Finding humanity: The lost heart of medicine

Imagine, if you will, it’s a sultry summer’s day in late June, 1970. You are sitting, somewhat uncomfortably, in the National Arts Centre in our nation’s capital. Within the vast auditorium is a convocation of students and their adoring families for graduation exercises. Multiple faculties are represented but you are totally oblivious to those other than Medicine. You are one of only 60 students in the graduating class, survivors of the past four years, exhausted, enthusiastic, enlightened and innocent, at least for now. There were 78 in the class way back in 1966 when first you entered the hallowed halls of the University of Ottawa Medical School. Attrition was tradition in those days. You were 21 years old with a Bachelor of Science degree, a suitcase and a pulse. The years of basic sciences, for me, compounded upon three prior years of science basics, were tedious, tortuous and treacherous. And then, late in year #2, we were introduced to “physical diagnosis.” We were given a handbook, a walking reference, to compliment the didactic teachings and leanings of our esteemed mentors. It would guide us through the darkness and into the light of clinical medicine. We gathered together our new tools; the stethoscope, mini-ophthalmoscope, reflex hammer and flashlight, strategically placing them in the oversized pockets of our newly acquired, starched, waist-length whites, one pocket always reserved for the “handbook.” We were released to prey upon the innocent and unsuspecting patients of the wards in the old Ottawa General Hospital. And, we examined our first patient! It was an epiphany. We learned to ask the questions, but more importantly, we learned to listen for the answers. Sir William Osler said “Listen to your patient; he is telling you the diagnosis.” This was the earliest lesson in the art of medicine. It was also the introduction to the “ritual” of the physical examination, the sanctity of human touch, a unique privilege afforded those of us in the “healing profession.” We partook in the symphony that was the examination, a calculated cascade of carefully orchestrated technical manoeuvres, ancestral in origin. The four movements; inspection, palpation, percussion and auscultation would become our talisman. We would carry this with us to the clinics and the bedsides and ultimately when we began our respective journeys into the world we had chosen and the divergent paths we would eventually follow. I left the nation’s capital and returned to the metropolis of my origins, Toronto, to embark on and embed in a rotating internship that would test both my mettle and my resolve. It was an intense year of discovery, occasionally “a worst of times” experience. The challenge was to consume as much clinical experience as possible, though sleep-deprived and physically spent, and all while first “doing no harm.” There were moments when that was an oxymoronic reality. Time management became an overarching theme as did an appreciation for endurance. This was a sprint wrapped in a marathon. And then one day, traditionally set as June 30, I was released from bondage, licensed with skills that would sustain me through the next five decades. I became a general practitioner, a GP, the anachronistic sobriquet which I carried proudly well into the days of “family doctor” officialdom and beyond. I will set the playing field at that time for you. In 1971, diagnostic ultrasound was in its infancy in Canada. CT scanners, well, they cost millions and most community hospitals, denied funding from government, relied on the benevolence of community and corporate donors. They began to germinate from tertiary hospital roots a decade later. As for MRI’s, we didn’t see them until the cranes hoisted the gargantuan units into custom-built secure suites another decade later. Our menu du jour of investigational testing bore little resemblance to today’s immense requisition possibilities. Acronyms have since replaced most common terminology. Consultations were a phone-call away, as were the specialists who actually came on the line to talk with you, reassuring voices in difficult times. I did daily hospital rounds, saw all my patients, sat bedside, held their hands, spoke with loved ones and gave them hope. I translated the medical jargon spewed forth by specialists too busy to explain, too rushed to listen. In time, “primary care” was nudged aside in the institutions, replaced by hospitalists. We returned to our offices, sequestered, siloed in the safety of our solitude. In practice, I recorded clinical notes with pen and paper, transcribing my findings following each visit. Most often, I wrote far too much; better to document than risk the intensive scrutiny and ire of a college intervention. Remember, “if it’s not written in the notes, it never happened.” Less than 20 years ago, the electronic medical record (EMR), began its meteoric rise, buffeted by an explosive evolution of software vendors, all claiming to ease the burden of medical record keeping and enhance the doctor-patient experience. Well, that’s what they claimed. Sadly, many vendors couldn’t deliver the goods. Eventually, the playing field was levelled, and only the fittest survived. Utility was king, the number of serious players in the game, reduced to a handful. The electronic environment extended beyond the office clinic and was adopted by hospital systems. The electronic health record (EHR), allowed patients to access their test results, consultation notes and clinic engagements often in real-time, much sooner than the followup clinician visit which was generally scheduled weeks later. There developed a dependancy, however, on the desktop or handheld electronic devices. They distracted and diverted attention from the primary source of information and focus of attention, the patient. Conversations became mechanical, scripted and templated. Boxes needed to be checked, upsetting the balance of the time-tested relationship between patient and doctor. Eye contact was lost as the physician turned away and hammered on the keyboard. Investigations were a click away, a requisition miraculously spit out of a printer, handed over without explanation. In time, investigations would be generated without any contact—virtually, the fallout of a pandemic and a posture of convenience. The cornerstone of medicine, the history and physical, was replaced by the digital and electronic revolution. Technology had seduced the profession! I am not a Luddite. I am a late adapter. In retirement, I see the folly of my ways. My problem was that I needed to adhere to the fundamental principles of the patient being at the centre of my universe. They were not an icon in a computer, a digital collective of populated data. They willingly granted privilege to share their innermost secrets and explore, through human touch, the mysteries of their body’s dysfunctions. They became integral to the sacred ritual of the physical examination our mentors and forbears had so diligently set forth. The bedside was their sanctuary. They spoke in such intimate and personal details without hesitation, knowing that these dialogues would be preserved in the domain of privacy. There existed a trust and respect for the doctor, a reality that many physicians today feel is lost, perhaps forever. Today is the beginning of an inspiring and fulfilling life in an incomparable profession. The knowledge and skills you’ve acquired thus far have but scratched the surface of what will follow. Your world today is unrecognizable compared to the world of 1970, literally light years ahead. You have technology and resources and access to information that will guide your future and open opportunities never before imagined. Your challenge, as physicians, will be to maintain the “calm equanimity” that Osler spoke about in his famous Aequanimitas address. Never forget that medicine is a “noble heritage” with limitless possibilities and that forever at its very core is the patient. Preserve and respect and sustain the humanism that is so essential, so vital in medicine today, despite the myriad distractions of politics, regulation, scarcity of resources and the ever-expanding universe of technologies that can be our undoing. And finally, in the sacred words of the Oath of Hippocrates: “May you always act to preserve the finest traditions of your calling.” Dr. Howard Goldstein is always looking for retired physicians to join his Virtual Retirement Lounge group, with the aim of easing the burden of retirement through collective conversation. Feel free to contact him for more information.

Finding humanity: The lost heart of medicine

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HOWARD GOLDSTEIN

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