What Would Be Ideal for the Patient; What Would Be Ideal for the Physician
Good medicine does not just happen; it is thoughtfully planned and practiced.
Throughout this book, the voices of patients have expressed what they need from their physicians and from the system of medical care. Young and without professional experience, my students at Macalester College devel- oped their own ideas about what is ideal for the patient and for the doctor, for unless physicians are happy in their work, both they and their patients suffer.
The students’ final assignment in the course each year is “to write a term paper on ‘Fashioning the best system of medical care possible: what would be ideal for the patient; what would be ideal for the physician.’” I tell them that I am not asking them to detail a “national health care system.” Rather they should “describe what you, as a patient, would seek from your physi- cian and from a system of health care, and what you, as a physician, would want in a career to which you have dedicated yourself.” I ask them to draw on many sources—the content of their reading and classroom discussions for the seminar, but also their own experience, feelings, and wisdom. I tell them that in this essay, I want to get some sense of their values.
In the assignment for this paper, I remind them that “medicine must be sufficiently attractive to bring talented, bright, compassionate, thoughtful men and women to a career that is, on the one hand, stimulating, satisfying, and intellectually challenging and, on the other, requires many years of training, a continuing commitment to learning, and a substantial invest- ment of time and money in education.” I am proud of their insights and reflections. They complement those of patients and experienced physicians. They validate my view that the es- sence of the human side of medicine is present in them all. Here are some eloquent excerpts.
WHAT WOULD BE IDEAL FOR THE PATIENT
This student essay provides a nice context.
Each of us faces moments when our reality becomes unrecognizable, our security weakens, and our choices no longer follow a familiar path. For many, it is illness that shatters this world of comfort, security, and certainty. When we become ill, we lose control over the functions and care of our physical being. Our weakness forces us to ask others for assistance, and… we must depend on the knowledge and skills of others to restore our health. This dependence creates a unique relationship be- tween the ill and the healer. We turn to healers when we no longer recognize the language of our body—we ask that they listen, understand, and respond to our body’s demands. In all communities, throughout all cultures, the healer, therefore, is a valuable and well respected member. The relationship between healers and their patients relies on the skill, knowledge, and dedication of the healer and yet is centered on the needs and story of the patient. It is this balance that remains fun- damental in the ideal relationship between the ill and their healers. . . .
Physicians are not asked to plunge into an endless series of medical interven- tions and therapies; we don’t ask them to continue treatment no matter what the consequence or never to fail. Instead, we ask physicians to listen to our choice of paths, our personal history, and our glimpse of the future. We ask that they never forget who we are and that they treat us as individuals. In asking for this under- standing, we ask for far more of physicians than simply their technical talents. We ask that they incorporate their personal judgments, skills, and opinions, with our expectations—that together we create the most effective plan of treatment. In this manner, we maintain the balance of our relationship. The focus remains on the pa- tient and all decisions are products of shared expectations and values.
Patients appreciate simple humanity. Another student saw her long-time personal physician as a model.
She was recommended to me by a friend. Once she entered, the room suddenly lit up. She had a warm smile, a caring look, and enthusiasm to see me. She gracefully approached me and shook my hand while introducing herself. I forgot for a mo-ment that I was ill and instead was in amazement. She set an atmosphere that was comfortable. She treated me with so much care and most of all respect. She lis- tened to my story, without writing any words on paper, and asked questions only when there was a pause. She examined me with care and had a correct diagnosis. I felt I could tell her anything, that I could trust her. It had only been a matter of minutes, and I wanted to tell her my life. After that appointment I was happier than I had been for a long time and made it a priority that I have her as my personal doctor. That is a doctor that every patient is entitled to.
Patients want the right to choose. Another wrote:
My first demand is that I should have the right to choose my physician. The qualities that I would search for in my ideal doctor would be medical astuteness, personable style, and concern about all aspects of my personal health, including my physical condition, my emotional state, and my psychological well-being. A physician who could respond to me personally would be perfect…. [Ina complex medical situation] I would like my physician to be my counselor, as well as the orchestrator, organizer, and conductor of all the specialists to whom I may be referred. [Such a physician] would be essential to my sense of security that everything is being coordinated in a manner that seems reasonable to someone who knows both the medical require- ments of the situation, and the needs that I pose as an individual.
