“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler






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Portrait of Dysfunction


There's an age-old debate: Is medicine an art or is it a science? It is, of course, both. The science without the art is research; the art without the science, faith healing. I can state one thing for certain, and that is whoever takes the practice of medicine halfway seriously will be forever changed by it. The Hippocratic Oath, one of the most moving and inspiring pieces of writing ever, makes this clear. I am not the person I would have been had I not become a physician. Left to my own devices, I believe I would have turned out to be the isolated mad scientist type. The blessing of my profession is that it forces me to confront, observe and understand humanity on a daily basis. I have learned from this and (I hope) have become a better person, though I undoubtedly have a long way to go.

To be a good doctor, you have to do two things: Listen and observe. It is amazing how much you can learn from body language and from watching family dynamics. I was reminded of this basic fact this week in the split second of observation that came when I walked into an exam room to see an elderly patient.

Every primary care doctor deals with gerontology (medical care of the elderly) though most of us are not necessarily specialists in this area. In case you were wondering, gerontology is now its own specialty and requires board certification. This fuels my belief that medicine is being fractured into smaller and more senseless specialties every day, but we can go into that some other time. (Just to give you an amusing side story here... many years ago my father, a family practitioner, took the gerontology boards when this first became a recognized specialty, hoping to get grandfathered in. He did not pass. With smoke emanating from his ears, he declared this was because "the only answer they want is 'Don't give them medication'! That's bullshit!" Shortly afterwards my grandmother's doctor, a boarded gerontologist, lost his license for drug abuse. My father's response: "Can you find out what drugs he was taking? Because maybe if I take them I can pass.")

Though I am not a gerontologist I certainly see my share of the elderly. One of the saddest things I see with aging patients is the conflict which so often develops between elderly patients and their concerned children/nieces and nephews/neighbors. Frightened aging people, feeling their autonomy slipping away, will defend it with everything they have. This holds true even for the most minor details of their lives. It's as though they are going through the Terrible Twos all over again, and for a similar reason. It's all about control.

To come to the point: this week I saw a longtime patient of mine with her daughter. The patient's health has been worsening for a long time and she is not the most compliant patient. The daughter often gets frustrated with her. As I opened the door to the exam room, what I saw was the patient clutching her cane and staring straight ahead while the daughter, arms wrapped tightly around her chest, stared angrily out the window.

Sometimes that's all you need to see.

Labels: Medicine

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