Sometimes these days, with the dominant biomedical model of health and illness it can seem like people don’t actually matter. The individual stories of patients are dismissed as anecdotes and treatments are divided into one of two categories “proven” or “unproven” on the basis of statistical analyses of clinical trials (experiments on pre-selected groups of volunteers). The implication is that what works in health care is the intervention, be that a drug or a surgical procedure. Who the patient is, and who the doctor is, seems to be of secondary, or, sadly frequently, of no importance at all.
Yet, if you are ever unwell, I bet it matters to you who you consult and how they behave. I think we all want to consult a doctor who, frankly, gives a damn! I know I do. How many of us would seek a health care system based on dispensing machines which dole out drugs after you input your symptoms?
Amazingly, this idea of the importance of the person in medicine is having to be fought for. So, it was with great interest that I read a review of a book in the BMJ this week. The book is “When Doctors become Patients” by Robert Klitzman (ISBN 978 0 19 532767 0). The author is a psychiatrist who became depressed and was so shaken by his experience of becoming a patient that he set about interviewing other doctors who had become patients too.
Time and again Klitzman found that becoming a patient transformed the doctors’ views (and of practice) of medicine.
Non-specific complaints, side effects such as weight gain and fatigue, fear, humiliation, and spirituality acquired new significance. Struggling to adhere to burdensome schedules, they became less draconian about poor adherence to treatment. In presenting medical information, they became aware of the importance of framing the information sensitively.
I guess this is not a surprise. You’d expect experience to change your views. However, you’ll probably find it more than a little shocking that the doctors needed the illness experience to figure this stuff out. We’re clearly missing something in medical education.
The phrase that really hit me between the eyes though was this –
In choosing their own doctor, most interviewees preferred bedside manner over technical skill.
It’s what I’ve always felt personally. I’ve always felt that what’s really important is that you find a person who cares, listens and puts your interests at the heart of the consultation. I take the technical skill bit as kind of a given. ALL doctors should have the technical skills they need to do the job and the processes of continuing education, annual appraisal and the coming revalidation procedures of the General Medical Council are all designed to ensure that. But what about the human bit? What about the importance of the person? We need to make this case more clearly. Too often, the technical skills are attended to, and then we stop.
Finally, the BMJ reviewer concludes –
Klitzman, like Gawande and Groopman, is part of a contemporary group of reflective doctors who, through their writings, contribute to the less palpable but nevertheless crucial moral, social, and experiential dimensions of medicine.
We need more of this. Maybe we are building a body of knowledge and opinion but we’re sadly lacking in the areas of research into the “experiential dimensions of medicine” and in providing medical education which considers this as of equal importance to the knowledge of drugs, trials and the technical skills required to do surgical procedures.
Heroes Not Zombies 
Well done again.
I worked as a nurse and midwife for many years. When I really connected with my patients (clients), all sort of wonderful things occurred. Even when the outcome was not what they had envisioned, like ending up with a cesaerian section, the time and caring that I brought to the experience usually left them feeling empowered. In other words, they did not feel that things had been done to them, that they had been part of the decision making.
The experience, as you mention, is all important. Explanations, time spent, compassion, caring, and yes, love, all go a long way to helping someone heal. My daughter has applied to medical school, was chosen for an interview,and I have forwarded your blog to her. She also just spend a day at a homeopathic seminar. She will make a fabulous doctor!
I can’t relate on a doctor-patient basis, really (though I do have a couple of pretty good doctors, I only see them once or twice a year because, well, I don’t really NEED them all that often). I CAN, however, speak to this as it relates to the teacher-student relationship.
I teach English at a small community college in New England. I am one of about six adjunct professors who teach the various sections of English-based courses the college offers.
