Opening lecture to the third-year students in their course, “Introduction to Clinical Medicine” at Johns Hopkins University School of Medicine, 1970
Abstract: A clinician is one whose prime function is to manage a sick person with the purpose of alleviating the total effect of his illness. The multifocal character of the impact of illness upon the patient and his family is stressed. Clinical evidence is the material with which the physician works, and a meticulous history and physical examination are paramount. The availability of more specific forms of therapy requires a clinician to be more of the scientist and, at the same time, more expert in clinical methods. Ability to listen and to talk, so that valued clinical evidence is gathered, anxieties are dissipated and understanding and motivation are instilled are the clinicians’ greatest assets.
SINCE this course marks your entrance into clinical medicine, it seems appropriate to discuss what a clinician is, and what he does. Sometimes it is easier to describe what something is not than to define what it is, and since a succinct definition of the term “clinician” is not easily conceived, it might be helpful to start with this approach. Thus, a clinician is not someone whose prime function is to diagnose or to cure illness, for in many cases, he is not able to accomplish either of these.
A clinician is more accurately defined as one whose prime function is to manage a sick person with the purpose of alleviating most effectively the total impact of the illness upon that person. Several of the terms used in this definition require development.
Management of a Sick Person
Managing a sick person is entirely different from diagnosing an illness and prescribing therapy for it. A simple example might be offered of a mother, by nature, keenly sensitive and perfectionistic, who has three young and perpetually active children and a husband who is preoccupied by his work. She doesn’t see much of him, and when she does, they are both tired and the children are boisterous. She visits her physician with complaints of headaches, stiffness and soreness in the back of her neck, persistent fatigability, frequent loose stools with mucous and a 10-pound weight loss. Her symptoms have reached an intensity that makes it difficult for her to care for her family. After appropriate examination and studies, the final diagnosis is as follows: “anxiety state with tension headaches and a spastic colon.” The physician prescribes diazepam (Valium), propantheline (Pro-Banthine), psyllium mucilloid (Metamucil) and propoxyphene (Darvon). She is told to return in six weeks for follow-up examination.
Thus, the physician has correctly diagnosed her condition, and has prescribed appropriate medications – but has he managed this sick person? Emphatically not!
Management of this patient would requires these additional ingredients: and explanation, in terms highly meaningful to her, of the relation between her symptoms and factors in her personality and home situation; a review of all the elements in her circumstances that might be creating stress; some constructive advice about children’s behavior and discipline, and about being a young wife; insistence on an hour’s rest period every day after lunch, free of the children, the writing down of a well organized weekly work schedule to bring some order out of household chaos, and insistence upon adherence to it; the suggestion that she employ a day worker every week or two to help with the heavy house-cleaning; a conference with the husband to ensure that he understands how to support his wife’s position (inquiries about sex adjustments would be apropos at this juncture); efforts to interest the patient in hobbies and activities affording some respite from daily unending household routines; and an admonition to go light on relaxing cocktails and nightcaps during this stressful period, lest dependencies develop.
Clearly, management of a sick person entails much more than diagnosis and the prescribing of medicines, and demands much more of the physician. Also, it gives much more back to the patient.
Management means that the physician comprehends and is sensitive to the total effects of an illness on the total person, the spiritual effects as well as the physical, and the social as well as the economic. With the wisdom born of education and experience, the clinician attempts to prevent or to diminish, or to heal this sum total of effect. Specific forms of therapy are brought to bear directly upon a pathologic process. Management is concerned with the sickened person, and the family, and the community.
Today, even highly sophisticated treatment schedules can be put on tapes, to be printed out at the push of the proper button. Computers are being successfully employed in diagnosis. But the ways of wise management of a sick person can only come out of an understanding spirit, and a sensitive as well as perceptive and educated mind.
A patient given specific therapy has something done to him to aid his recovery. A patient who is well managed is capable of helping himself to recovery, for he has been provided with insight and knowledge, hope and security, and the motivation to do whatever may be required.
In incurable illness, treatment of the disease may become a hopeless, vain gesture, and anguished suffering and ultimate death are stark admissions of its failure. However, if a sick person is thoughtfully managed, the effects of incurable illness can be made immeasurably less devastating for both the patient and the family, and triumph can even be had over some of the of the most mortal effects of illness, which are often far more psychologic than physical.
