Handoffs

I was a newly appointed head of a department of medicine. Supervising the care of 44 patients and instructing interns and residents was a new and thrilling experience. Some patients presented complex problems, which satisfied my detective instincts and provided a stimulating intellectual challenge. Many others were less intellectually demanding, but I loved the personal interaction, the ability to change things for the better, and the endless variability.

It amazes me to reflect on how uncritical I was at the time, adopting and following common clinical practices with little questioning. It never really crossed my mind that medicine could be practiced in a different and better way. When I managed after some months to set aside one day a week to continue basic research, I was overjoyed. On that day, I became a scientist, putting each assumption to rigorous testing. At the hospital however, I was much more self‐assured and complacent. It was during a break between experiments at the research institute that I slumped wearily into an armchair in the library and picked up a shabby copy of the Green Journal. Being too tired for anything serious, I started reading what looked like a fairy tale. It was titled In a stew, by Michael LaCombe, whom I knew to be a gifted medical writer.1 Soon I found myself immersed in the story. The princess is seriously sick, and all the court doctors are baffled. She already has had 4 CT scans, 3 MRIs, and dozens of other tests. All the tests were fine, but the princess remains very sick, and the king is terribly worried. Then, somebody remembers an old, forgotten clinician who has been relegated to a small dusty den somewhere in the basement. For his services to be rendered, all he demands is that someone find him his stethoscope and that he be allowed to have a pupil. Using observation, knowledge, and wisdom (but no further tests), he elegantly elicits the relevant history and makes the correct diagnosis, which has eluded all the sophisticated court doctors armed with their batteries of high‐tech tests but with little regard for old‐fashioned clinical methods.

This was good fun, but though I enjoyed it very much, I had no idea that it would remain in my mind and shape my thinking, my practice, and my teaching. Nevertheless, I gradually found myself during rounds reflecting on this story with the patient who had had 2 CT scans done before anyone bothered to listen to him or examine him and with the patient who had been studied for months before a simple fact that should have been noted at once was finally revealed, which led to a single test that was diagnostic and to the patient's recovery.2 Then there was the patient who underwent a procedure, which looked innocent enough, but resulted in an adverse event that cascaded into months of life‐threatening illness.3 Was the procedure really necessary?

One night, a couple of years later, I woke up and instead of going back to sleep, sat in the silent living room, suddenly thinking of our departmental routine and realizing somehow that many things we physicians do may be seriously flawed: taking a superficial history and performing a perfunctory exam; having a light finger on the trigger of test ordering even if imaging and tests may mean little out of the clinical context and often beget more unnecessary testing; skipping significant information only because it is not immediately available but has to be found at another hospital or clinic or by calling the primary physician; disregarding the ubiquitous and influential emotional aspect or the patient's perspective and health literacy, which are essential for shared decisions; and the repeated underuse4 of highly effective medications and especially of proven preventive measures that are not pharmacological and hence not vigorously promoted by the large pharmaceutical companies.

The seed for this heresy was sown by the fable, and it colored my clinical life with a vein of skepticism and self‐criticism. Slowly it also grew into a long‐term commitment to teaching about and research on avoidable pitfalls in patient care.5

Thus, Lacombe's little piece often comes back to me, teaching me that a fairy tale can sometimes be more powerful than a randomized controlled study of 10,000 patients.

I was a newly appointed head of a department of medicine. Supervising the care of 44 patients and instructing interns and residents was a new and thrilling experience. Some patients presented complex problems, which satisfied my detective instincts and provided a stimulating intellectual challenge. Many others were less intellectually demanding, but I loved the personal interaction, the ability to change things for the better, and the endless variability.

It amazes me to reflect on how uncritical I was at the time, adopting and following common clinical practices with little questioning. It never really crossed my mind that medicine could be practiced in a different and better way. When I managed after some months to set aside one day a week to continue basic research, I was overjoyed. On that day, I became a scientist, putting each assumption to rigorous testing. At the hospital however, I was much more self‐assured and complacent. It was during a break between experiments at the research institute that I slumped wearily into an armchair in the library and picked up a shabby copy of the Green Journal. Being too tired for anything serious, I started reading what looked like a fairy tale. It was titled In a stew, by Michael LaCombe, whom I knew to be a gifted medical writer.1 Soon I found myself immersed in the story. The princess is seriously sick, and all the court doctors are baffled. She already has had 4 CT scans, 3 MRIs, and dozens of other tests. All the tests were fine, but the princess remains very sick, and the king is terribly worried. Then, somebody remembers an old, forgotten clinician who has been relegated to a small dusty den somewhere in the basement. For his services to be rendered, all he demands is that someone find him his stethoscope and that he be allowed to have a pupil. Using observation, knowledge, and wisdom (but no further tests), he elegantly elicits the relevant history and makes the correct diagnosis, which has eluded all the sophisticated court doctors armed with their batteries of high‐tech tests but with little regard for old‐fashioned clinical methods.

