Blog | Friday, February 3, 2012

The Good Things in Medicine #1: The Exam Room

I said I would do it and I will follow through with it: I am going to talk about good things about my job. I must confess, however, that finding 53 of them might be difficult at this moment, as I am overwhelmed with the craziness and stupidity of the system. I must also confess that I can't find a whole lot of good things to say about our system. I fight the system and its foibles all day long, and try to practice good medicine despite the way I am forced to do it; so finding good stuff about the structure of our payment system will be difficult, if not impossible.

Maybe it's just me and my current mindset. I hope so. Unfortunately, it is how good the good is that makes the bad all the worse. The fact that the system itself stands in the way of the good in medicine makes the system all the more broken.Anyhow, I do have things that I really, really like about medicine. I've got to have them, as I could not deal with these negatives if I didn't have a reason to stay that was at least as strong as my reason to leave. It's like the nucleus of an atom. We know that the forces holding the protons together is strong, because they repellant force of two positively charged particles is very strong. There must be a stronger force keeping them together.

Likewise, I am drawn to medicine in a very strong way, and nothing draws me back more than the exam room.No, I am not talking about the table that is too high for my old people to climb on, out-of-date magazines, or the smell of rubbing alcohol. I am talking about the interchange I get to have every day with people. To me, the exam room encounter is medicine. It is the Holy of Holies, the sacred part of a secular system. The practice of medicine can be boiled down to a single thing: the interchange between a person with a need and a person who tries to meet that need.

While this is actually the description of all commerce and much of human interaction, it is the nature of the interchange and needs that make it so special to me. Here are the things that make this encounter so unique and so (in my mind) sacred:

It is personal
The patient does not need an object or a luxury item. They don't want to be entertained. The things the patients need are themselves. They want to live and to be healthy. They want to have a good life and to be out of pain. Our possessions are not what define us, but to a large degree, our bodies do. We are what is confined in that package of flesh. Our time on earth is defined by what that body does, and how long it does it. So, to come asking for care for our bodies is intimately personal, a fact unfortunately forgotten by many in health care.

It is private
The door to the exam room is closed and I am committed to keeping what goes on in the room closed off to others. The more that I can assure the patient that their privacy is safe, the more they will expose their needs to me. We humans don't like to share our needs with many people, as it exposes our weakness and vulnerability. We also feel that we are intruding on others' lives when we ask them for help. So, actually asking for help is only possible when done in a situation of great trust.

The fact that people can be asked to get naked in the exam room is evidence to the degree of vulnerability they are exposing to me. The nakedness extends to the emotional realm, as boundaries that are expected on the outside are not present behind the closed door.

It is relational
The thing that is so sacred about the exam room to me is not the fact that it's private or personal, however; it is that I am asked to be with them in that vulnerable moment and hear the weaknesses. The relationship is physical: I listen to what they say, look at what they are, and feel their bodies with my hands. It is mental: I listen to them, think about them, and help them decide what to do. It is emotional: I hear their sadness, fear, and relief; I feel emotion as I hear their emotions; I try to help, heal, or comfort them. This is the sacred, as it is human relations stripped to the core, free from most of the pretense and facades that are there in nearly every other place.

It is meaningful
I take great comfort in the fact that what I do has meaning. When other parts of my life are difficult, I find refuge in the opportunity I have every day. When I am feeling sad or anxious about other things, feeling insecure in my relationships or in my future, or regretting my decisions, I heal myself in the exam room. It's not that I see that my life is good compared to my patients--that's no comfort at all--it's that I get to do and to give to other people; and while I can lose relationships and material things, nobody can take away the good I have done.

It's really an honor to be a part of the exam room encounter every day. It does take its toll on my emotions, and it is a convenient escape when I'm avoiding other areas of my life, but I know it's where I need to be. I am glad that I am a doctor. I really lucked into the profession I chose, as I didn't know most of the good things before I enrolled in medical school. It's good for me to remember this good, as I can get lost in the struggles and troubles that the other part of my job brings. Our system needs to do everything it can to enable more real exam room encounters, and remind health care providers that they do more than just work at their jobs; they heal.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.