What decades in medicine have taught me

Prioritize human connection before medical intervention. Hospitalized patients and their medical teams need to work through serious issues together but usually start as strangers. Therefore, it's especially important to establish rapport quickly. I often start with a nonmedical topic—family, hobbies, and so on—before moving on to medical issues. I find this approach especially helpful when I'll have to deal with potentially contentious issues, such as pain management. But one must “read the room” correctly and determine if the medical circumstances permit this approach and a patient is likely to be receptive. Expect surprises. Admissions take unforeseen twists and turns! We have all seen the unexpectedly negative culture, the unexplained drop in hemoglobin, and so on. I often ask my team members to imagine writing out for each patient, upon admission, a rough outline of how the hospitalization will play out. I then ask how often they think they'd be able to look back and say that they essentially nailed the prediction, with no surprises. Though it might seem counterintuitive to laypeople, the more experienced residents (and I) almost always offer a lower estimate than do interns and medical students. Avoid applying inpatient urgency to outpatient issues. In inpatient medicine, we continuously monitor and fine-tune management. But sometimes we fail our patients if we apply that urgency to issues that are better addressed in the outpatient setting over months and years. One example is hypertension. Studies show that we may worsen outcomes when we urgently treat moderate1 or even asymptomatic severe2 blood pressure elevations in the hospital setting. Moreover, when it is appropriate to increase the dose of a long-acting antihypertensive, we must remember that the soonest we would typically evaluate that change in the outpatient setting is 1–2 weeks. It's tempting in the hospital to keep increasing the dose each day if the pressures are still high, even though the medicine hasn't yet achieved steady-state levels. Ask yourself, “Can I Afford to Be Wrong?” This is my way of framing medical decision-making when a patient is acutely ill or when particularly dangerous conditions are prominent on the differential diagnosis. If the answer is “no,” we may need to do things we otherwise try to avoid, such as ordering multiple tests simultaneously, instead of sequentially, or starting a treatment (e.g., antibiotics or heparin) before a diagnosis is confirmed. Of course, newer clinicians may be unsure how to answer this question, and it behooves them to consult with a more experienced physician or to err on the side of caution (in essence, acknowledging that they can't afford to be wrong about whether they can afford to be wrong). Be aware that common sense can lead you astray. If elevated homocysteine levels are associated with a higher risk for heart disease and folic acid supplements reduce them,3 it seems obvious that the supplements should reduce heart disease. But randomized trials proved otherwise.4 Likewise, it seems reasonable to assume anemic patients will always do better with higher hemoglobin. However, studies have shown this to be untrue5 and we're forced to consider that the means by which we get there—transfusions— may have adverse consequences. As noted above, treatment to “normalize” blood pressure in the inpatient setting can be detrimental. There are many examples of common sense leading us to conclusions that were later shown to be erroneous. The studies need to be done. And when specific studies haven't been done? We need to rely—cautiously— on the best available evidence and our clinical instincts. Recognize that it's easier to tolerate diagnostic uncertainty when patients are improving than when they are getting worse. Outcomes trump understanding. Remember: what's routine for you is not routine for your patients. In medicine, we have the privilege of working with people during moments that are often among the most stressful and consequential they will ever have. However ordinary these days may seem to us, we must recognize that they are exceptional for our patients. As a clinician, I have always tried to be mindful of this, but I appreciated it most when my hospitalized daughter had a difficult day that was made much better by the compassion of a wonderful nurse. I told her, “When someone asks how your workday was, I bet you'll say ‘just routine, nothing special.’ But it wasn't routine for us and we will always remember your professionalism and kindness.” Remember that patients generally appreciate comfort more than they appreciate your intellectual triumphs. We might spend 20 min dissecting a complicated acid–base disturbance, only to find the patient cold and struggling with a dry mouth. At that moment, he probably cares less about our brilliant explication of his physiology than he does about his discomfort. Shouldn't we take a minute and get him another blanket and some water? He could signal for the nurse, of course, but we're there. And it's more meaningful if we do it. Be wary of “tunnel vision.” When evaluating patients who have frequent exacerbations of a chronic illness (inflammatory bowel disease, asthma, etc.), avoid assuming that the current presentation is “just another flare.” I say to patients, “You're the expert on your version of this condition. Does anything surprise you this time around?” Recognize that sleep is therapeutic. Sometimes it's kinder to let patients sleep and return later. To justify this practice, I like to quote from literature that supports the therapeutic value of sleep. It is rather old literature, though, and I concede that it isn't a randomized trial. It's a passage from Shakespeare's Macbeth that concludes by describing sleep as “chief nourisher in life's feast.” Don't prescribe diets patients won't follow at home. We've all had patients who vigorously protest a diabetic diet or the restriction of sodium and fluid intake. Except in the initial treatment of profound hyperglycemia or severe congestive heart failure, I see no advantage in enforcing dietary restrictions that a patient doesn't intend to continue at home. The patient will be unhappy, and we will be adjusting our medications to artificial circumstances instead of real ones. Reframe difficult discharge decisions. Perfectionism can make us want to delay discharges until every issue is fully resolved. However, this is impractical. I ask myself “If this patient awoke at home this morning in exactly the same condition, would I have recommended hospital admission?” Likewise, sometimes we are anxious about a discharge because the patient has complex medical conditions and may not do well at home. In that situation, I ask “Is there anything we can realistically accomplish that will make me less anxious about a discharge tomorrow or the next day? Or will I be just as concerned because this patient's status is inherently troubling?” Heed the concerns of experienced nurses. Hospital nurses, the medical professionals who spend the most time with patients, typically develop great clinical instincts. In general, if nurses are worried, we should be worried. And if we feel the need to interrupt their care, we should acknowledge the interruption and apologize. Recognize that normal test results don't always make patients happy. They want an explanation, in hopes that a successful treatment will follow. And in some cases, they are looking for objective validation to prove to others (sometimes including physicians) that their symptoms are real. Accept that sometimes “optimal” isn't available. We practice under constraints, including patient preferences, financial/insurance limitations, family support, community resources, housing availability and location, and so on. Sadly, we often can't implement what we view as the “ideal plan.” We have to learn to live with that. Appreciate that experience should bring humility. Over time, we're humbled to learn that we should expect to be surprised, that there is going to be diagnostic uncertainty, that we can't always trust our “common sense,” and that we'll need the input of experienced colleagues. And asking, “can I afford to be wrong?” obviously implies that we will sometimes be wrong. But though we regret our lack of omniscience, effective medical care is always more about prioritizing the experiences and perspectives of our patients. The author has no funding to report. The author declares no conflict of interest.