Thursday, 17 November 2016

#ThinkSpeak: for Professor Bothwell

Professor Tom Bothwell (1926-2016): a mensch. #ThinkSpeak


I found out yesterday that Prof. Tom Bothwell passed away on the 12th November. He was professor of medicine at my medical school (Wits). I worked for him for as a house-officer for 6 months and then as medical registrar for 4 months. The latter was very stressful for me as I was an SHO and was asked to act-up during the medical staffing crisis of 1988. Despite being out of my depth, and very inexperienced, Prof. Bothwell supported me and made me fell like a champion. He used to call me and the other registrars maestro. 


Prof. Bothwell was a brilliant clinician and had a remarkable bedside manner; although somewhat aloof he was compassionate and knew how to empathise with patients. He was more than a mentor to me, but an inspiration; I wanted to be as good a doctor as Prof. Bothwell. 

He was a heamatologist, and a heam-oncologist, and he made giving bad news an art. He also knew when enough, was enough, and that nature had run its course and there was nothing more to be done than to make the patient comfortable. I recall when one of the senior consultants wanted to try a new chemotherapy regimen on a patient with acute myeloid leukaemia, who had relapsed for the third time; he resisted. His classic put down phrase was 'Down Boy' as if speaking to a dog; he used this exact phrase on that ward round. He said that patient would not tolerate the chemotherapy protocol, had suffered enough, and that the chance of more chemotherapy being successful were too slim. He simply asked me to make sure that patient was comfortable. After the round I came back to see the patient and found  that he had returned, before me, to speak her on his own; to explain to her and her husband his decision. He was holding their hands and they all had their heads bowed in prayer. I don't think he was religious; whether the act of prayer was symbolic I don't know, but he instinctively sensed that this couple needed religion more than chemotherapy. We discharged the patient a few hours later and she passed away peacefully at home 5 days later. 

Prof. Bothwell was an advocate of the human side of medicine, he would definitely not like the way the practice of medicine has evolved. The best word that comes to mind to describe him is 'mensch'; an old Yiddish term. The irony is that Yiddish is a dying language in the same way that Prof. Bothwell's style and practice of medicine is dying, or has died. 


I read last week's NEJM perspective with nostalgia. It reminded me of my house job and my time as a medical and neurology registrar. How I long for those days, when we believed that what we did on the wards had meaning beyond the working day, beyond 10 programmed activities, and beyond a job plan that wants us to justify how we use each 15 minute slot of our time. It's time we rehumanised the practice of medicine. 


“So we beat on, boats against the current, borne back ceaselessly into the past.”


Rosenthal and Verghese. Meaning and the Nature of Physicians’ Work. N Engl J Med 2016; 375:1813-1815.

Excerpts:

..... In a past era, the work of the hospital physician was done primarily at the bedside or in the adjacent wet laboratory. Residents had the opportunity to witness the unfolding of diseases (for which we may now have cures) and to come to know their patients over the course of lengthy hospitalizations. The life was grueling and all-consuming — and those who took it up were almost invariably unmarried white men, with teaching hospitals actively discouraging marriage. Medicine was a fraternal order. Doctors’ lounges were central locations where community internists, specialists, and surgeons ate together, socialized, and “curbsided” each other for patient consultations. Charts were kept on paper and were often indecipherable......

...... Every aspect of medicine and training has since evolved. Progress has been remarkably quick in some areas and painfully slow in others. The past 20 years have seen much debate over the amount of time worked by house staff. As residents’ duty hours have changed, so has the nature of their work.....

...... Typically in our field, internal medicine, residents arrive at the hospital at 7 a.m., get sign-outs from nighttime residents, and conduct “pre-rounds” to see patients they have inherited but don’t know well, before heading to morning report or attending rounds. Attending rounds often consist of “card-flipping” sessions held in a workroom, frequently interrupted by discharge planning and pages, calls, and texts from nurses and specialists. Finalizing discharges before noon can feel more important than getting to know new patients. Increasingly, the attending physician doesn’t see patients with the team, given the time constraints......

