Bernadette Keefe MD

The Unease

Over the past few decades there has been an increasing disquiet among doctors and patients. Prior to the late 1970s (pre CT/MRI era) other than basic blood work and plain xrays, there was little in the way of testing for disease. However physicians were well equipped with a robust heritage of  patient bedside history-taking and examination skills. Adept physicians in elucidating a pertinent historical record and performing patient examinations were brilliant diagnosticians. Lavishly written patient narratives and exquisite physical examinations filled voluminous charts.

The late 1970s ushered in organized medicine, HMOs, regulations and abundant technological and medical advances. This potent combination resulted in a tremendous escalation in the volume and pace of healthcare. Physicians, once loved for their bedside manner and comfort (1950’s-1960’s) found, from 1980s-present that they were so rushed and burnt out they had little empathy to spare. Patients picked up on this and, coupled with little time to ask questions and (now) electronic medical records consuming their doctor’s attention, stopped feeling cared for. They stifled their questions and stopped buying into the therapies being proposed for them. (Note: Perceived lack of empathy has been shown to adversely affect clinical outcomes.)

This discontent has surfaced starkly in the recent release of several “tell all” books authored by physicians which focus on their deep unhappiness with current practice of medicine. They describe the tremendous frustration about the lack of time to adequately discuss complex medical issues or to reaffirm mutual trust and understanding with their patients. It is distressing is to read about the degree of physician anger, detachment and lack of empathy. But, quoting Dr. Danielle Ofri:

It’s no wonder that empathy gets trounced in the actual world of clinical medicine…empathy gets in the way of what doctors need to survive.

Amidst all of this patients are left adrift and confused. As Meghan O’Rourke described in her remarkable piece in the Atlantic recently “Doctors Tell All – and It’s Bad” on her experience as a patient:

I always felt like Alice at the Mad Hatter’s Tea Party. I had woken up in a world that seemed utterly logical to its inhabitants, but quite mad to me.

Technology

Technologies are proposed as a panacea for this situation, with the argument that they might free up the physician from various computational tasks so that he/she can concentrate fully on their patient. Thus far, technology has done the opposite. Design flaws, poor execution and inadequate orientation/education all contribute. The sophisticated computational analysis needed to improve therapies is in its infancy so that carrot is yet to be a significant reality.

Additionally, and more importantly, technology cannot replace the human elements in medical care, which are so effective in producing the therapeutic effect. Berci Mesko, the great MD futurist, eloquently said as much in his recently released book “The Guide to the Future of Medicine: Technology AND The Human Touch” (his caps).

…ever improving technologies threaten to obscure the human touch, the doctor-patient relationship and the very delivery of healthcare…People have an innate propensity to interact with one another; therefore we need empathy and intimate words from our caregivers when we’re ill and vulnerable.

He is convinced that there can be a happy marriage of technology and the human touch but only if we prepare for the changes and work to make that happen.

Slow Medicine

Slow Medicine has been described and applied in various ways over the past several decades. Perhaps the most poignant description of Slow Medicine in in the book by Dr Victoria Sweet : “God’s Hotel: A Doctor, A Hospital and A Pilgrimage to the Heart of Medicine”. Dr Danielle Ofri wrote a moving post about the book which is a description of the last almshouse in the US, Laguna Honda, where patient care was geared only towards the comfort and nurture of the patients. It was hands on, very inefficient yet very effective.

Integrative medicine is a type of Slow Medicine model with the goal not just of physical but also mental, emotional and psycho-spiritual wellness.

Others such as Dr. David McCullough describe Slow Medicine as applied to the geriatric population. Here slow medicine means a literal slowing of the delivery of healthcare, taking extra time to make sure patients are understanding therapies, allowing more time for decision making, allowing more time for healing, reassessment of drug therapy (even deprescribing) and the presence of patient advocates. I might argue that this geriatric application of Slow Medicine is amenable/useful for a wide swath of the population. Many patients could benefit from this approach.

Dr Atul Gawande in his recent book “Being Mortal” movingly addresses the need for a more considered, realistic and sensitive practice of medicine, much more attuned to patients’ lives  and desires. Regarding the end of life, such an outlook would be far more cognizant and accepting of human mortality and when further medical care is futile.