Patients want a relationship and understanding. As one student suggested:
The best health care system is one that should model after the family…. The rela- tionship between the parent and the child is a delicate one. Even though the par- ent and the child are from the same family, they experience life differently because of age, sex, or other factors. In order for understanding to take root and the family to work together as a unit, each person must listen and be listened to. This is the same interaction that must occur in a doctor’s office, because doctors and patients come from different worlds. They have their own backgrounds. They live their own lives.
Physician and patient need to like each other. One of my students wrote of her doctor, “I liked him from the start, and I felt that he liked me as well, which mattered a lot. . . . It never occurred to me that [he] even had pa- tients other than me….I never felt that I had to handle anything alone, including the uncertain future of my condition.”
Patients want a partnership with their physician. One student described some aspects of that partnership.
Collaboration between doctors and patients is important to the patient and to the relationship. It empowers patients and makes them active members in determining their future; and it attests to the doctor’s trust of the patient’s judgment. Collabora- tion indicates to patients… that doctors think of them as individuals… that physi- cians realize that although the patient may have the same sickness as someone else, he is also unlike anyone else in that he requires his own treatment. . . .
The doctor-patient relationship is similar to a business deal sealed with a hand- shake. There is no written agreement that the doctor will always be available to answer questions, no clause stating that the doctor must present every treatment available to the patient, no law guaranteeing that the doctor will even be willing to collaborate on a treatment with a patient. Yet, in a successful doctor-patient rela- tionship, all these things are present because of an established mutual trust and re- spect between the physician and the patient.
Another student recognized other unique qualities of the partnership.
Doctors work as the “expert” on the technical, medical part of the problem, and patients work as the “expert” on the lifestyle and context parts of the problem. Of course, the boundary between the two roles is not (and should not be) completely clear. The doctor may have recommendations for lifestyle changes, and the patient may have opinions or insights regarding possible treatments. Nevertheless, these two “experts” come together and inform each other of the various aspects within their areas of expertise.
Though one student said it differently, she appreciated the unique part- nership, in which the patient is not passive.
Although it is doctors who have been educated in the anatomy and physiology of the human body and in the diagnosis of ailments, it is patients who live in the body and relate this body to the world. Therefore, it should be the role of patients to share what they know as the long-time owner and inhabitant of the body and the role of physicians to apply this information to their academic knowledge in explor- ing and making a diagnosis. Thus, it is vital that patient and physician together dis- cuss what they know so a complete diagnosis and understanding of the illness as a whole can be obtained. In the process of exchanging information, a relationship between patient and physician develops, allowing both life worlds to overlap in a wealth of information and insight used to make a more complete diagnosis…. Pa- tients should ultimately be the co-creator of their own medical treatment, using physicians’ medical expertise to make safe, satisfying health care decisions unique to their individual needs.
Sometimes patients need authorization to tell their story and to be honest about their feelings. If patients are reticent, it is the physician’s responsibility to as- sist them through thoughtful inquiry. Encouraging patients to be forth-coming regarding information and feelings adds to the quality of the story. One student recognized that
many people don’t tell the truth, or don’t relate all their symptoms because they aren’t comfortable telling such personal stories. They feel as if they must be the only one [who has such a story]—or that it is “bad” for them to be feeling the way that they are. Different people have varying levels of comfort within a doctor’s of- fice, and this can often be noticed in the telling of their stories. I think being naive, unaware, or ignorant of important symptoms can also be a problem for patients. Many people just don’t know—or suspect, but think their suspicions are un- grounded—and don’t relate crucial symptoms or happenings to their physicians.
Patients want their physicians to listen. They want to tell their story and have sufficient time to do it. Another student tried to plumb the feelings of a myth- ical patient, when he wrote:
It feels very frightening to think that a doctor can confuse a patient’s diagnosis be- cause he or she doesn’t have time to listen. That “well-known” doctor became “ill-known” for me. He didn’t possess the patience to listen to my story. Perhaps telling stories was the only time where I felt I was in control, but that doctor took this satisfaction away from me. . . . How could he go on and say this particular kind of treatment is appropriate in my case when he didn’t know my whole story?
