Last month marked 30 years since I graduated from the training program that led to my becoming a PA. I was in a short-lived program (we were called Health Associates, or HA-HA for short) at the Johns Hopkins University School of Health Services, which is no longer in existence. The school was unique and in many ways ahead of its time. The majority of my classmates had previous degrees, at a time when most programs offered only certification and a few associate and/or baccalaureate degrees. (No one dared dream of a master’s degree.) We all had prior extensive experience in health care, an entrance prerequisite. The program was also unusual in that only two of my classmates came from military backgrounds and most were female.
In the three decades since then, I’ve taken (and passed) the PA recertification exam more times than I can remember. And I have seen so many amazing changes in medicine and our health care system.
At the same time I have found that certain fundamental truths never change. This would be my list:
1. Listen to the patient. Listening is as important as talking—maybe more so. Focus on what the patient’s concerns are and address them. Leave your agenda outside the door. Caring for an individual requires not just knowledge but empathetic understanding, which can only come from taking the time to listen, to learn from patients what they are experiencing, to hear their concerns. In today’s busy practice settings, taking a few minutes to listen can go a long way. (And studies repeatedly show that providers who spend time with their patients are much less likely to be sued.)
2. Most of the diagnosis comes from the history. Taking a thorough history is key to both building rapport with your patient and getting the vital information necessary to make the right decisions that will eventually lead to the right diagnosis and the right treatment plan. In today’s high-tech environment, the importance of obtaining accurate information from a patient (or a surrogate) is too often discounted. It’s essential.
3. Think horses, not zebras. Look for the usual, the common, not the exotic. Most of medicine is routine, regardless of the practice setting. In my work caring for the elderly, I have found that simple, treatable conditions (constipation, dehydration, bladder infections, adverse drug reactions/interactions) are often the underlying cause of a patient’s confusion, fall, or deterioration. On the other hand, in my work at a large, publicly funded rehabilitation hospital, I often joke that the hoofbeats aren’t zebras but unicorns. The unusual, I have come to learn, does occur and can sneak up on you, and it seems to be found more often among the disenfranchised and ever-growing uninsured and underinsured populations.
4. Respect cultural differences. Everyone brings their life experiences to the health care setting. These experiences influence how individuals react to changes in their health and how they interact with providers and the health care system. Sometimes cultural differences are obvious—when the patient doesn’t speak the same language as the provider, for example, or the patient is a recent immigrant. Cultural differences can, however, be more subtle, as evidenced by the increasing use of alternative health care practices by people of all backgrounds. Often, it is the lack of understanding of cultural differences that leads to problems in patient-provider relationships, with patients labeled as “noncompliant” and providers as “uncaring.”
5. Admit what you don’t know. When I was a student, this was easy, because I really didn’t know much. The reality is there are always things I don’t know, because either I never learned them, what I learned is outdated, or I’ve forgotten what I once knew. Over the years, as my medical knowledge and experience have grown, I have become ever more aware of how much I don’t know. With the exponential growth in scientific knowledge, it is difficult to remain current in all areas of medicine. For those in clinical practice, the basic knowledge and skills learned in school continue to serve us well, but often it is the students who teach us about the newest technology or leap in scientific understanding. I learned early on never to hesitate to say, “I’m not sure what’s going on here, let me talk with the physician”—a phrase I continue to use regularly.
6. Describe what you see, hear, and feel on the physical exam. The skills used in the physical examination are the basic tools of a medical provider, and the laying on of hands is a key component of the patient-provider relationship. Although it is rapidly being subsumed by technology, the knowledge gained from a good physical exam is not easily replaced by a machine. By honing one’s skills in observation, auscultation, and palpation, a provider can more judiciously determine what additional diagnostic testing is appropriate. Trust your senses and record what you see, hear, and feel, not what was written down by a prior examiner or anyone else.