Others such as Dr Gianfranco Domenghetti and Dr Richard Smith (see BMJ Blog post “The case for slow medicine”) describe slow medicine as encouraging healthy skepticism about the medical market and medical treatments, acknowledgment of conflicts of interest and the understanding that medicine is not an exact science. Part of this model is making sure patients have access to evidence based information and shown data that their health often depends on factors outside formal healthcare such as lifestyles etc. This interpretation stresses the need to pull back from what Ivan Illich called: the hubris (pride) of medicine.

Words of Wisdom -Past to Present

At the age of 90, in 2011, Dr. J Willis Hurst wrote an essay : “Dr Francis W. Peabody, We Need You” . In it he included the famous quote of Dr. Peabody from his lecture “The Care Of the Patient” (1925)

Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.

Dr Hurst wrote about taking a patient’s history:

The history-taking period is when the doctor not only obtains vital clinical information, but also has the opportunity to know the patient as a person—as a human being. This is also when patients begin to know their doctor as a person. It is during the history-taking period that patients decide if the doctor is a robot with no feeling or a caring individual.

At times, it is useful to hold the patient’s hand, elbow or shoulder….(patients) feel comforted ……recognize the human touch as a signal of caring because machines don’t comfort people.

We are blessed today to have the “modern day equivalent” :Dr Abraham Verghese (watch his TEDGlobal (see reference list below). His eloquent words of wisdom, love of the profession of medicine and deep love and understanding of humanity are a soothing balm for today’s healthcare environment.

-BK 

November, 2014

References

“Slow Medicine”,  Ofri and Danielle, The Health Care Blog,  January 26 2012,http://thehealthcareblog.com/blog/2012/05/11/slow-medicine-2/, accessed November 1 2014

”Doctors Tell All – and It’s Bad”, Meghan O’Rourke, The Atlantic,  October 14 2014,http://www.theatlantic.com/magazine/archive/2014/11/doctors-tell-all-and-its-bad/380785/, accessed November 1 2014

“The Influence of the Patient Clinician Relationship on Healthcare Outcomes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials”, John M Kelley et al, Plos One, April 9 2014,http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0094207, accessed November 1 2014

“How does physician empathy affect patient outcomes?“, Brandy King, Research on Humanism in Medicine, July 3 2013, http://humanism-in-medicine.org/how-does-physician-empathy-affect-patient-outcomes/, accessed November 1 2014

”The case for slow medicine”, Richard Smith, The BMJ Blog, December 17 2012,http://blogs.bmj.com/bmj/2012/12/17/richard-smith-the-case-for-slow-medicine/, accessed November 1 2014

“The Common Principles of Slow Food and Slow Medicine”, Michael Finkelstein, Huffington Post Living, October 27 2014, http://www.huffingtonpost.com/michael-finkelstein-md/the-common-principles-of-_b_6045212.html, accessed November 1 2014

”Slow Medicine Is the Medicine of the Future”, Michael Finkelstein, Huffington Post, August 26 2014,http://www.huffingtonpost.com/michael-finkelstein-md/slow-medicine-is-the-medi_b_5705923.html, accessed November 1 2014

”Slow Medicine strikes a chord”, Melinda Morales, Visalia Times, October 17 2014,http://www.visaliatimesdelta.com/story/news/local/2014/10/17/slow-medicine-strikes-chord/17400861/, accessed November 1 2014

”Slow Medicine”, Dennis McCullough, Dartmouth Medicine Journal, Spring 2008,http://dartmed.dartmouth.edu/spring08/html/grand_rounds.php, accessed November 1 2014

”Dr. Francis W. Peabody, We Need You”, J. Willis Hurst, Texas Heart Institute Journal, 2011,http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3147198/, accessed November 1 2014

“The Caring Physician: The Life of Dr. Francis W. Peabody”, Harvard University Press  (Contains Dr. Peabody’s lecture 1925  “The Care of the Patient” ),http://www.nejm.org/doi/full/10.1056/NEJM199303183281123, accessed November 1 2014

”A Doctor’s Touch”, Abraham Verghese, TedGlobal, July 2011,http://www.ted.com/talks/abraham_verghese_a_doctor_s_touch?language=en, accessed November 1 2014

Header: The Doctor  – By Sir Luke Fildes  1891  http://www.tate.org.uk/art/artworks/fildes-the-doctor-n01522/text-summary