I’ve been teaching internal medicine for a number of years now. The practice of internal medicine falls into two broad categories; inpatient medicine, and outpatient medicine. Because of certain historical imperatives, internal medicine training is heavily biased toward inpatient education, and these days, inpatients are sick. To qualify for hospital care a patient must be receiving care that cannot be given outside the hospital; they must meet criteria for intensity of service and severity of illness. Ask any old-timer doc and they will tell you that hospitalized patients are much sicker than they used to be.
This makes hospital-based medicine very interesting. The acuity, the excitement, and the challenge are much different than primary care medicine. There is a real thrill in becoming competent at running a code or putting in a central line. In some ways, inpatient medicine is easier than outpatient medicine. Primary care requires a high tolerance for uncertainty—you can’t run stat labs in the office, you can’t monitor vital signs every six hours. The hospital feels safe to medical residents, while the office can seem simultaneously boring and confusing.
With that knowledge we can better understand a common complaint of patients, what we can call the “Why are you bothering me” problem. When residents rotate through the outpatient clinic with me, they often wonder aloud to me why people bother to come in with “silly” problems, like the common cold. That’s when it’s time to put the pen and stethoscope down and have a chat.
People come to the doctor because they want to feel better. Most doctors want to help them achieve that goal, but healing isn’t all about ripping out an appendix or performing CPR. Leaving aside the fact that a lay person cannot always distinguish a bad cold from strep throat—an important distinction—people want a little healing, even the intangible kind. People come to my office and pay me in order to hear my opinion, to get advice about feeling better, and to be reassured. The fact that they are not always happy with my advice is a natural and important part of this interaction.
It is important for all of us who are physicians to remember that there is no such thing as a stupid appointment. If nothing else, the time can be spent getting to know someone new—-misanthropy is not a good trait for a clinician. And building that rapport can lead to more gravid revelations in the future. Once you get a complete stranger to trust you, you start to experience “door-knobbing”, where a patient, holding the doorknob on the way out says, “By the way doc…”. That “by the way” is often the most significant part of the visit. The cold they came in for becomes the mole on their leg that is getting bigger, or the heart burn that only bugs them when they climb the stairs.
Once you have decided that a visit is a waste of time, the patient will share that conclusion, and will have no reason to tell you anything of consequence. And that’s not good medicine.