Introduction: Defining the Human
Side of Medicine and Identifying the
The patient is the center of the drama.
At a time of great changes in the technology and delivery of medical care, what is timeless and unchanging for patients and physicians is the human side of medicine, the nontechnical part. Many feel that unless one is by na- ture a compassionate and understanding person, that dimension of medi- cine is hard to teach and hard to learn.
Two premises inspired this book and the course of the same name that I teach at Macalester College, a small nationally known liberal arts college in St. Paul, Minnesota: that it is as important for a physician to master the human side of medicine as its technology and that the human side of medi- cine can be taught. Attending to the human side enhances care. Again and again, elements of the human side hold the key to diagnosis and treatment by recognizing the unique qualities of each patient. Attending to the hu- man side of medicine enriches the experience for all those in the caring professions.
Some years ago, I was a guest in a class of adult students of a world-re-nowned biblical scholar. When they asked him to eulogize a recently de- ceased colleague, equally well known, they expected high praise. Instead he was critical. “He didn’t leave even one person to carry on his work,” he said. “He created a private language that was not transferable. It was opaque and so it was not useful to others. Transparent knowledge can be used by others and can be transmitted. There are those who do what they do well, but it is not teachable. He gave solutions but not formulas, and for- mulas can be used by others.”
In this book, I reflect on “formulas” for the human side of medicine, based on over thirty years of practice and of teaching, mentoring, and ad- vising medical students and undergraduates. I describe them so that others can use them as students, practitioners, teachers, and informed patients. I suggest “transparent” formulas for thoughtful medical interviewing, ex- ploring the psychosocial issues related to illness, addressing uncertainty, collaborating, developing relationships, attending to values, and for inte- grating all of these skills into preparation for a career’s worth of good pa- tient care.
The Human Side of Medicine describes what keeps the practice of medi- cine stimulating: not fascinating cases, but fascinating people—the best reason to enter medicine. Attention to the human side is the physician’s best protection against professional disenchantment. The book validates the relationship between physician and patient as crucial to all that tran- spires between them; it is not simply a vestige of “the good old days.” It inte- grates science and technology with the human side but declares that knowledge of science is not enough if one is to be a good physician. The hu- man side of medicine is not simply “being nice to patients”; it is a combina- tion of many dimensions of care, a deliberate, focused, reproducible process. Its elements can be analyzed, and most anything that can be ana- lyzed can be taught. I continued to analyze and learn as I wrote this book.
I know that the human side of medicine can be taught, because I learned about it from other physicians, nurses, psychologists, social workers, clergy—and from patients, an almost infinite number and the real experts. As physicians, we have an obligation to the community of patients, to col- leagues, to prospective physicians, and to teachers to share and teach what we do in a way that is attractive, interesting, transmittable—and transpar- ent. Then the teacher-student relationship becomes a model for the doc- tor-patient relationship.
The Human Side of Medicine addresses a primary audience of students al- ready committed to a career in medicine, those just beginning to consider it, those who counsel them, and physicians-in-training in medical school and residency training programs. It also speaks to experienced physicians, nurses, social workers, clergy, and others in the clinical professions, to those who teach medicine, to those who work with doctors and patients in hospi- tals and physicians’ offices, and to patients.
The Human Side of Medicine addresses students already committed to a career in medicine and those beginning to consider it and wondering what it is like. It is a recruiting book, intended to attract talented, compassionate people to the profession. Though this is not a book about tactics in apply- ing to medical school, it will enhance the reader’s understanding of a med- ical career and help the process of applying by focusing the student on the essential elements of being a physician. Among the most important choices in life is that of a career and life’s work. In this single choice are combined our values and aspirations, our self-expectations and assessment of our talents, uncertainty, consideration of costs—time and money, and concern about how the choice will have impact on our personal and family life. The choice is, in a word, complex. The choice of a medical career is all of that.
This book is intended to provide fundamental information and perspec-tive about the experience of being a patient and a physician in a way that is rarely taught at the undergraduate level, so that students can make an in- formed choice, the first step toward a satisfying career. The book will help those who have thought about a medical career for the right reasons—the desire to serve and the intellectual challenge—but declined serious consid- eration for invalid ones. One is that the current system of medical care, es- pecially managed care, intrudes inappropriately on the relationship between patient and physician and the amount of time spent together. Re- gardless of their practice setting, physicians who have always put their pa- tients’ interest first and never compromised their professional values have preserved their identity and enthusiasm as caring doctors. Attending to the human side of medicine does not take much time, and it is time well spent. The book should help to dispel other myths: that physicians can not have a personal life and that it takes a genius to be a doctor.
