Addressing Some of the Myths about the Doctor-Patient Relationship

20 May

Addressing Some of the Myths about the Doctor-Patient Relationship
How can I keep from becoming emotionally involved?

In a class for first-year medical students, excerpts from Anatole Broyard’s book, Intoxicated by My Illness, are required reading. In it, Broyard, faced with the diagnosis of prostate cancer, declared his requirements for a physi- cian: “not only a talented  physician, but a bit of a metaphysician, too. Someone who can treat body and soul . . . [one] who enjoyed me.”1 In re- sponse to the reading, a student asked me, “How can I keep from becoming emotionally involved?” 2 The question had additional weight because sev- eral of her classmates in the section had responded to my question, “What is the most important  issue facing you now as a physician-in-training?” with these answers: “becoming too emotionally involved” and “losing my humanity.” Patients and friends had often asked me the same question. And Robert Coles took note of this issue when he wrote in The Call of Stories, “I learned [from my teaching supervisor] that it was best for me not to get ‘too involved.’”3

The class discussion made it clear that the students saw “emotionally in-

volved” as a pejorative term. It implied weakness on the part of the physician. It implied that we would become less effective and less professional and would lose our objectivity. It was dangerous to become emotionally involved, placing ourselves at risk of having our practice “take over” our personal life.

In fact, good physicians do their job in a sensitive, involved way and avoid these pitfalls. And so I believe that seeing the term “emotionally in- volved” in a negative way is invalid. Centering the discussion around the question as the student asked it would have tainted and inappropriately confined the discussion. I thought that we should reframe the question be- fore we proceeded, and so I proposed this continuum:  At one end was “cold,” as in “That doctor is a ‘cold fish.’” At the other end was “emotion- ally involved.” And in the middle was, well, “the middle.”

cold———the middle———emotionally involved

We agreed that either extreme was undesirable.

I asked the students to define the middle. They answered: “Finding out what it’s like for patients, taking time with them, going beyond the techni- cal aspects of their illness. Understanding that an illness may have impact on patients’ income, the viability of their career, and on their self-image. Finding out what it’s like for families. Recognizing that illness is a family experience. Understanding that an illness may have impact on the dynam- ics of family life. Asking the appropriate questions to address those issues.” They recognized already that developing a sense of the patient’s experience through interested inquiry could not only enhance the relationship be- tween the patient, the family, and the physician but also might affect the process of care and even improve the outcome.

To their definition of “the middle,” they added: “Empathy and under- standing. Not simply an awareness of what it’s like, but an expression to the patient of that understanding. Saying it!” Sad to say, many patients no lon- ger expect that from their physicians. “Saying it” signals the patient that the physician is “involved,” may have thought about the patient’s experi- ence, perhaps even wondered, “What would it be like if it were me?” and has thought about issues beyond the technical ones.

“Sitting at the bedside rather than standing,” one student offered. We had talked previously about patients’ perception that a seated hospital visit seemed longer than a standing one. They recognized that not only was it ac- ceptable, it was advisable to involve oneself in an inquiry about what it was like for the patient, but also to do it in a way that seemed unhurried to the patient. Sitting meant that the physician was not in a hurry, that the pa- tient  at that  moment had her undivided attention.  Patients often note other body language and subtle signs of interest and involvement: eye con- tact, concentration on what the patient was saying, validation of what was said with restatements and further inquiry, and expressing respect for the patient’s point of view and values. They also noticed when these qualities were absent in their physicians. The “middle,” then, is a continuum. There are many appropriate, yet not excessive, aspects of involvement.

“What is excessive involvement?” I then asked the students. “What is ‘too involved’? What  breaches the threshold between ‘the middle’ and

‘emotionally involved’?” “Babysitting for the patient’s children” was one answer. I followed up by asking, “What are ‘babysitting’ equivalents?” Pro- viding care at a discounted fee is appropriate; paying patients’ rent bills or loaning them money is inappropriate. Participating in a prayer with a pa- tient at his request is appropriate; initiating prayer is not, for it may be im- properly imposing the  physician’s values upon  the  patient.  Intent  is important. Touching with romantic intent  is inappropriate; touching to comfort is not. At the edge, of course, was sexual involvement or meeting a patient for a drink.

“Doctors’ inappropriate sharing of their personal lives” was another an- swer. It may be acceptable for doctors to comment on their own experience of illness in order to validate for the patient that they understand the pa- tient’s struggles. On the other hand, it would be inappropriate for physi- cians  to  discuss their  own  family conflicts  and  financial  dilemmas. “Allowing ourselves to take on the patient’s burdens. Not seeing that we are going beyond our skills.”

“Could someone be an effective physician for a relative or friend?” Ad- dressing this question seemed to complement the larger discussion and fur- ther clarify the issue. Practicing in a small community—a small town or ethnic community—we can hardly avoid taking care of friends and rela- tives. And it works. The lesson for all care is clear: So long as doctors do not inappropriately taint their decisions or alter basic patterns of diagnosis, treatment, and interaction, they avoid the dangers of becoming “emotion- ally involved.”

We explored the meaning of “cold,” at the other end of the spectrum: “The physician doesn’t talk at all, doesn’t connect at all. The physician sees only the technical aspects of the medical problem.”

When we completed the discussion, we renamed the entire continuum of involvement.  Just as we realized that  “emotionally involved” was a phrase burdened with too many negative connotations,  we also realized that “cold” was pejorative. We changed the continuum from:

cold———the middle———emotionally involved

to

uninvolved———involved———inappropriately involved

Doing so allowed us latitude to consider the dimensions of involvement without being defensive. It allowed us to say that involvement is a virtue of being a good doctor or, better yet, a requirement. This story from my prac- tice illustrates.

