Fernando Kawai, M.D. — Assistant Professor of Clinical Medicine
[Transcript of video]
This was completely an out-of-the-box experience and I had fun with it, I hope that you enjoy. I’ll be talking about the main medical investigational tool that we use in medicine for many centuries: History & Physical. I will demonstrate a History & Physical into our object, our patient. And as a palliative care doctor, I always see people that are unfortunately close to the end. We do what we call meaning centered therapy, and I’ll talk a little bit about that as well.
What is the History & Physical? It is a universal medical tool — it’s the first thing they teach us when we start to go to the clinical years. And every time you go to a doctor — maybe in the ER, an office, or a hospital — there will be an H&P in your charts. With all the technology — it’s still the tradition. I always teach my students: yes, we have CAT scans, MRIs, EKGs, but good medicine starts with a good H&P.
In fact, often you can get a diagnosis and a treatment plan just with an old-school H&P. What is H&P? It’s a set of verbal questions. What brought you to the hospital today? When did it start? Is it severe? Anything that makes it better or worse? Any past medical history? Diabetes, hypertension, any allergies? Do you take any medications? Social history. Where were you born? Do you drink? Any drugs? Smoking? Sexual activities? Family history. Anyone in your family that has problems?
We also do a physical examination in which we use senses, listening, observation, palpation. We do use some fancy stuff — maybe too much these days — chemical analysis of bloods, x-rays, MRIs, EKGs etc. And then we document an assessment plan. I did have a problem because my patient was nonverbal. Since we are already an out-of-the-box experience: what about seeing the world through a child’s eyes? I was going to set my sights of investigation to the H&P — but what about using someone that was born in 2007? I felt curious to see what a child would say as a response to my set of medical tools:
I’m Dr. Kawai and I’m the doctor who will be helping you today. What’s your name, sir?
Thanks Doctor. My name’s Antonio, I’m representing Mr. Wire D. Phone.
Wire D. Phone. Okay, nice to meet you, Mr. Wire D. Phone. So, how can I help you today? What brings you to the hospital?
He said that he’s been unwired for a few months.
A few months?
Correction, a few years.
He has been unwired for a few years? Okay, I’m sorry to hear about that. And anything that makes the problem worse?
He says water makes it really bad for him.
Water makes it worse. Okay. Anything that makes it better?
High volt electricity.
High volt electricity, all right. Any other symptoms that came together with this problem of being unwired?
Occasional overheating. Okay. And tell me from one to ten, one is like a mild problem, ten a very serious problem, how severe is your problem?
He says he’s really annoyed that people haven’t been giving him enough electricity recently. I mean, too much of a good thing is bad, but he really needs electricity to function.
I see. So it is a severe problem, okay. Any past medical history, any past medical problems, Mr. D Phone?
He says that, if he does have any, he’s got a bone to pick with its creators.
I see. Any allergies?
He has a severe allergy to sand. It makes him real gritty, and water makes him all rusty on the inside.
Oh my god, so he has allergies to sand and water. Are you taking any medications, Mr. D. Phone?
Not at the present time.
Okay. Some social history. When were you born?
He said he wasn’t born, he was built.
Okay, I’ll get that information. Do you drink any alcohol?
He says, heck no! I mean, alcohol is part water, so he’d go rusty on the inside.
Oh, all right. Any smoking?
He says he smokes when he overheats, but that’s pretty rare.
Oh, so he smokes when he overheats. And, any family problems? Any problems in his family?
He said that his great, great, great, great, blah-blah-blah-blah grandson, Samsung, has a tendency to blow up.
I’ve heard about that there are some Galaxy that explodes. I’m sorry to hear about your great, great, great, great grandson.
He said that, sadly, he won’t be able to travel the world. By plane, at least.
Now additional social history: I did not ask because it would not be appropriate but was interested to learn that, since the very beginning there was some sexuality related to the phone. We saw that, and maybe Mr. D. Phone did have some adventures in the past that I didn’t know what they were.
As a doctor, of course, I do a physical examination so, a general inspection. He is unresponsive, I see some rust here, so maybe he was exposed to water. We check if the pupils are reactive, in the eyes. Right, to look inside but there’s not much there. Then we do a palpation and try to listen to any activity, right? Uh oh, no heart sounds. We do palpation and sometimes percussions, so using our senses as well, right? Percussions to see there it’s the liver or perhaps a bowel. Some sounds there, so it does sound like he has stuff on the insides.
Maybe we need to order some tests. I forgot the reflexes, to check if there’s any reaction to… hmm, no reflexes. So let’s do some additional exams. I wish I could order an x-ray, but I got the diagram and lots of internal structures and they look okay, these structures. And then you do an EKG to check for electro-activity. I’m concerned that he was going towards a flatline.
So my assessment plan: 78 years old, Model 500 that has been unwired, the patient is in a terminal condition. His technology became obsolete since buttons were invented. The invention of touch phones and recent wireless technology made the situation really critical. So let’s keep him comfortable, allow a peaceful death, and provide support to his family. We are going to provide the life review and meaning centered therapy to support the patient during this critical illness as a patient approach the end of life.
So what’s the life’s quest? Freud would say that life is a quest for pleasure, sex being a most common form of pleasure, and maybe he did have his adventures.
Adler would say that life is a quest for power — money being a very common form of power. I do believe that the phone industry has quite a bit of power. But Victor Frankl, who survived Auschwitz — he was an Austrian psychiatrist, wrote in a beautiful book called” Man’s Search for Meaning” that life as his quest for meaning. And meaning can come from relationships, from your work, and from many other things. And for each person it can be different. As people get close to the end, we try to make a life review to help the patient and the family to reflect during the time.
And the questions that we ask are: what accomplishments are you most proud of? What would you like to be remembered for? What gave meaning to your life? Would you like to give any advice to your family?
I think one of the things that maybe Mr. D. Phone would be proud of— I’m thinking because he has a 9-1-1 here as you can observe — is that the 9-1-1 system is alive and well. 240 million calls a year. And I like to think that — thanks to the 9-1-1 system — many sons still have their fathers, many daughters still have their mothers, husbands still have their wives. We live longer and quick access to medical help makes a big difference. I’m sure he’ll be proud of leaving this behind and it’s still alive.
What kind of advice he’d give to his family? Respect the elderly! We carry out mobile phones but it’s good to remember that it’s just because someone did lots of heavy lifting before we got here. Remember where we come from. And respect that you are not here alone. That you are just one piece in a small lineage, and guess what? Soon enough you’ll be joining them. So maybe it’s a piece of advice that he would give to the iPhone, don’t be so full of yourself. As people pass away, they’ll remain in our memories. As people pass away, we should honor their memory. And, here we are – I am so happy that we are celebrating him (the Model 500), and he is, at the Smithsonian Museum, celebrated. Thank you so much.
Fernando Kawai, M.D.
Dr. Kawai is a Geriatrician and Palliative Care physician and Assistant Professor of Clinical Medicine at Weill Medical College of Cornell University. His research interests include: Medical education, Hospital Medicine, Inpatient Geriatrics and Palliative Care, Mindfulness and Contemplative Care, Medical Care of Ethnic minorities.