S/JAMA-Landmark Article: The Care of the Patient [full text JAMA,. file: ///C: /Documents%20and%20Settings/jpelley/My%20Documents/Iw must not drop him after you have taken the history and made your physical it by every means. Watch his condition closely and he will see that you ae aleister examination. Once your relationship with him has been established, you must fos professionally. Take time to have little talks with him-and these talks need not always be about his symptoms. Remember that you want to know him as a man, and this means you must know about his family and friends, his work and his play. What kind of a person is he--cheerful, depressed, introspective, careless, conscientious, mentally keen or dull? Look out for all the little incidental things that you can do for his comfort. These, too, are a part of"the care of the patient. "Some of them will fall technically in the field of"nursing" but you will al ways be profoundly grateful for any nursing technic that you have acquired. It is worth your while to get the nurse to teach you the right way to feed a patient, change the bed, or give a bed pan. Do you know the practical tricks that make a dyspneic patient comfortable? Assume some responsibility for these apparently minor points and you will find that it is when you are doing some such friendly service, rather than when you are a formal questioner, that the patient suddenly starts to unburden himself, and a flood of light is thrown on the situation Meantime, of course, you will have been active along strictly medical lines, and by the time your clinical and laboratory examinations are completed you will be surprised at how intimately you know your patient, not only as an interesting case but also as a sick human being. And everything you have picked up about him will be of value in the subsequent handling of the situation. Suppose, for instance, you find conclusive evidence that his symptoms are due to organic disease, say, to a gastric ulcer. As soon as you face the problem of laying out his regimen you find that it is one thing to write an examination paper on the treatment of gastric ulcer and quite another thing to treat John Smith who happens to have a gastric ulcer. You want to begin by giving him rest in bed and a special diet for eight weeks. Rest means both nervous and physical rest. Can he get it best at home or in the hospital? What are the conditions at home? If you keep him in the hospital, it is probably good for him to see certain people, and bad for him to see others He has business problems that must be considered. What kind of a compromise can you make on them? How about the financial implications of eight weeks in bed followed by a period of convalescence? Is it, on the whole, wiser to try a strict regimen for a shorter period, and, if he does not improve, take up the question of operation sooner than is in general advisable? These, and many similar problems arise in the course of the treatment of almost every patient, and they have to be looked at, not from the abstract point of view of the treatment of the disease, but from the concrete point of view of the care of the individual Suppose, on the other hand, that all your clinical and laboratory examinations turn out entirely negative as far as revealing any evidence of organic disease is concerned. Then you are in the difficult position of not having discovered the explanation of the patient's symptoms. You have merely assured yourself that certain conditions are not present. Of course, the first thing you have to consider is whether these symptoms are the result of organic disease in such an early stage that you cannot definitely recognize it. This problem is often extremely perplexing, requiring great clinical experience for its solution, and often you will be forced to fall back on time in which to watch developments. If, however, you finally exclude recognizabl organic disease, and the probability of early or very slight organic disease, itMS/JAMA - Landmark Article: The Care of the Patient [full text JAMA,... file:///C:/Documents%20and%20Settings/jpelley/My%20Documents/1W... 9 of 11 8/8/2007 10:33 AM must not drop him after you have taken the history and made your physical examination. Once your relationship with him has been established, you must foster it by every means. Watch his condition closely and he will see that you are alert professionally. Take time to have little talks with him—and these talks need not always be about his symptoms. Remember that you want to know him as a man, and this means you must know about his family and friends, his work and his play. What kind of a person is he—cheerful, depressed, introspective, careless, conscientious, mentally keen or dull? Look out for all the little incidental things that you can do for his comfort. These, too, are a part of "the care of the patient." Some of them will fall technically in the field of "nursing" but you will always be profoundly grateful for any nursing technic that you have acquired. It is worth your while to get the nurse to teach you the right way to feed a patient, change the bed, or give a bed pan. Do you know the practical tricks that make a dyspneic patient comfortable? Assume some responsibility for these apparently minor points and you will find that it is when you are doing some such friendly service, rather than when you are a formal questioner, that the patient suddenly starts to unburden himself, and a flood of light is thrown on the situation. Meantime, of course, you will have been active along strictly medical lines, and by the time your clinical and laboratory examinations are completed you will be surprised at how intimately you know your patient, not only as an interesting case but also as a sick human being. And everything you have picked up about him will be of value in the subsequent handling of the situation. Suppose, for instance, you find conclusive evidence that his symptoms are due to organic disease; say, to a gastric ulcer. As soon as you face the problem of laying out his regimen you find that it is one thing to write an examination paper on the treatment of gastric ulcer and quite another thing to treat John Smith who happens to have a gastric ulcer. You want to begin by giving him rest in bed and a special diet for eight weeks. Rest means both nervous and physical rest. Can he get it best at home or in the hospital? What are the conditions at home? If you keep him in the hospital, it is probably good for him to see certain people, and bad for him to see others. He has business problems that must be considered. What kind of a compromise can you make on them? How about the financial implications of eight weeks in bed followed by a period of convalescence? Is it, on the whole, wiser to try a strict regimen for a shorter period, and, if he does not improve, take up the question of operation sooner than is in general advisable? These, and many similar problems arise in the course of the treatment of almost every patient, and they have to be looked at, not from the abstract point of view of the treatment of the disease, but from the concrete point of view of the care of the individual. Suppose, on the other hand, that all your clinical and laboratory examinations turn out entirely negative as far as revealing any evidence of organic disease is concerned. Then you are in the difficult position of not having discovered the explanation of the patient's symptoms. You have merely assured yourself that certain conditions are not present. Of course, the first thing you have to consider is whether these symptoms are the result of organic disease in such an early stage that you cannot definitely recognize it. This problem is often extremely perplexing, requiring great clinical experience for its solution, and often you will be forced to fall back on time in which to watch developments. If, however, you finally exclude recognizable organic disease, and the probability of early or very slight organic disease, it