Patients want empathy. Students reinforced the idea that patients want their doctors to appreciate what it is like for them and to understand that ill- nesses and people are complex. One wrote, “I want the medical system and my physicians to see . . . the humanism of [my illness and that even] a ratio- nal person can do that which is not in his or her best interests. …I don’t want my doctor to conclude that if I am not doing well, it’s because I’m bad, i.e., ‘noncompliant.’ I’m just having a hard time.”
Another observed that physicians should… try to understand what it is like to go through the illness from the patient’s perspective, of being ill in a world full of prejudices and generaliza- tions based solely on appearances. Social stigmas accompany any illness; and with illness that may affect patients’ physical appearance or ability, the stigmas can be especially harmful. Cancer patients who go through chemotherapy and lose their hair know that this is a side effect of the chemicals used, but may not be mentally prepared for having everyone look and know that they have cancer. Illness is a very private matter…. Physicians who are honest about what is at stake relay the mes- sage that they understand some of the silent concerns about going through the ill- ness. By being honest with a patient and not covering up some of the emotionally
detrimental aspects of an illness, a doctor can begin establishing trust with his pa- tient.
One student elaborated on physicians’ unique position to validate pa- tients’ experiences and feelings. “Doctors should be able to acknowledge that patients’ discomfort and/or illness are crises in their lives, not just an- other addition to the doctor’s rounds….I think that it is unrealistic and un- desirable for physicians to become every patient’s personal counselor, but by merely acknowledging the emotions accompanying illness, doctors commu- nicate to patients that they empathize and see them as human beings.”
One wrote simply, “The quality of compassion in a physician should not be a bonus, it should be a prerequisite.”
In their physicians, patients need original thinkers. That student also ob- served that “the physician should be innovative; he or she should know how to examine problems from all different angles and consider new solu- tions.”
Patients need physicians who recognize that technology alone is not always the answer. One student saw that “the existence of powerful medical technol- ogy doesn’t mean one must do away with more ‘old-fashioned techniques,’ most notably careful history taking and clinical judgment, [which] can pro- vide information that a CT scan or blood test cannot…. An understand- ing of the real problem, and the most effective treatment for it, is [often] not even touched on by a test, but is arrived at, rather, by human insight.” He was concerned about what technology could come to symbolize for some patients.
Certainly CT scans, laparoscopy, blood tests, and the like can symbolize safety and certainty to patients. But in talking to people and recalling some of their feelings about their doctors, I also get the sense sometimes that the use of these types of tests at the same time symbolizes something cold… and inhuman about the prac- tice of medicine to some patients. Tests are designed to measure biological vari- ables relevant to disease. But more often than not, these same measurements are what seem to be of the least essence to the patient. If tests are not balanced by a thoughtful consultation and history-taking by the doctor, the patient may get the feeling that the doctor’s main interest in these seemingly mysterious measure- ments means the patient and his experience have been fundamentally misunder- stood.
The ability to deal with emotional issues should be part of the armamentarium of each physician. One student observed that “individualizing treatment and humanizing medicine . . . requires that physicians address the emotional difficulties faced by persons who are ill. For this to occur, the doctor must listen well and be especially perceptive of the unspoken words.” Another recognized that “the commitment to handling the deeply felt emotions of patients and caregivers cannot be dismissed as someone else’s responsibil- ity. Dealing with the patient’s emotions is not a peripheral task of the phy- sician. Rather, along with controlling the disease process, it should be one of the physician’s main objectives.”
Patients want adequate explanation. Still another student cited the need for enough information in understandable language.
Illnesses are difficult situations that are only complicated by stress, confusion and complex medical terminology. As a result, I believe that I would greatly appreciate an attentive physician who was willing to explain the illness and its possible conse- quences in a clear, open, and honest manner…. Ina time of fear and uncertainty, clear and complete information is absolutely necessary…. My ideal doctor would serve as a “guide” or “translator” throughout the illness, functioning as someone who could inform me about what to expect and assist me in making complex medi- cal decisions.