Total Impact of Illness
In the definition of “clinician,” I employed the expression, “alleviating most effectively the total impact of the illness upon that person.” Two concepts here require further development.
The impact of sickness upon a person is always multifocal, and the effect highly complex, involving as they do the whole person, with this spiritual, intellectual, emotional social and economic components.
A pair of kidneys will never come to the physician for diagnosis and treatment. They will be contained within an anxious, fearful, wondering person, asking puzzled questions about an obscure future, weighed down by the responsibilities of a loved family, and with a job to held, and with bills to be paid. A biochemist or a physiologist can ignore all these secondary factors, and can confine his attention to the kidney. But the clinician must learn all the fact about it all, and comprehend it all, and have a feeling for it all, and develop a plan of management for it all. Otherwise, his approach is superficial.
Finally sickness rarely affects only the patient. If he is the member of a family, the entire family is inevitably affected, to greater and lesser degrees. Hence, in a peculiar and special sense, all clinicians have family practices – even the most erudite and hard to get to see consultants. This magnifies the clinician’s responsibility greatly, for his success or failure in managing a patient’s problem will be reflected in the welfare of the patient’s family members. Few, indeed, shoulder a burden of personal responsibility heaver than the clinician’s.
Function of a Clinician
So much for what a clinician is. How does he function?
First of all, he listens thoughtfully to the patient’s complaint. Secondly, he proceeds to gather together all the available clinical evidence pertinent to it, beginning with the history and physical examination. Thirdly, through logical analysis of this clinical evidence, he formulates a reasoned explanation for the cause of the patient’s complaint, in the light of his knowledge and past experience; Fourthly, he develops a program of management for the patient, in the terms already discussed.
Clinical evidence is the basic material with which the clinician works. He gathers it from several sources: the history; the physical examination; laboratory studies and special technics (such as x-ray study); and consulting opinions.
The source of the clinical evidence is not the essential point, although experience daily points out the primacy of the history and physical examination. The essential point is that the evidence be both complete and valid, that its total implications be understood, and that it be critically reviewed in relation to other evidence already at hand.
It is foolish to argue that the history is a more important source of clinical evidence than the physical examination, or that the latter is a more valuable source than laboratory or x-ray study. The key evidence in understanding a particular patient’s complain may be disclosed by any of these evidence-gathering technics. A clinician must be equally adept in the employment of all of them. Facts are his concern, no matter how they are harvested, and he must seek them by every means available.
Regard yourselves as indomitable gatherers of clinical evidence. Hunt for it anywhere it might be hidden, in the history or physical examination, in some special test, or in conversation with a family member, or tucked away in some previous medical report, for hidden anywhere it may well be.
Nowadays, in contrast to the past, a diagnosis must often be specifically correct if the patient is to get well, for so many modern forms of therapy have highly specific actions. This scientific advancement compels the clinician to sharpen his clinical skills to the very keenest edge, so that he can extract from a meticulous history and physical examination every particle of pertinent clinical evidence, which he then coordinates with evidence gathered by other means.
Never before has such a premium been placed upon expertise in the performance of the history and physical examination as the prime steps in the diagnostic process from which all other investigative steps logically proceed.
Once analysis of the clinical evidence has led to a diagnosis, and a plan of management for the patient’s problem has been constructed, the physician comes to a highly critical point in his relation with his patient he must explain to him the nature of his illness and formulate for him the program of management. Unless these matters are handled with clarity and sensitivity, so that the patient understands fully what is wrong and also has the will to marshal his personal resources to co-operate fully, the correctness of the diagnosis and the soundness of the therapy may have no practical meaning whatever for the patient. Ignorance, misconceptions, fears, insecurities, resentments, hopelessness and unanswered queries may block his response.
Communication with the Patient
This brings us to one of the last but surely one of the most essential considerations of what it is a clinician does – a clinician spends a great amount of his working hour communicating with his patients. What the scalpel is to the surgeon, words are to the clinician. When he uses them effectively, his patients do well. If not, the results may be disastrous.
You are surely aware that physicians are not now as highly esteemed by the general public as formerly. It seems unlikely that the public, so easily impressed by what appears to be scientific, resents the fact that physician nowadays have become more scientific in their education and methods. Actually, what many patients miss and resent today is their inability to communicate with their physician in a meaningful manner. Patients have question that they want answered, fears requiring dissipation, misunderstandings that need clarification and abysmal ignorance about themselves that demands enlightenment.