This book is for those who are already learning how to be physicians in medical schools and residency training programs. For those in the first years of medical school, it will provide an ongoing context for learning about the human side of medicine. For those in the clinical years and the residency beyond, it will enlarge and reinforce what they have learned. I have set out to write for them a book full of stories to create a warm anticipation of the joy of a medi- cal career.
This book is for physicians, those in practice or retirement and those who may be struggling with change or disenchantment. It is directed also to those who never had the opportunity to talk—really talk—with a colleague about what it is like to be a physician and the meaning of the career. By validating the physi-cian’s commitment to the human side of medicine, I hope to reinforce the joy of recognition and to rekindle that joy for those who, in the midst of day-to-day pressures, may have forgotten the real reason why they chose that career—for the human side. In the course of this writing, I have, of course, heightened my own joy. The book is meant to model the role of reflection on one’s career; such an activity can be satisfying and renewing, like a “sabbati- cal in place.” The book is also meant to encourage physicians to recycle their experience by teaching and modeling it for students.
This book is for teachers of medicine, those who are good at it, those who wish they could do it better, and those who would like to examine what works in teach- ing and what does not. Not many of us who teach medicine have had formal training as educators or speak regularly with our fellow teachers about ef- fective techniques. As teachers describe, understand, and reflect on what they do in caring for patients and teaching others, they can better critique, sharpen, discard, reproduce, and improve their techniques and teach them. Medical school curricula are often long on teaching disease states and short on teaching the human side of medicine.
This book is for other professionals—nurses, physical and occupational thera- pists, psychologists, social workers, chaplains and other clergy—and staff who work with patients and their families in hospitals, physicians’ offices, nursing homes, and patients’ homes. By enhancing their appreciation of what it is like to be a patient and a physician, they will see even more clearly the op- portunities to work together and serve patients better.
Finally, this book is for patients. This book will help them recognize good care and affirm that they need not choose their physicians either for their humanity or for their technical skill; they can expect both. Older patients remember what it was like to have a physician who knew them well, over a long period of time, who appreciated their place in their family and in their community, who asked what was going on in their lives, and who could in- tegrate that knowledge into the decisions made and advice offered. Other patients may not know that they can expect both technical excellence and humanity. By understanding how their physicians work, patients can be more effective partners in their own care.
This book, in short, is for all of us kindred souls. The goals are common to us all.
THE PHYSICIAN EXPERIENCE: AN INTRODUCTION
Physicians have the privilege to serve in ways that few careers allow. Pa- tients and their families depend on us, by sharing their burdens and often by turning their burdens over to us completely.
Being a physician is a joy. The intellectual stimulation of dealing with people and their problems, simple and complex, and the variety of chal- lenges is exhilarating. Sobering, too, for patients share the stories of their lives, given only the simplest of encouragement: “How is this for you?” or “What’s going on in your life?” Such questions give them permission to tell their stories.
Each patient has a story, and few are reluctant to tell it. When I ask, “Who do you share your feelings with?” many will answer, “My wife (or hus- band or uncle or friend),” but more than you can imagine will say, “You’re the only person I’ve ever told about this.”
So being a physician—privilege and joy aside—is a responsibility. If we are to be partly responsible for the physical and psychological problems of our patients, we must know what we are doing. We must know what to look for, how to get the information, how to identify all the issues, how to dis- card the trivial, how to use the technology of medicine (and how to restrain ourselves from using it unnecessarily), how to address issues of ethics and uncertainty, and how to integrate all of this information and knowledge quickly into action that serves our patients well.
Physicians are perpetual teachers. We teach our patients; uninformed, they are less likely to follow our instructions. We teach our colleagues also; each consultation, formal or informal, is an opportunity to teach. Many of us teach in medical schools, residency programs, and a few, like me, in un- dergraduate settings. We are also perpetual students. We learn from our teachers and our colleagues, from what we read and hear in the medical mi- lieu, from our patients, and from our students. We learn from our experi- ence within and outside of our careers. A career in medicine is a commitment to lifelong learning.
But because medicine is changing, the community faces the hazard that attention to the human side of medicine may be neglected. Of all the let- ters of appreciation I received from patients during my years of practice, not one thanked me for “that great CT scan,” “that great blood test,” or “that great surgical referral.” Rather, they expressed gratitude for my listening, being present, helping them through difficult times, providing emotional support, and enabling them to understand what was going on and how to deal with it—all aspects of the human side of medicine. Patients ought to expect that from all their physicians.
