S/JAMA-Landmark Article: The Care of the Patient [full text JAMA,. file: ///C: /Documents%20and%20Settings/pelley/My%20Documents/IW little time in which to cultivate more than a superficial personal contact with the patients. Moreover, the circumstances under which the physician sees the patient are not wholly favorable to the establishment of the intimate personal relationship that exists in private practice, for one of the outstanding features of hospitalization is that it completely removes the patient from his accustomed environment. This may, of course, be entirely desirable, and one of the main reasons for sending a person into the hospital is to get him away from home surroundings, which, be he rich or poor are often unfavorable to recovery; but at the same time it is equally important for the physician to know the exact character of those surroundings Everybody, sick or well, is affected in one way or another, consciously or subconsciously, by the material and spiritual forces that bear on his life, and especially to the sick such forces may act as powerful stimulants or depressants When the general practitioner goes into the home of a patient, he may know the whole background of the family life from past experience; but even when he comes as a stranger he has every opportunity to find out what manner of man his patient is and what kind of circumstances make his life. He gets a hint of financial anxiety or of domestic incompatibility; he may find himself confronted by a querulous exacting, self-centered patient, or by a gentle invalid overawed by a dominating family, and as he appreciates how these circumstances are reacting on the patient he dispenses sympathy, encouragement or discipline What is spoken of as a"clinical picture"is not just a photograph of a man sick in bed; it is an impressionistic painting of the patient surrounded by his home, his work, his relations, his friends, his joys, sorrows, hopes and fears. Now, all of this background of sickness which bears so strongly on the symptomatology is liable to be lost sight of in the hospital: I say " liable to" because it is not by any means al ways ost sight of, and because I believe that by making a constant and conscious effort one can almost al ways bring it out into its proper perspective. The difficulty is that in the hospital one gets into the habit of using the oil immersion lens instead of the low power, and focuses too intently on the center of the field When a patient enters a hospital, one of the first things that commonly happens to him is that he loses his personal identity. He is generally referred to, not as Henry Jones but as"that case of mitral stenosis in the second bed on the left There are plenty of reasons why this is so, and the point is, in itself, relatively unimportant; but the trouble is that it leads, more or less directly, to the patient being treated as a case lying awake nights while he worries about his wife and children, represents a s, of mitral stenosis, and not as a sick man. The disease is treated, but Henry Jone problem that is much more complex than the pathologic physiology of mitral stenosis, and he is apt to improve very slowly unless a discerning intern happens to discover why it is that even large doses of digitalis fail to slow his heart rate. Henry happens to have heart disease, but he is not disturbed so much by dyspnea as he is by anxiety for the future, and a talk with an understanding physician who tries to make the situation clear to him, and then gets the social service worker to find a suitable occupation, does more to straighten him out than a book full of drugs and diets nry has an excellent example of a certain type of heart disease, and he is glad that all the staff find him interesting, for it makes him feel that they will do the best they can to cure him; but just because he is an interesting case he does not cease to be a human being with very human hopes and fears. Sickness produces an abnormallyMS/JAMA - Landmark Article: The Care of the Patient [full text JAMA,... file:///C:/Documents%20and%20Settings/jpelley/My%20Documents/1W... 3 of 11 8/8/2007 10:33 AM little time in which to cultivate more than a superficial personal contact with the patients. Moreover, the circumstances under which the physician sees the patient are not wholly favorable to the establishment of the intimate personal relationship that exists in private practice, for one of the outstanding features of hospitalization is that it completely removes the patient from his accustomed environment. This may, of course, be entirely desirable, and one of the main reasons for sending a person into the hospital is to get him away from home surroundings, which, be he rich or poor, are often unfavorable to recovery; but at the same time it is equally important for the physician to know the exact character of those surroundings. Everybody, sick or well, is affected in one way or another, consciously or subconsciously, by the material and spiritual forces that bear on his life, and especially to the sick such forces may act as powerful stimulants or depressants. When the general practitioner goes into the home of a patient, he may know the whole background of the family life from past experience; but even when he comes as a stranger he has every opportunity to find out what manner of man his patient is, and what kind of circumstances make his life. He gets a hint of financial anxiety or of domestic incompatibility; he may find himself confronted by a querulous, exacting, self-centered patient, or by a gentle invalid overawed by a dominating family; and as he appreciates how these circumstances are reacting on the patient he dispenses sympathy, encouragement or discipline. What is spoken of as a "clinical picture" is not just a photograph of a man sick in bed; it is an impressionistic painting of the patient surrounded by his home, his work, his relations, his friends, his joys, sorrows, hopes and fears. Now, all of this background of sickness which bears so strongly on the symptomatology is liable to be lost sight of in the hospital: I say "liable to" because it is not by any means always lost sight of, and because I believe that by making a constant and conscious effort one can almost always bring it out into its proper perspective. The difficulty is that in the hospital one gets into the habit of using the oil immersion lens instead of the low power, and focuses too intently on the center of the field. When a patient enters a hospital, one of the first things that commonly happens to him is that he loses his personal identity. He is generally referred to, not as Henry Jones, but as "that case of mitral stenosis in the second bed on the left." There are plenty of reasons why this is so, and the point is, in itself, relatively unimportant; but the trouble is that it leads, more or less directly, to the patient being treated as a case of mitral stenosis, and not as a sick man. The disease is treated, but Henry Jones, lying awake nights while he worries about his wife and children, represents a problem that is much more complex than the pathologic physiology of mitral stenosis, and he is apt to improve very slowly unless a discerning intern happens to discover why it is that even large doses of digitalis fail to slow his heart rate. Henry happens to have heart disease, but he is not disturbed so much by dyspnea as he is by anxiety for the future, and a talk with an understanding physician who tries to make the situation clear to him, and then gets the social service worker to find a suitable occupation, does more to straighten him out than a book full of drugs and diets. Henry has an excellent example of a certain type of heart disease, and he is glad that all the staff find him interesting, for it makes him feel that they will do the best they can to cure him; but just because he is an interesting case he does not cease to be a human being with very human hopes and fears. Sickness produces an abnormally