The details of the night have escaped me. It was late in my intern year, on night float, when a nurse called about a patient refusing care. I think it was a “hard stick” at 2 am. In situations like this, I usually try to revisit the plan of care to see if my patient's needs can be accommodated. I am working on showing patients that I am in it for them,1 without risking their safety. I do so conscientiously: too many physicians can think of a time when they honored a patient's requests and got burned.
While speaking to my coresidents later in the shift, 1 of my colleagues disagreed with this approach. “Don't make concessions like that, David. They compromise patient care,” she said.
Her point was well taken, but it sounded strange to me, almost paradoxical. Such considerations are made to enhance patient care, not worsen it. For all the emphasis we put on communication, I was surprised that the core tenant of our work—patient care—seemed to have a different meaning for each of us.
It got me thinking: If a patient is being admitted to the hospital, and you ask a resident to take care of that patient, what would he or she do?
I would imagine, generally, that the resident would review the patient's chart, perform the history and physical, arrive at a tentative diagnosis, come up with a management plan, compassionately explain this plan to the patient, and ask, “What questions do you have?” Next, he or she would put in orders, reconcile the medications, drop a note, update the sign-out, and perhaps give a verbal report to the nurse. If the plan is executed as intended and no errors are made, this is our “gold standard.”
But what about the patient? He or she may have been too sedated to understand the plan, or too overwhelmed to process it. He or she may be wondering when to take that family trip in case things get worse. Maybe what matters most is enjoying ice cream and football.2 Or, he or she is tired and simply wants to rest.3 These are important details for the seriously ill.
Has this patient been cared for?
What if it were your parent or sibling? Or your child?
Expectations from the Accreditation Council for Graduate Medical Education are that “residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.”4 Health is not explicitly defined, so while respecting the World Health Organization definition, I turn to the commentary of Rambihar and Rambihar5 on how “health, like beauty, may lie in the eye of the beholder.”
Still, nomenclature matters, and ambiguity surrounding what it means to engage in patient care is problematic. Our “gold standard” is unparalleled for managing disease, but too often our system fails to address the needs of the person who has that disease. I suggest we call this act what it is—medical care. Without routinely acknowledging our patients' values, goals, and concerns, we are doing a disservice to true patient care.