My style of teaching is very personable. I CARE about my students, and they know it. I respond to their emails quickly and personally. I give them my phone number (something, I have to admit, it took me a while to be comfortable doing) because I want them to have access to me if they need me – not only for school-related stuff, but also because I recognize that, for many of them, I may represent one of the few responsible and trustworthy adults in their lives. There’s not been a single semester that’s gone by without at least one of my students coming to me outside of class for something desperately important to them – they’ve confessed unwanted pregnancies or have asked advice on escaping an abusive relationship, they’ve admitted alcohol or drug problems and, more happily, students have come out of the closet to me and celebrated professional and personal successes with me. They seek me out because they know I care.
Does that mean that students do better in MY classrooms than they do in the courses taught by more stand-offish or “professional” instructors? I don’t know and, frankly, I don’t care. My commitment to my profession demands that I love my students and care about their success, and the way that *I* manifest that love and care is by being maternal – hard-assed when I have to be (I don’t care how much I love you, your homework is still due on time) and empathetic and kind as often as I can be. It’s a mode that works for me and, so far, no one has taken advantage of it.
Coming back to your idea of the doctor as patient, I think the experience is an important one. I’ve BEEN a student – for a pretty long and intense time – and I completely understand (perhaps more than they give me credit for) what my students are experiencing. I was a grad student with a husband, two children under 6, two part time jobs, and all the responsibilities that come with being a grown-up in modern society. I GET that my college kids are stressed out, and they believe me when I tell them that I get it. Having a doctor who knows what it’s like to be scared and sick and in pain, I imagine, would go a long way toward trusting that person with one’s care.
I agree with your argument that empathetic communication is an essential skill if a physician is to provide optimal patient care. That said, I’d suggest that a couple of issues deserve additional emphasis.
Noting the changes in Dr Klitzman’s perspective consequent to his becoming a patient, you write, “However, you’ll probably find it more than a little shocking that the doctors needed the illness experience to figure this stuff out. We’re clearly missing something in medical education.” Perhaps that is true, but I would point out that it is not because bedside manner, empathy, the ecology of the patient, patient-centered treatment, and similar approaches have been ignored or avoided. Even when I trained in the ohmygodcanitreallybethatlongago 1970s, my medical school required us to take a full-fledged course, during our pre-clinical years, that centered on understanding and dealing effectively with patients. And, in the clinical rotations, it was the atypical instructor who did not address relating to as well as treating the patient. At least until 5 or 6 years (when I last had routine dealings with those involved in medical education) such courses and concerns were prevalent in medical schools.
The problem is that teaching anyone to be empathic and to use that empathy in his or her everyday work has proved, throughout the years, incredibly difficult. That has been true, by the way, not only for medical practitioners but also educators, lawyers, clergy, and every other professional.
Further, even becoming a patient is no guarantee of enlightenment. After all, most doctors become patients at some time, yet not all of us experience this sort of epiphany.
I’m not arguing that the difficulty excuses a doctor who acts thoughtlessly or coldly to a patent; I’m arguing that “We’re clearly missing something in medical education,” is incomplete as an analysis of the problem.
I would also warn that the the the perspective you describe approvingly as “I’ve always felt that what’s really important is that you find a person who cares, listens and puts your interests at the heart of the consultation. I take the technical skill bit as kind of a given,” is not without its risks.
Distinguishing between genuine caring and being told what one wants to hear is another difficult task. I’ve been convinced by some professionals, including but assuredly not limited to doctors, that they were devoted to my interests only to discover later, to my loss, that that was not the case. And, even if these individuals have the necessary technical skills (no sure thing, certificates and test scores notwithstanding), there is no assurance they will use them appropriately.
I want the same great doctor everyone wants – the one who, for example, will understand my reluctance to undergo an invasive diagnostic procedure but will not cave in because of my jitters and instead will continue to kindly insist on that test if it is necessary to my care.
I do propose we recognize how difficult it is (1) to teach that set of skills and (2) for the individual to acquire and maintain them.
All good. As a general doctor my most important rule is “doctor know thy patient,” and try to always act in their best interest- hard to get it all right sometimes, but gotta keep trying.
Dr. B
Thankyou everyone so much for such thoughtful and interesting comments.
