lombard, I was so sick and now I am getting better! What happened to me?” Standing there and smiling I responded, “Why, Miss Mabel, you had a pneumonia and we gave you antibiotics. That is why you are getting better.” “Why, thank you,” was her reply. As I stood by her bedside the following day she once again asked, “Dr. Lombard, could you again tell me what happened to me?” After a momentary pause I responded, “Miss Mabel, you had an infection in your lungs and we gave you some medicine to make you better.” “Why, thank you, Dr. Lombard,” and she closed her eyes and went to sleep. The next day as I entered the ward (this was 1980) where she was I observed Dr. C. sitting next to Miss Mabel’s bed and holding her hand. They did not see me. I heard Miss Mabel say, “Oh, Dr. C. that Dr. Lombard is so nice but I’ve asked him twice about what happened to me and he told me but I just don’t understand. Could you tell me what happened to me?” “Of course,” came Dr. C’s reply, “you had some bad stuff hurting your lungs and we made you better with some good stuff that took away the bad.” Miss Mabel’s face lit up and she responded, “Oh, thank you, Dr. C., I jes’ now understand!!!” And she did. And I had my first real life lessons in empathy and the art of the explanation.
I tell you that story not to demean Miss Mabel in any way but to show how ignorant I was of the different levels of understanding that people may have about medical situations. The learning process for me, and I suspect also for others, begins by assessing, sometimes more quickly than one would like, the level of medical sophistication and education a patient or family may have. I did not realize that Miss Mabel’s medical sophistication centered no further than around “sick” and “better” and that she had had no formal schooling of which to speak. Her humanity was now peeking out from what I had been centered on, her disease. Time for some soul searching and to review, unbeknownst to Dr. C, the three things he taught me that day: 1) explanations at eye level (I stood; he sat) are important, 2) hand holding can be comforting, and 3) explanations can be very simply put.
There have been innumerable articles in the medical literature on how to approach a patient regarding provision of medical information and explanation of medical situations. I’ve read my fair share but all the reading needs to be tempered by experience. This was driven home to me in one of the last years of practice. The system for which I worked “strongly urged” all employed physicians to participate in an afternoon of mentoring to assist us in dealing with patients as it pertained to their degree of medical sophistication and level of education. Obviously, speaking to a Miss Mable should be entirely different from speaking to a CEO. Participatory “interviews” where one MD is the physician and another MD is the patient were part of the session. We would then switch roles. The “patient” could play as dumb or smart as they wished. The goal was to craft the provision of medical information or answers/explanations commensurate with the level of understanding of the “patient.” The interview was overseen by one of the mentoring physicians. Initially I was paired with an older physician, such as myself, and we had a grand time. We would parry each other’s comments and questions ranging from sophisticated to dumb and really got caught up in the moment. In time older physicians were paired with younger ones. The mentoring physician quietly took it all in and never offered a comment as, I presume, he didn’t have anything to refine (or was too dumbstruck that we older physicians had survived for as long as we did). As the overall session wrapped up the participants were asked for feedback. Not surprisingly most all of the physicians who had been in practice the longest felt the session was of little value while those just starting out were more appreciative especially when interacting with an older physician. As someone once said, “Wisdom is knowledge tempered by experience.”
While didactics can provide the knowledge, experience comes from different sources. These range from seeing the results of direct application (“administration of morphine relieves pain”) to observational (“so that is how it can be done”[which is a polite way of saying, “Monkey see, monkey do”]). Physicians begin to plumb these sources while in medical school. In residency they have enough experience to utilize the direct application but what of the observational? Physicians at any level may observe a particular way to close a wound, put in a central line, etc. As importantly those same physicians may observe a way a patient or family was approached in particular situations and gauge their response. In either case the physician’s observation can lead to a current or future modification in their approach leading to an improvement, no change, or rejection of what they have observed. So begins the “art.” Some in time can paint a situational masterpiece while others, unfortunately, never learn more than to hold the crayon.
Allow me to provide two examples commonly observed over my years of practice to make my point.. The first has to do with the “death rattle.” Often unresponsive patients at the end of life will have an accumulation of secretions/mucus at the back of their throats. Families can become quite distressed especially if nothing is said by healthcare personnel in way of explanation. However, a simple comment such as, “Secretions not uncommonly build up in the back of the throat; we can give some medicine to reduce the amount of secretions, and [most importantly] your loved one is not drowning.” Relief for most is almost instantaneous. The second example has to do with “agonal respirations”, those deep sighing breaths taken by a patient as they near death. These are often interpreted by families as their loved one is suffering or dying in pain (hence the term “agonal”). Their concern can be easily addressed by explaining, “As the body slows down, carbon dioxide, which is the “waste gas” of the body, begins to build up. This leads to some deep sighing breaths as the carbon dioxide levels increase. In turn these increased levels essentially have the effect of Mother Nature giving your loved one a BIG shot of morphine allowing them to slip painlessly and quietly into a coma and pass on.” Again, the relief can be quite obvious. So basic, so simple, but, unfortunately, I’ve heard some rather callous explanations given in these types of situations.
As a parting thought, far be it from me to imply that the “art” of an explanation should be relegated only to medicine. Regardless of where you are in life consider that any explanation you are providing, while not necessarily ending up as a masterpiece, should result in more than holding the crayon.
If you wish to leave a comment, click on the particular blog title on the sidebar at www.docmentation.com. This will open up that topic again and at the bottom of the narrative there will be a comment section). Earlier blogs: Inaugural, Oscar, “That will be $108”, SODA POP, On the Evolution of the Medical Record, Housecall, The Four Reasons, Medicare and Medicaid, Responsibility, Decisions, Tales from the ER, Conversation, Covid 19 and HIV, Rationing in the Age of Covid,,,and other thoughts, Ode to a Ventilator During Covid, The Covid Vaccine Conundrum, The Almost FMG, can be found with “search” or, for some, just scroll down the page.