The Lessons That Will Not Change in Medicine

I entered medical school in 1980, a year in which the mean physician salary was approximately $55,000. That was twice the annual earnings of the average working man at the time.

Prior to that time, medicine more closely resembled a public service than a business. But from my time in school into the 1990s, salaries of physicians skyrocketed way out of proportion.

Money was never my interest in becoming a doctor. Rather, I wanted to have a career that could make a difference in the lives of people, one that would garner respect of my peers, and perhaps treat the secret sense of inadequacy that I carried. The fact that it didn’t involve working outside, or doing any heavy lifting was an added plus.

Medicine was about to change drastically in the coming decades, but I didn’t know it—nor did I care. I just wanted to start being a real doctor.

Things change, but good ideas endure. That’s what this story is about.

During my last year of training at Princeton University Medical Center, I had a chance to interact with my chief of medicine, Dr. Charles Ream, on a regular basis. Ream was a stately man of few words who had begun practice in the 1940s. He had been part of the revolution in medical discovery, a time often referred to as our “golden years.”

He and I had long conversations about the way we practiced and the way that he thought physicians should conduct themselves. Ream was a companion of Albert Einstein prior to his death, and had many stories to share about Einstein’s strong character and a sense of humor that shone despite his fame and genius. That ability added greatly to Einstein’s largess in life, and it gave me an unexpected role model.

Of course, the more obvious role model in my early career was Ream himself. The stories and platitudes he shared with me are as applicable to medicine now as they were in those early years of my career. These are the good ideas that have endured through the great changes of our field, courtesy of Dr. Ream.

1. When you visit your patients in the hospital, always sit down. It will appear to the patient as if you are unrushed, and that more time has been spent together. If you must sit on the bed, always ask permission. Hospital patients especially have very few rights, and they can be insecure about their space. Respect their boundaries.

2. Always call the family of hospitalized patients daily with an update—even if there is nothing much to tell. They find this to be part of thorough care, and should something go wrong, you will have built some rapport prior to discussing bad news.

3. The patient is the one who has the disease. They do not get sick on purpose, they do not fail to respond to treatments by choice, and we should be careful not to blame them (even secretly) when they don’t get better. Remember we cure very little, but can often heal by being kind and empathetic. ‘MD’ does not mean Medial Deity. If you don’t take credit for curing someone, you can’t blame yourself when they are not cured, because it’s mostly out of your control anyway.

4. It is very important to take vacations. When you go away for a week’s vacation, your patients will need to see by the time you get back. If you take 2 weeks, they will have realized that they did not need you in the first place.

5. Always carry a business card.

6. Make house calls. Even if you only do it occasionally, it will make you a local hero. Over the years, I found making house calls gave me the most pleasure while practicing medicine because I learned a great deal about the lives of my patients, seeing them comfortable at home.

7. Medicine is an arduous task. It involves being available 24 hours, 7 days a week, even when you are not on call. It is important to be available to your covering physicians, patients and families even when not on call, should situations arise that only you can answer. I was never reluctant to give my telephone number to patients. I found over the years people did not abuse that, and mostly went to great lengths not to disturb me. People who own a Mercedes take care of it, because it is valuable. Making yourself valuable to your patients instills loyalty.

8. Medicine and business do not mix. Do not be corrupted by the influence you have over people who will do what you ask, even if it’s unnecessary.

9. Be patient. When in doubt of what to do, sometimes doing nothing is the best option. Things have a way of getting better on their own, if you stay out of the way.

10. When in doubt, ask for help. You will be sometimes shocked to find that help comes from the places you least expected. If you make a mistake, promptly admit it to the appropriate person. You will learn far more from mistakes than from your victories.

11. Be respectful of your patients’ time. Do not call them by their first names unless invited to. Listen to their questions about all the crazy things popular in the media. Disdain prior to investigation is a form of ignorance. If you find a newspaper clipping or piece of news about the patient, cut it out and put it in their chart and discuss it with them next time you see them. Remind your staff to treat every patient as they would want their grandparents treated.

12. Be wary of new drugs. Do not be the first to use the newest, best, and the most expensive medicines until they have a track record. Take the time to educate yourself about the price of drugs. If you do so, you will be shocked to learn the huge differential in costs of the same medicine. You can refer to good prescriptions, which gives you a good idea of what the patient might pay for medicine. Take advantage of the coupons and discounts that are offered by pharma companies, and be generous with samples.

13. Be respectful of pharmacists. There will come a time when they might save you from making a medication error. Likewise, an unsympathetic pharmacist could kill your reputation with careless remarks. Take the time to get to know the pharmacists, consider their opinions and even drop in a visit with them sometimes. When I began practice, local pharmacists would send me a bottle of whisky as a gift and always discounted anything I purchased.

14. You will miss many family events, school plays, baseball games, weddings. You may not be around on the holidays, so when you have the time, try to spend it with your family. In the summer, every Wednesday I took my daughter to the beach, from the time she was 4 years old. Spending time is not doing charts or watching football when you are home. If you don’t make the effort, they will understand, they will respect you, they may not complain—but they will resent you.

Above all else, learn to deal with the anxiety of uncertainty, because you will be uncertain much of the time. Develop a sense of humor, learn a few good jokes to use as ice breakers.

Einstein said that if you understand a subject you can explain it simply, so get in the habit of explaining complex medical ideas as if you were telling a story.

If you haven’t learned yet, you will learn that there is no absolute truth in medicine. What we believe to be true at this moment is fleeting. It is certain to change, so keep an open mind with a dose of skepticism about medical truths.