GaleG, I think if your care for a patient leaves them feeling empowered, then you are doing well. We can’t predict how things will turn out (maybe especially in obstetrics!) but if we care compassionately and do our best for the patient then even the unexpected can turn out well. I completely agree. I’ve had similar experiences.
mrschilli, I think your comparisons with education are fascinating. The teachers I remember most fondly are those who seemed to care about their work and about the individual pupils. I think you highlight a very important point when you say “Does that mean that students do better in MY classrooms than they do in the courses taught by more stand-offish or “professional” instructors? I don’t know and, frankly, I don’t care. My commitment to my profession demands that I love my students and care about their success…….” You don’t care in order to get good results. You care because you care! Caring for your students is a value in its own right. It doesn’t need to be reduced to a utility of some other value. (PS. wish I’d had teachers like you!)
Allan, thankyou for stoppping by and welcome. I 100% accept your two proposals. I don’t know how possible it is to teach empathy or, perhaps more accurately, to train empathy. I do know it only emerges in genuine caring though. If a doctor doesn’t really care about a particular patient it’s very hard for him or her to be empathic towards them. And, that leads to your second point, about maintaining the skill. In fact, a part of the review I didn’t quote challenged the “need to be strong” and to not show feelings that is so often expected of doctors and which may contribute to burnout (Klitzman suggests).
I too trained in the 70s and yes, there have always been, and still are, courses in patient communication skills and consulting skills, but I’m afraid that even in today’s new graduates it’s not unusual to hear them dismiss the non-physical aspects of illness as “soft” or “touchy-feely” (always a pejorative term).
But I’m not arguing that what is missing in medical education is in any way a complete analysis of the problem! Much more fundamental is the rather mechanistic aspect of the biomedical model itself which seeks to reduce suffering to pathology and treatment to the removal or suppression of pathology. When was the last time you saw an entry in a medical textbook for “healing”? It comes down to our concept of “health” I think.
I’m arguing that this book seems to be another piece of the jigsaw which is helping us to argue for the importance of the human beings who receive health care and the human beings who deliver it.
That’s the nub of the issue – deciding what’s important in health care will be determined by the concept we have of health.
I do so appreciate your comments Allan. If you are so disposed would you mind saying something about your own concept of “health”?
Hi Dr B. You are so good at putting things in a nutshell! You are so right. Knowing the patient is the key. And it might be hard but you “gotta keep trying”!
Doc, what I was getting at with my “I don’t care” response is that I don’t think in terms of competition with what other professors are doing (or not doing, as the case may be). I also recognize that my approach – which might be considered well within the realm of that pejorative “touchy-feely” – isn’t going to work for everyone. I can’t reach all of my students, and may really fail someone who might have better thrived in a more stand-offish, just-the-facts-ma’am class. *I’M* not built like that, though; I believe that there’s much more to my subject than facts and rules, and it’s that that I try to convey with my love – both of my students and of my concentration.
Polonius said “to thine own self be true, and it must follow, as the night the day, thou canst not then be false to any man.” If I’m living – and teaching – according to my most authentic self, then I’m always going to do the best job I can. Really, that is the most anyone can expect of me – or that I can expect of myself.
You make another really important point here and it’s one I don’t think medicine has considered at all seriously. Because we are all different and have different ways of experiencing the world, different sets of strengths and characteristics, and because the doctor patient relationship is exactly what it says on the tin – a relationship – no doctor is the best doctor for ALL patients. In Primary Care in the UK doctors practice in groups and traditionally patient choice within the group practice allows patients to find the doctor who works best for them (you know I’m not aware of any research in this area – if anyone else is, could you let me know?). How they select is a mystery to me but in my practice we all found that if one of the partners was on holiday we would see a distinct subset of the practice population – those who identified with and usually consulted with the absent doctor. It was clear that a lot of patients had a clear preference for one particular doctor and that no one doctor was any more popular than the others.
I think this is a fascinating phenomenon but when you stop to consider it, it has rather challenging implications for the design of health care systems. Turns out who the doctor is matters after all and that no one size fits all.