ABCs of medicine

Paul Rousseau

doi:10.1503/cmaj.080531

Never forget that it is not a pneumonia, but a pneumonic man who is your patient. — William Withey Gull

He travels down the hall on an embarrassing and uncomfortable gurney, bundled in layers of blankets, a hospital chart sitting painfully on his skeletal legs. He looks burdened and tired from the journey, so I decide to let him rest before doing an admission assessment.

“Hi, I'm Dr. Rousseau.”

“Hi doc, nice to meet you.”

“I'll be your doctor here in the nursing home — but I'll let you get settled in first, and I'll see you a little later, say 60 minutes or so, sound okay?”

“Okay doc, see you then.” He hesitates, and then continues: “You're not one of those young doctors. Kind of nice to see someone a little older.”

Image by: Andrew Young

Those “young doctors” are the medical interns and residents, the omnipresent worker bees of teaching hospitals who walk the halls 24 hours a day, 7 days a week. They are encumbered with the overwhelming responsibility of attending to our fellow human beings who are languishing in the belly of disease, a calling that is not easy, but one filled with honour, privilege and duty.

I retreat to my office and settle down behind the computer and begin to peruse his medical record. My eyes rummage for the history and physical examination, and I find the following: 62-year-old male admitted for hospice placement with the diagnoses of HIV, DVT, PTSD, GERD, BPH, and PUD.

As I lean back in my chair, I am reminded of an essay I read a few years ago1 wherein it was noted that William Strunk, the author of The Elements of Style advises “Omit needless words.” In most writing endeavours, this is sensible advice, as we tend to be too wordy. And while I understand the acronyms of this medically impoverished patient, what I am questioning is whether there is a limit to the use of these assemblages of letters and, even more importantly, if it encourages demotion of the patient to a disease rather than a person.

I contemplate the overworked schedule of the medical house staff and remember my own years in training. Perhaps the use of acronyms is evidence of a clinical inertia secondary to a paucity of time, or perhaps it is a lamentable symptom of an increasing reliance on radiographic and laboratory data that relegates interactions with patients to an inconvenient nuisance. Or perhaps a little bit of both.

I read on. Under the rubric Social History, a mention is made that he is pleasant, lives with his wife and quit smoking 20-plus years ago. I scroll down some more, arriving at the physical examination, which is cursory — most likely because the intern or resident was overwhelmed by numerous admissions, decided this was not an interesting patient or that his priority was less than other patients, or that he was dying and a detailed examination would do nothing more than increase discomfort with little clinical or therapeutic benefit. I pause to reflect, and hope it was the latter. I return to the chart, and read the plan of care: SW consult for transfer to IH, which translates to social work consult for transfer to inpatient hospice. More acronyms. So from my brief read-through of the medical chart, I have discovered a pleasant and alphabetized man who is dying, who no longer smokes and lives with his wife.

I stare out a winter window and muse over the psychosocial silence in this chart, the total absence of a being. I know everything about this man's physical ailments, but little-to-nothing about him as a person. The neglect of the individual — the person, the human being — continues, in spite of attempts to weave humanistic medicine into the fabric of medical education. And while the care of the person seems imbued in the annals of medicine, I find it woefully absent in today's chaotic environment.