Grand Rounds Report: On Being a Physician

by Academy of Clinical Excellence on October 15, 2009

Sometimes, trying to distill a ‘clinical excellence pearl’ from grand rounds is difficult.Today, the challenge is what to include in this post because the session entirely focused on the outstanding patient care delivery. The title for today’s session was ‘On being a physician’ and it was presented by Dr. John Burton who had long been Chief of Geriatrics at Johns Hopkins and is acknowledged as one of the founders of Geriatric Medicine.

Although he completed fellowship training in Nephrology, he decided to pursue a career in the ‘primary care of older adults’ and he began by describing how much he has enjoyed and cherished his clinical role.
To assist him in the presentation today, Dr. Burton was accompanied by a patient with whom he has had a relationship for decades. Mrs. H had been nurse supervisor at our hospital (previously named City Hospital) back when he was an intern. Geriatric Nurse Jane Marks coordinates the home care program also shared her views about nurse-physician collaboration in caring. She has been instrumental in helping the division’s physicians to provide high quality primary care.
The following 5 ideas were emphasized as this master clinician described Mrs. H's personal and clinical evolution as she aged.
1. Effective medical care for patients who have multiple chronic illnesses requires collaboration among multiple physicians and is dependent on excellent communication between primary care physicians and specialists.
2. Older patients often have a constellation of many illnesses which may result in variable loss of physiological function. As such, he reminded us of two important lessons: (i) that one 83-year old person is one 83 year-old and so it is imperative that we consider each individual individually, and (ii) atypical presentations are the norm in older patients with multiple chronic illnesses.
3. When caring for patients like Mrs. H, you can’t possibly get it right all the time. When making medical decisions, doctors have to weigh the various options, explain them to the patient, and together decide upon the plan. Close follow-up is necessary to re-evaluate the shared decision so that alterations in the plans can be made if need be. Humility is required as is a priori acknowledgement that we won’t always get it right.
4. Delivery of optimal primary care involves a team of individuals including the patient, their caregivers, the nurses, and the primary care physicians, and consulting physician. Communication, trust, and openness between all team members is essential. Dr. Burton also explained the value of home visits for gaining insight into to the patient’s world, strengthening the relationship, and reassuring patients when they are not strong or well enough to come to the medical center.
5. Dr. Burton modeled and explained his commitment to lifelong learning he spoke about how he carries around a card in his pocket and makes notes during the week about clinical questions and uncertainties. At the end of each week, he tries to learn about these issues and reconcile them for his own learning and for the good of the patient.
While his presentation clearly exposed challenges associated with practicing primary care in contemporary medicine, the joys and rewards seemed to more than make up for these. Dr. Burton is an ideal role model and he alone could solve the primary care workforce issue by inspiring young physicians to follow in his giant footsteps.
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