Today, many patients with serious health problems leave their physician’s office with less comprehension of what is wrong and what they must do to get well than the average customer understands able his car when he drives is out of the repair shop. “Pay your bill and drive off.” “Get these prescriptions filled and come back in two months.” And, if the patient feels deprived of adequate communication with his physician, family members are often totally devoid of it.
No wonder the resentment. We clinician are better educated and more scientific than ever before, but we have a great failing; we sometimes do not communicate effectively with our patient, or with their families. Some of us do not provide the time, or make the effort. Other simply do not know how to talk to sick persons. If this seems exaggerated it might be recalled that in the entire Marburn Building as Johns Hopkins, there is but one small room suitable fore serious family conferences. The general daily practice, therefore, is to discuss critical and frequently shocking issues with relatives while standing in the noisy halls, dodging food trucks and litters. Critical information and advice is given to sick persons and their families buffet style – standing up!
An effective clinician must have a number of skills, and these you must endeavour to make your own. He must be a scientist. He must be knowledgeable about the natural course of common and uncommon diseases. He must be able to harvest clinical evidence from all available sources. He must be a keen analyst of these gathered fact, and through logic proceed to a reasonable conclusion concerning their significance. But in addition, if these capabilities are to have a practical effect upon the patient, the clinician must have the facility to communicate with him, and his family members.
The wisdom of Thomas Aquinas, the logic of Newman and the clinical genius of Osler will not be effective in making well a patient who does not fully understand why he is sick, or what he must do to get well. A first-rate clinician trains himself to do two things exceedingly well: to talk to his patients and to listen to them. And he acts similarly with responsible family members.
Through well conceived conversations, the physician hopes to accomplish a number of indispensable purposes, the first being the extraction of all the clinical evidence about the historical development the patient’s illness, followed by the quieting of the patient’s anxieties. Here it is essential to realize that all illness in all persons is inevitably productive of varying degrees of fear and anxiety, though they are often well submerged under seeming indifference, bravado or sophistication. These emotions may spring from many causes and assume many forms, but they are always there. If the doctor is powerless to do anything else to aid a patient, he has accomplished a great deal, and has justified his being that patient’s physician, if, through his conversation, he strips from an illness ugly, eroding, undermining fear. The fear of cancer is widespread. Ne less prevalent is the cancer of fear in people who are ill. Its only cure is therapeutic conversation with the physician.
In addition, the clinician must constantly ask patients to undergo diagnostic and therapeutic maneuvres that are costly, or unpleasant or very hard for the patient to accomplish. Recovery from an illness often depends on the ability of the patient to exert stern self-discipline over himself. Only full understanding of the problem by the patient can lead to adequate motivation. Only the clinician can bring this about, and only to the degree that he is able and willing to converse with his patient.
Therefore he has to learn to talk to his patients and – even more important – like to talk to his patients. It is his greatest asset as a clinician. The most rewarding study of man is man. No one has the privilege of knowing man so intimately, at time of such great personal moment, and under such highly sensitive circumstances, as the physician. He becomes intimately family with man as he is born, and as he sickens, and as he dies. Like no one else, he has the opportunity to listen to the laughter and to the cries. Like no other man, he has the opportunity to speak to man, and through his words to guide and to correct him, and to heal him, and to give him solace, to the very edge of eternity.
When the clinician is exceedingly busy, as most clinicians are, there is a widespread tendency to substitute tests, for talk, and various therapeutic maneuvers take the place of enlightenment and motivation. One must remember that talk is indeed cheap, but it can be so healing.
Here are some practical guidelines in talking to patients:
Almost all patients, regardless of intellectual capacity, are naïve and simplistic when dealing with their own health problems. One should assume nothing, and start from basic facts, and build upward. A brilliant person is often a dull patient. A less endowed patient is often like a child.
Patients quickly forget what they are told, and are easily confused if told too much at once. Therapeutic conversation should be administered in small but continued dosages, in a preplanned fashion.
Very often, patients will retain only part of the conversation which agrees with their own ideas, or is pleasant to them. Gentle, firm, persistent reiteration is essential if important concepts are to be acted upon. One must emphasize and re-emphasize, again and again.
