Sunday 30 April, 2006

Keep a broad holistic outlook

Posted in Advice, Michael Tam, Rants, Wards at 16:58 by Michael Tam

Original article by: Michael Tam :: Printer friendly

Don't loose sight of the forest

Your patient is more than the sum of
their symptoms and signs

It is easy to loose perspective during a busy medical or surgical term. Patients become known by their illness or disease, and you may soon find yourself doing tests and asking for consultations on routine rather than for clinical indication. It is easy to be too heavily focussed on the “tree” and miss the “forest”. Many hospitals have set protocols and they are generally a good idea as it means that a clear clinical pathway is followed. However, a protocol is not a substitute for thinking and clinical decision making; context is important.

At these times, you have to step back and remember that your patient is not a collection of symptoms, signs and syndromes but is a real person. You should always try to consider and reflect on what is the goal of management at least each time you see them on a ward round. With the wisdom of hindsight, it is not uncommon to see patients, particularly the elderly, admitted for vague reasons under a busy general medical team and then investigated extensively with no definitive results. During their time in hospital, they may develop any number of iatrogenic disorders (e.g., intravenous line site infection or hospital acquired pneumonia) which will require further treatment. Only several weeks later, after a brief trip to the rehabilitation ward are they able to return home.

Most of the time, your investigations and management are keyed towards diagnosis and treatment. Sometimes, however, it doesn’t matter what the diagnosis is as long as people improve and are happy. And sometimes, the only treatment that is required is time and some supportive care. Remember that health care is voluntary and it is the patient’s choice.

“Primum non nocere”

First do no harm. Don’t let your zeal for “doing your all” for your patients actually harm them in the end.


  • your patient’s view of their health and their goals of hospitalisation;
  • your patient’s psychological and social context;
  • if the tests you are ordering are actually necessary (i.e., will they potentially change management?);
  • the potential harms and side-effects of medical investigations (e.g., discomfort, infection, delay in discharge) and balance them with the potential benefits;
  • if you are obsessing over clinically irrelevant minutia;
  • whether your patient’s pharmacological therapy is in their best interests (from a holistic point of view, not just biomedical point of view);
  • whether you have truly explored all management options;
  • if you are keeping the patient admitted for their sake or for your peace of mind.

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