Saturday, September 02, 2006

Delicate conversations

One of the new experiences every medical student knows is that of having his friends and family members ask for medical advice. On a certain level, this is entirely understandable, we are, after all, studying medicine in order to relate our knowledge to others (probably wiser) who haven't given ten years of their life to its study.

But on another level, this is an intensely difficult situation. Medicine deals with the most intimate secrets of a person's physical existence, and, (not being a dualist) with their most intimate spiritual secrets as well. There is a certain level of secrecy which decorum demands we keep in our interpersonal interactions, and while it is jarring enough to see beyond that veil in a stranger, with friends and relations it can be staggering. The other side of this is that, as we get more used to knowing about people, and to reading the small details which betray so much about them, a comfort with that greater level of familiarity grows. Probably this explains the propensity of physicians and other health care workers towards crude humor.

But I am being sidetracked. I was reminded of this today, but only in passing. More important than any level of personal discomfort with medical knowledge is understanding the impact medicine has on others. Most people in medical school are young, and generally healthy. To practice medicine we have to have some level of health, and sometimes we forget how important that is. It is easy to forget how scary the unknown is.

Combining the two thoughts above, today I was asked by someone I know relatively well about a fairly involved medical issue. I've long gotten used to this sort of question, and I'm not far enough in my training to have tired of it. The second point about came to mind as I did some reading before getting back to my interlocutor. With any medical problem, from hang-nails to amputations, there is a range of severity in outcome. And this range is apparent in the medical literature. It is easy, when dealing with a person about whom you did not care one way or the other before they walked into your office, to rattle off percentages, and follow them with concern and cooperation in forging a treatment plan.

When you actually know and care for the person before the serious conversation, it puts a different perspective on things. You question how frank to be, how best to couch what you say, and what effect every single word will have on their perception of the problem.

Fortunately, the problem I was being asked about has an excellent prognosis. But even that phrase "excellent prognosis" can sound like medical evasion. And in explaining it, the necessity arises of discussing worst case scenarios along with best case ones. I suddenly understood, better than ever before, the paternalistic attitude of previous generations of physicians.

But the nervousness I experienced was instructive. For I realized that I should be that concerned with every patient. I think I am empathatic, to at least some degree, but I've never been so careful to relate pro and con, positive and negative. I very much wanted to convey exactly what I knew, without causing undue concern, but without hiding anything either.

This is why medicine is the art of science.

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