In his mid-60s, a retired laboratory technician had most of the complications of di- abetes mellitus: His vision was failing, the circulation to his legs was impaired, nerve injury hampered his ability to feel pain in his feet, and his heart muscle, in- jured by previous heart attacks, pumped inefficiently. Now he was hospitalized for the third time in as many months for kidney failure, with fluid accumulated in his lungs and an accompanying disorder of body chemistry. While renal dialysis was an option, it was clearly only a short-term solution, one of many that seemed to divert him and his wife from dealing with his approaching death.

Here were my options for involvement:

•  Uninvolved: Simply addressing the urgent technical issues—treating the con- gestive heart failure and the kidney failure with medication and dialysis and treating the diabetes with insulin.

•  Inappropriately involved: Taking his and his wife’s burden as my own; taking their anticipated loss as my own.

•  Involved: My concern was that they not squander this precious and uncertain time in futile therapeutic maneuvers and false hopes. I was concerned also that when the patient died, his wife not be faced with a grief prolonged by the feel- ings that “if only he and I had talked more, if only I had said once more how much our relationship meant,” and “I wonder if I did all I could.” I wanted to help provide them with the time to deal with concrete matters, legal and other- wise, and emotional matters.

I chose to be involved. The patient, his wife, and I addressed these issues together and agreed to cease vigorous treatment beyond that related to his comfort. The patient died a week later. In a letter after his death, his wife thanked me for “the precious week that [he] and I had.” What I had done was not trivial.

Physicians and others have taken the position that involvement, de- scribed this way, is more properly the role of someone else—social workers, nurses, clergy, psychologists. Besides, “It takes too much time, and physi- cians’ time is better spent in other activities that only they can do.” But who else is in a better position to do it than the physician? Our knowledge of the patient, details and nuances of the illness, its uncertainties and prog- nosis, our ongoing presence and our relationship with the patient and the family make us uniquely qualified to participate in the patient’s care in this way.

What about the concern that being involved takes too much time? My conversation with this couple, enabling them to explore these important issues, took a few minutes. Each prior transaction through the years of his illness was a deposit in the “trust account” of our relationship; our long rela- tionship validated the current series of transactions. It simply does not take much time to do this.

Another concern, and perhaps the real concern, is that the accumula-tion of every involved transaction will ultimately overwhelm the physi- cian. If involvement is seen as appropriate and necessary, in the same way that taking a thorough medical history and doing a physical examination are, and if it is seen as a continuum, done more or less as the circumstances require, then it will not be overwhelming. On the contrary, it will be mea- sured, appropriate, and satisfying.

Both patients and physicians need the reinforcement and validation of the relationship. I recall a moment in the fall of 1998, when two women who had breast cancer spoke to the first-year medical school class at the University of Minnesota about their reactions to the illness and its impact on their lives. During the question-and-answer period, two students rose to thank them and then the entire class gave them a standing ovation, both extraordinary responses to a medical lecture. By so doing, they validated them as patients and as their teachers. In effect they said: “We heard what you said. We understand—or can begin to understand—what it has been like for you. We admire the way you’ve handled things and have a great deal of respect for you.”

One may think that these women did not need that. After all, they had long since demonstrated their strength by coming so far. But all of us—pa- tients, students, teachers, and physicians—need validation, and it does not have to be in the form of a standing ovation. It can be something as simple as saying, “That’s some story. I can only begin to imagine what this must have been like for you. You deserve a lot of credit for the way you’ve han- dled things.” Given a choice, a moment’s pause about whether or not to do it, just do it. It is another way to be involved.

What does the “involvement,” the relationship, mean? For the patient, the physician’s involvement dignifies the transaction by taking it beyond a technical exercise to one of humanity and caring. It allows the patient to reflect, “This doctor I’m dealing with is a complete person. She under- stands. She understands me. In the matter of my illness, we are equal part- ners.” Especially when  the  illness is complex,  involvement  provides reassurance that the patient has an advocate, a “general contractor,” some-one who knows what questions to ask, who provides the authorization to have feelings and fears, and who can help address those feelings. Involve- ment enriches all the transactions. Absent involvement, the patient and the family miss support at the very least, but also they can miss the opportu- nity to explore options, uncertainty, and values and to plan thoughtfully for the future.

But the relationship works both ways. For the physician, it is affirming and enriching. An undergraduate wrote, “The human experience is one of great depth and wisdom and I am continually amazed at the strength and resilience we seem to show time and time again. As a physician, I would be able to witness these wonders of the human spirit, and in this way I feel it would be a great honor to be a healer.” It is reinforcing to have an apprecia- tive, long-standing patient. When the relationship makes the patient feel better, it makes the doctor feel better. Lacking involvement sterilizes the transaction. Without involvement, each patient with abdominal pain be- comes just one more case rather than an opportunity for exploration and discovering new insights about people and their lives. Broyard again: “It doesn’t take much time to make good contact, but beyond that, the emo- tional burden of avoiding the patient may be much harder on the doctor than he imagines.”4 And author Anne Lamott describes a conversation with her dying friend’s doctor: “ ‘Watch her carefully right now,’ she said, ‘because she’s teaching you how to live.’ ”5“People fulfill themselves as human beings through relationships,” my friends were charged during their wedding ceremony. Absent the relation- ship, both patient and physician lose.

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