Because of anxiety and tension, patients are easily confused and poorly retentive. Therefore dissipations of anxiety and tension is always the first order of business. Frequently, one accomplishes more with subsequent conversations than with the initial, as rapport develops and first fears fall away. First conferences often merely set the stage for subsequent effective ones. One proceeds in a stepwise manner. If the first are not well handled, not much can be expected later.
Effective conversation with patients must be planned ahead, and cannot just be off the cuff.
Careless or ill planned conversations can be disastrous to the patient. A phrase or word having so little meaning to the clinician that he may not even recall saying it may be seized upon by the patient, and may have a profound effect upon him.
Needless details and technicalities should be avoided. They will not be understood, and may prompt a host of new anxieties.
Above all else, the clinician should be protective of the patient’s position, and not his own. He must be a wise censor, filtering out matters that will either cause needless anxieties or fail to achieve positive motivation. The physician who is impelled to tell the patient or the family (or both) all the facts is frequently protecting his own insecurity.
It must be remembered that conversation is therapeutic only to the degree that the patient has confidence in what the clinician says. This, in turn, is directly related to the patient’s respect and trust. Most laymen will not take clinical abilities for granted, and will not judge the physician in terms of his basic medical skills, which they assumes he possesses merely because he is a physician. He will be judged, and then trusted, accordingly, solely in terms of the following: the genuineness of his interest; the thoroughness of his approach to the problem; his personal warmth, understanding and compassion; and the degree of clarity with which he gives the patient insight into what is wrong and what must be done.
This bring us back once again to the primacy of the history and physical examination. If they are properly executed, nothing so manifestly demonstrates the qualities of the good physician to his patient as a meticulous accomplished history and physical examination. They set the tone and create the background for future therapeutic relations between the patient and his physician. The patient has the opportunity to see his physician functioning at his best, and he judges him, assaying the qualities of the man and the abilities of the physician.
He becomes willing to entrust himself to this person who gathers so meticulously each relevant fact from the history and who misses no clue during his searching physical examination, each fact, each clue being scientifically scrutinized, and eventually so understandingly interpreted for the patient, whose confidence grows. He already begins to feel better. He knows he has found himself a superb clinician.
This, as I see it, is the vocation to which you have been called. Understand what it is, and what it requires from you with gleaming clarity. From this first day, immerse yourself in learning its technics and skills. Discipline yourself to accept and meet the burdensome demands that it will continuously make upon you. From now on, you are engaged in the service of the sick. With the knowledge that you are acquiring as a scientist, with your clinical art developed through experience, with the warmth of your own spirit and the strength of your own character, with the laying on of your hand, and in response to your words, you can make the sick better, and fill the dying with peace. These are great powers. Always deserve them.
In conclusion, today’s young people seek models. Here is an image of a clinician:
He is meticulous in accumulating the historical and physical data from the patient. His questioning of the patient is searching and incisive, like that of a wise barrister. He interprets the clues the derived from the physical changes with the precision of an experienced detective. His analysis of the clinical evidence is methodical and disciplined, so that no diagnostic or therapeutic possibility can be overlooked. The reasonableness of his logic make his conclusions appear inevitable. They are based upon a personal clinical experience of the most sophisticated sort. His special interest is any human illness. His care of the patient does not end with the correct diagnosis. His thoughtful management of the total problems of the sick person make mere treatment of a disease or a symptom seems woefully inadequate He is inexhaustibly capable of infusing into his patients insight, self-discipline, optimism and courage. Those he cannot make well, he comforts. Versed in medical science, he also understands human nature and enjoys working with it. Analytical, logical, his is at the same time warm and charming, and although gentle, he is strong in his beliefs and ideals, but never brittle. The things he works with are intellectual capacity, unconfined clinical experience and the perceptive use of his eyes, ears, hands and heart.
1) This speech was written over 40 years ago – if it were given today what would you expect (/hope) to change and what would you keep? What role does language in particular play in this shift (think gender, both in terms of pronouns and the example used early on, as well as tone, etc.). What aspects of his language do you find effective (ex. short simple sentences in the imperative.)?
2) The author states: “What the scalpel is to the surgeon, words are to the clinician.” How does this statement speak to the importance of the humanities in medicine?