....... No longer are there paper charts at the bedside. The advent of the electronic era, while reducing the time required for tracking down laboratory or radiology results, has not substantially changed the time spent with patients: recent estimates indicate that medical students and residents often spend more than 40 to 50% of their day in front of a computer screen filling out documentation, reviewing charts, and placing orders. They spend much of the rest of their time on the phone coordinating care with specialists, pharmacists, nutritionists, primary care offices, family members, social workers, nurses, and care coordinators; very few meetings with these people occur face-to-face. Somewhat surprisingly, the time spent with patients has remained stable over the past six decades.......

...... The skills learned early by today’s medical students and house staff — because they are critical to getting the work done — are not those needed to perform a good physical exam or take a history, but rather the arts of efficient “chart biopsy,” order entry, documentation, and sign-out in the electronic age. When a medical team gets notice of a new admission, it seems instinctive and necessary to study the patient’s record before meeting him or her. This “flipped patient” approach has advantages, but it introduces a framing bias and dilutes independent assessment and confirmation of history or physical findings.....

..... In short, the majority of what we define as “work” takes place away from the patient, in workrooms and on computers. Our attention is so frequently diverted from the lives, bodies, and souls of the people entrusted to our care that the doctor focused on the screen rather than the patient has become a cultural cliché. As technology has allowed us to care for patients at a distance from the bedside and the nursing staff, we’ve distanced ourselves from the personhood, the embodied identity, of patients, as well as from our colleagues, to do our work on the computer.....

..... Meanwhile, drop-down menus, cut-and-paste text fields, and lists populated with a keystroke have created a medical record that (at least in documenting the physical exam) at best reads like fiction or meaningless repetition of facts and at worst amounts to misleading inaccuracies or fraud. Given the quantity of information and discrepancies within medical records, it’s often impossible to discern any signal in the mountains of noise. Yet our entire health care system — including its financing, accounting, research, and quality reporting — rests heavily on this digital representation of the patient, the iPatient, and provides incentives for its creation and maintenance.3 It would appear from our hospital quality reports that iPatients uniformly get wonderful care; the experiences of actual patients are a different question.....

...... It’s clear that physicians are increasingly dissatisfied with their work, resentful of the time required to transcribe and translate information for the computer and the fact that, in that sense, the work never stops. Burnout is widespread in the workforce, and more than a quarter of residents have depression or depressive symptoms.4 In response, health care leaders have advocated amending the “Triple Aim” of enhancing patients’ experience, improving population health, and reducing costs to add a fourth goal: improving the work life of the people who deliver care......

.... But technology cannot restore our professional satisfaction. Our profession will have to rebuild a sense of teamwork, community, and the ties that bind us together as human beings. We believe that will require spending more time with each other and with our patients, restoring some rituals that are meaningful to both us and the people we care for and eliminating those that are not.....

..... Solutions will not be easy, since the problems are entangled in the high cost of health care, reimbursement for our work, and obstacles to health care reform. But we can start by recalling the original purpose of physicians’ work: to witness others’ suffering and provide comfort and care. That remains the privilege at the heart of the medical profession.....

P.S. Interestingly, the first patient I saw with MS was on Professor Bothwell's ward; I clerked her as a 4th year medical student on my first medical rotation and presented her to a neurology consultant. I think I started my love affair with neurology that day and have no regrets. 

6 comments:

  1. How lovely to remember someone who inspired you so much as a young doctor.
    Keep speaking out and fighting for change. We really are so grateful to have a voice through you Prof G.

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  2. Yes to remember your inspiration and why you are doing the job you do for so long and with passion and love is quite simply something well done keep fighting the cause and thankyou for sharing

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  3. Prof G you have done Professor Bothwell proud.

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  4. Nice post; it is clear that Prof. Bothwell was a very special man. I like how your are evolving this blog. Please keep doing more posts like this it makes things more interesting and dare I say more human.

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  5. Humanity needs more empathy, in all aspects of life, in Medicine, especially. But Medicine has become "Big Business".

    All of you, Blog's Docs, approach the ideal of Prof. Bothwell's than distance from him...

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  6. Lovely comments. Indeed Tom was well loved and respected man and a giant in the fields of Clinical Medicine and Iron Metabolism.

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