Henry Schneiderman

A piece of my mind. Efficacy at the bedside.

Last year I changed jobs. After 19 years full-time at a geriatric facility, I became a palliative care physicianleader at a large tertiary teaching hospital. Among the blizzard of change since I last served as a ward attending physician in 1995, hospitalist coverage is now permeative and house staff presence less so. Many patient care duties are now performed (beautifully) by advanced practice registered nurses (APRNs) or physician assistants. The roles of the consultant attending physician have also changed. I went to see my first several consultative patients in the Med-Surg ICU with trepidation. The nurses there proved incredibly expert, as one would expect. But the critical care nurses were friendly to me, direct, open and accessible, helpful, proactive, and visibly pleased to collaborate, without exception; the antithesis of the caricature embedded in the old ICU nurse stereotype. In the unit I employed all my old standard practices, both because they are now hard-wired and to alleviate my anxiety about what felt new and scary. So I helped turn patients even as I dreaded dislodging the ventilator connection; wanted to see the skin of the patient’s bottom with the nurse, and any ulcerated areas. I took down adhesive dressings with the nurse or by myself, and then replaced them. I pulled a tongue blade from my tackle box to inspect the mouth around the endotracheal tube and then disposed of it. I performed a rectal examination on some, then cleaned the patient’s anus and adjacent skin with a “wipie,” which I then threw in the trash. When such an examination prompted reflex expulsion of stool, I helped get the patient cleaned, helped remove the soiled soaker-pad and johnnie gown, and helped put new ones in place. I replaced antiskid bed socks after inspecting feet. In the desire to dent my ignorance, and also to be safe for patients, I asked what the tubes attached to a new unexpected orifice were for. After examination, I replaced the bedside table where it had been before. These are minimal simple human courtesies. All are automatic for every nurse, and familiar to any house officer who has accompanied me on physical diagnosis rounds,1 where I make a point of doing these things and explicating that they are intrinsic to effective medical practice. They are utterly obvious and elemental, yet few physicians seem to practice them. But to leave a patient disordered, uncovered, or miserable is improper; we physicians are not here to strew mess for others by failing to exhibit necessary awareness and accountability. Three different unit nurses labeled me a hands-on bedside physician. One said that the group is impressed by my demeanor and my willingness to get my hands dirty. I replied, “I’m so glad you are, because you certainly could not be by my knowledge of critical care!” Amidst the frenzy that is any US hospital in 2015, we need to find the internal peace to slow down. We have to keep our eyes, our hands, our brain, and our spirit on a patient for long enough actually to learn something about him or her. When we do this, in part by disrobing a human being before examining and then recovering and repositioning him or her, several desirable consequences follow: Foremost, we become more connected to the patient. This is not hand-holder babble: it is the psychology of human beings. This phenomenon persists through the thousand layers of our formative professional experiences and practice history; and despite the unrelenting pressure of time, including the oft-trumpeted need to maximize productivity, which is to say billables. The personal connection arises despite whatever psychic wounds, idiosyncrasies, and resentments brew beneath the surface. Touching creates and transmits acceptance of the earthy, inconvenient, mortal, fleshy reality of our patients. Bedside touch conveys acceptance powerfully even to many patients who are demented or delirious or septic. It calms and reassures any family who are in the room. I welcome family visitors to stay in the room during physical examination if neither they nor the patient is embarrassed. They then can witness that the interaction is not cursory, pro forma, anonymous, generic, or depersonalized. Their loved one is not interchangeable or, worse, handled as though merely an organ in a body in a bed or, worst of all (and one hates even to say this but we have each seen it), “a piece of meat.” My shorthand for this approach is “old-fashioned”; it is akin to Verghese’s “traditional way” at bedside2,3 and to “slow medicine.”4 These timeless practices have atrophied in many quarters and need once again to be embedded in every patient interaction. One’s acceptance of the patient comes through loud and clear to nurses, whose favorable response I translate in part, “Whatever else you do, since we see you making an honest effort to serve and know this patient as an individual human being with disease and not as ‘The appendix in room 9,’ we will try our utmost to pull with you and to sustain you.” My way takes more time, two minutes perhaps, maybe in the extreme five. But can any physician doubt that nurses who observe this pattern will save us thrice this much, at every opportunity? When we clean the patient’s bed as though she were our own mother because we would not want her left soiled, we are making our idealism concrete and active. We are behaving more like nurses, and our work as physicians becomes more effective: the enhanced quality and completeness of our physical examinations means better primary clinical data5 about both the illnesses and the human context in which illness has flared. With this knowledge we plan management better, and more senA PIECE OF MY MIND