Many argue that unless one is by nature a compassionate and under-standing person, the human side of medicine is hard to teach. Not so. I be- lieve that exposing undergraduates to that aspect of a medical career should help attract talented and compassionate people to the profession and provide a context for lifelong learning. I also believe that teaching the human side of medicine as a primary, and not incidental, subject in medical school and that continuing to emphasize it throughout postgraduate resi- dency training is critical to becoming a good doctor. The community of pa- tients is the ultimate beneficiary. Absent the human side, both patients and their physicians lose.
I am a primary care physician, an internist trained before the advent of the major technologic advances in medicine. I learned medicine at the University of Rochester in upstate New York, a medical school whose cur- riculum was firmly based in the biopsychosocial view of illness. I have had good physicians as models. I have been a patient, a concerned family mem- ber, and I am the husband of a talented and compassionate medical social worker. All of these influences contribute to how I look at the doctor-pa- tient relationship.
I am also a perpetual student. I am accustomed to asking, “What did I learn from this encounter with the patient? What did I learn from this class that I taught? From this student?” The insights from these sources make me a better physician and teacher.
My ongoing experience as a teacher is threefold. I have taught medical students, interns, and residents for thirty years at the University of Minne- sota, and during most of those years, I have taught small groups of first- and second-year medical students in one of their first direct experiences with patients, as they are beginning to form their habits of practice. Though the course was designed to teach them skills in medical interviewing and diag- nosis, I added dimensions emphasizing the human side of medicine. In the last eight years, I have taught undergraduates at Macalester College. The course is called, “Seminar in the Human Side of Medicine: What It’s Like to Be a Patient; What It’s Like to Be a Physician.” And finally, each day of my practice, I taught my patients the meaning and implications of their ill- ness and treatment. One of our roles as physicians is to transmit the best of what we have learned, to build on those lessons, and to preserve the time- less values. A statement in rabbinic literature declares, “We may not be able to finish the task; even so, we shouldn’t shrink from it.”1
My generation of physicians—I am in my 60s and graduated medical school in 1961—is especially important as a bridge generation. Our teach- ers were educated before the arrival of big medical technology—fiberoptic endoscopy, coronary artery catheterization, CT and MRI scanners, even blood chemistry screening tests—and so they relied a great deal on the medical interview, the patient’s story of illness. They valued it as the entrée to the patient’s diagnosis and treatment and squeezed more information out of it. They thought things over as much as possible before pressing on to laboratory work or consultations. They recognized the value of presence.
Less reliant on technology, they were better listeners. Treatment in those days was simpler also. The therapeutic choices often included no treat- ment, simple treatment such as penicillin for infection or digitalis for con- gestive heart failure, time, or rest. There were no intensive care units or “extraordinary measures” like ventilators, cardiopulmonary resuscitation, and dialysis.
Wherever I practiced, there were always one or two extraordinary physi-cians, people with unique viewpoints and approaches and extra measures of diagnostic and therapeutic wisdom. Colleagues recognized them as com- munity treasures and resources. When, despite their own best efforts and those of their consultants, physicians still did not know what was going on with a patient and what to do next, they turned to one of them. Most of the time, they came up with the solution to the unsolved diagnostic problem not by collecting more laboratory data, but simply by reinterviewing the patient, reviewing the other material, and looking at all the information in a different way. When they taught their “method,” they did it by “thinking out loud,” by making their process “transparent.”
Similarly, I have had other remarkable teachers, inside and outside of medicine, noteworthy not only for what they taught me but also for how they taught and how they organized and presented their material. When these people, master clinicians and teachers, retired or died, they took many of their secrets with them, a loss to the community of patients and physicians. Would it not have been great for them to have been debriefed and to have had their skills and secrets described, sorted out, and pub- lished?
To a certain extent, this book is my attempt to debrief myself. Not that I
am extraordinary in the way that I have described these others. Nonethe- less, I reflect on these matters, and, through the years, I have kept good re- cords, not only of clinical data, but also of how patients, students, and teachers say things. I have recorded how I say things to patients and stu- dents and what works and does not work.
Lest we forsake the best of the past as we move to the future, we should recognize that medicine, like the Talmud, a compendium of biblical com- mentary and discussion, “is built layer upon layer, the result of the com- bined labors of many generations…. The creative work of one generation serves as the basis for the creative work of the next.2 . . . [It] is thus the re- corded dialogue of generations of scholars [and] has all the characteristics of a living dialogue.”3 If we do not continually write about, clarify, inte- grate, and carry on the “dialogue” of medicine, then we do not build on prior knowledge, and we are condemned forever to reinvent the wheel. Our task, as physicians and teachers who appreciate the importance of the human side of medicine, is to preserve those values and techniques and pass them on to our students.