This was good fun, but though I enjoyed it very much, I had no idea that it would remain in my mind and shape my thinking, my practice, and my teaching. Nevertheless, I gradually found myself during rounds reflecting on this story with the patient who had had 2 CT scans done before anyone bothered to listen to him or examine him and with the patient who had been studied for months before a simple fact that should have been noted at once was finally revealed, which led to a single test that was diagnostic and to the patient's recovery.2 Then there was the patient who underwent a procedure, which looked innocent enough, but resulted in an adverse event that cascaded into months of life‐threatening illness.3 Was the procedure really necessary?

One night, a couple of years later, I woke up and instead of going back to sleep, sat in the silent living room, suddenly thinking of our departmental routine and realizing somehow that many things we physicians do may be seriously flawed: taking a superficial history and performing a perfunctory exam; having a light finger on the trigger of test ordering even if imaging and tests may mean little out of the clinical context and often beget more unnecessary testing; skipping significant information only because it is not immediately available but has to be found at another hospital or clinic or by calling the primary physician; disregarding the ubiquitous and influential emotional aspect or the patient's perspective and health literacy, which are essential for shared decisions; and the repeated underuse4 of highly effective medications and especially of proven preventive measures that are not pharmacological and hence not vigorously promoted by the large pharmaceutical companies.

The seed for this heresy was sown by the fable, and it colored my clinical life with a vein of skepticism and self‐criticism. Slowly it also grew into a long‐term commitment to teaching about and research on avoidable pitfalls in patient care.5

Thus, Lacombe's little piece often comes back to me, teaching me that a fairy tale can sometimes be more powerful than a randomized controlled study of 10,000 patients.

I was a newly appointed head of a department of medicine. Supervising the care of 44 patients and instructing interns and residents was a new and thrilling experience. Some patients presented complex problems, which satisfied my detective instincts and provided a stimulating intellectual challenge. Many others were less intellectually demanding, but I loved the personal interaction, the ability to change things for the better, and the endless variability.

It amazes me to reflect on how uncritical I was at the time, adopting and following common clinical practices with little questioning. It never really crossed my mind that medicine could be practiced in a different and better way. When I managed after some months to set aside one day a week to continue basic research, I was overjoyed. On that day, I became a scientist, putting each assumption to rigorous testing. At the hospital however, I was much more self‐assured and complacent. It was during a break between experiments at the research institute that I slumped wearily into an armchair in the library and picked up a shabby copy of the Green Journal. Being too tired for anything serious, I started reading what looked like a fairy tale. It was titled In a stew, by Michael LaCombe, whom I knew to be a gifted medical writer.1 Soon I found myself immersed in the story. The princess is seriously sick, and all the court doctors are baffled. She already has had 4 CT scans, 3 MRIs, and dozens of other tests. All the tests were fine, but the princess remains very sick, and the king is terribly worried. Then, somebody remembers an old, forgotten clinician who has been relegated to a small dusty den somewhere in the basement. For his services to be rendered, all he demands is that someone find him his stethoscope and that he be allowed to have a pupil. Using observation, knowledge, and wisdom (but no further tests), he elegantly elicits the relevant history and makes the correct diagnosis, which has eluded all the sophisticated court doctors armed with their batteries of high‐tech tests but with little regard for old‐fashioned clinical methods.

This was good fun, but though I enjoyed it very much, I had no idea that it would remain in my mind and shape my thinking, my practice, and my teaching. Nevertheless, I gradually found myself during rounds reflecting on this story with the patient who had had 2 CT scans done before anyone bothered to listen to him or examine him and with the patient who had been studied for months before a simple fact that should have been noted at once was finally revealed, which led to a single test that was diagnostic and to the patient's recovery.2 Then there was the patient who underwent a procedure, which looked innocent enough, but resulted in an adverse event that cascaded into months of life‐threatening illness.3 Was the procedure really necessary?

One night, a couple of years later, I woke up and instead of going back to sleep, sat in the silent living room, suddenly thinking of our departmental routine and realizing somehow that many things we physicians do may be seriously flawed: taking a superficial history and performing a perfunctory exam; having a light finger on the trigger of test ordering even if imaging and tests may mean little out of the clinical context and often beget more unnecessary testing; skipping significant information only because it is not immediately available but has to be found at another hospital or clinic or by calling the primary physician; disregarding the ubiquitous and influential emotional aspect or the patient's perspective and health literacy, which are essential for shared decisions; and the repeated underuse4 of highly effective medications and especially of proven preventive measures that are not pharmacological and hence not vigorously promoted by the large pharmaceutical companies.

The seed for this heresy was sown by the fable, and it colored my clinical life with a vein of skepticism and self‐criticism. Slowly it also grew into a long‐term commitment to teaching about and research on avoidable pitfalls in patient care.5

Thus, Lacombe's little piece often comes back to me, teaching me that a fairy tale can sometimes be more powerful than a randomized controlled study of 10,000 patients.