Friday, April 13, 2012

What is "the doctor look"?

Docs who are reading, imagine this scenario.  You're walking down a hospital hallway, and someone in a white coat, stethoscope around the neck, rounds a corner in front of you and begins walking toward you.

Question #1.  You don't personally know this person, but can you tell from 50 feet away whether she or he is a doctor?

I've started randomly asking some colleagues this question, and the answer is uniformly "yes."  Doctors have no problem distinguishing other doctors from the nurse practitioners, clinical pharmacists, and physician assistants who also roam the hospital in white coats.  Heck, my questionees even volunteered that they can still tell the difference even if the person wasn't wearing a white coat (for the record, I have no interest in rehashing the Great White Coat Debate at this time).

Question #2.  "How?"  I'd ask next.  "How can you tell that person is a doctor without reading their name badge?"

The response to this question was usually a shrug of the shoulders and, "You can just tell!"

In my two-year Faculty Development Fellowship, I learned how a physician's diagnostic reasoning process develops over time.  Most expert clinicians are pattern recognition experts.  These seasoned docs, without conscious effort, match the scenario in front of them to what they have seen before.  They recognize a diagnosis without deliberately walking through a problem representation and matching it to an illness script, the way a novice physician does.

Interestingly, experts often can't explain exactly how or why they arrived at a diagnosis.  Something happens to the edges of those details we each try so hard to master in our medical training; they blur into indistinct edges, into fuzzy caricatures of diagnoses that wait for ocular input to subconsciously call them into duty.

So, I posed the above questions to my resident team this week; we were in the elevator with a gentleman with a mop and janitor's bucket wearing a hospital housekeeper's uniform.  The residents all agreed that the answer to the first question was "yes" but were stumped with the second.

The man with the mop didn't hesitate.  "It's the attitude!" he exclaimed.  "You can always tell who the doctors are by their attitude."  Unlike clinical pattern recognition, the diagnosis of "doctor" apparently does not require a career to acquire.

Perhaps, like most expert clinicians' patterns, it will defy a straightforward explanation.  He or she is a doctor because it, well, he or she just is.  No one has to explain why an apple is an apple; apples can be red or green, sweet or tart, crisp or mealy, but we recognize without difficulty that they're all apples.

Here's hoping I'm at least somewhere on the red/sweet/crisp end of that scale.

Thursday, April 12, 2012

Leave it at the stage door

I've done some musical theater in the past, and anyone who's done theater knows that people who engage in the dramatic arts tend to be, well, a bit dramatic themselves.  I once had a director in college who exhorted us to "leave it at the stage door," the "it" being any of life's current issues, problems, or concerns.  He expected us to temporarily disengage from our personal dramas for a few hours to put our full energy into rehearsal.

I have thought of that phrase many times since then.  In polite, adult society, we expect each other to progress through our work days with equanimity and diligence. I can't give my learners and patients my full attention if I allow myself to be overly preoccupied with personal matters.  Sure, we might share some issues with a confidant or two, but most of the time we physicians - and other professionals, I'm sure -  set aside personal concerns during the work day.  In my observation, it's usually only when this setting aside becomes permanent neglect that this necessary process is harmful.

Sometimes, though, I can't help but wonder how many of the people I pass by in the hospital and in my office have left something significant "at the stage door."  I wonder about the cache of secrets we walk around with, issues that tear at our heart that secretly wait for acknowledgement until the workday is done.  This status quo is certainly best for our patients, but is it best for us?

Physicians are well-trained in self-neglect, in this unwritten curriculum to always put the patient first.  And, in the end, I can't bring myself to disagree with that order. This profession is about selfless service, not accolades and marquee listings.

Every now and then, though, part of me wishes we could allow ourselves to be vulnerable, too.  I suspect that we each possess enough caring to take good care of our patients and still reach out to our colleagues.

After all, that pile by the stage door probably isn't getting any smaller.