In their physicians, patients need teachers. One student realized the many dimensions to that role. “As teachers, doctors can reach out to the families and serve as supporters of the family’s struggle by providing context and in- formation. To patients, they can act as knowledgeable guides on the path of illness, showing them where the pitfalls are and how best to avoid or sur- vive them.”
There are many dimensions to healing. Patients need them all. Another stu- dent’s questions and insights about healing and the dimensions of medicine beyond the technical were shaped in part by her father, a minister.
I grew up thinking about medicine and healing from a spiritual as well as a physical perspective…. Healing… as in the case of a chronic or terminal illness… means coming to terms with the pain and what is to come…. Healing asks for the support of other people, and this support system can be an area of brokenness in people’s lives. Healing involves learning how to better communicate with loved ones, so that each person’s needs are fulfilled and dreams understood. . . .
To be artfully, humanly competent . . . is what distinguishes a good physician from a great one. [Competence is] built upon the foundation of patient-centered care and policies, effective communication, awareness of the familial, societal, and medical context in which illness and health care take place, and a sense of the pro- found. Good medicine does not just happen; it is thoughtfully planned and practiced…. [Italics mine]
Illness, especially serious and terminal illness, often causes people to rethink the course of their lives and reexamine goals and what is ultimately important. The physician is in a privileged position to share these moments with patients.
WHAT WOULD BE IDEAL FOR THE PHYSICIAN
One student’s observations provide the context. In essence, they are about values. His father, a cardiac surgeon, is his model and teacher.
My father told me once that he was trained as “a technician,” but he emerged “a healer.” …I realized . . . that it was not his job that he placed above everything else, but the people whom he served—his patients. I understood then the true human- ism of medicine. . . . The practice of medicine today consolidates the two disci- plines of science and art—the science of technology and the art of healing…. This doctor-patient partnership is the foundation of the art of healing. . . .
The privilege afforded physicians is to be a part of the lives of other people…. What can be learned from treating patients contributes to the physician’s profes- sional and personal growth…. Ifa physician can see the patient as a valuable re- source—if the physician will search for the truth of the illness in the patient’s story—only then will the patient best be served. Through all of this comes the re- ward of practicing medicine.
Physicians need time. Another student wrote that “as a physician, I would desire a medical system that would allow me to be the kind of doctor that I want to be….I would want to have the time necessary to get to know each patient as an individual . . . the freedom to organize my own time and choose how many patients I am going to see.”
Physicians need a learning, intellectually challenging, and collaborative envi- ronment. A student described her goal as a learning environment where I can establish mutually beneficial relationships with patients and co-workers. Learning is a continual process, and being a physi- cian provides a unique opportunity to learn from people’s unique stories and expe- riences. . . . Working with patients, peers, and other co-workers in a team would give me access to a problem-solving think tank….I want to look back at my life and career and see where I have helped out humankind and what I have learned from my patients and my peers.
One of her classmates had similar views:
The primary care physicians are the first doctors to deal with all the problems of their patients and must perform a multitude of tasks. Collaboration is key…. Asa physician, I would want this type of intellectual challenge, always dealing with something new and having to figure it out. Having a consortium of peers to consult would be critical as well. Not only my [physician-]partners, but schoolteachers, re- ligious figures, nurses, families, friends; from all I would seek to learn. . . .
A diverse pool of patients would help me to recognize some of my [own] preju- dices, so that I am able to work around them…. [From them] I would learn the va-riety of ways in which people heal or motivate themselves. Religion, optimism, meditation, inspirational readings, music—there are so many things in this world that people draw on to “get them through” and to stay centered…. Through a di- verse group of patients, I would hope to learn techniques which I might apply to another patient’s situation.
Physicians need the opportunity to reflect. One student would like a setting in which “we [colleagues] might discuss moral implications of certain methods of treatment, suggestions for solutions to case problems, or ideas for further resources. . . . I would like to have programs in which I would have the time to bring together people who have similar health concerns, so that they could share their experiences, and I could have a chance to teach what I can about taking care of ourselves.”
Physicians need to feel comfortable in recognizing that no one is perfect; every- one makes mistakes. Another student’s ideal medical system “would allow doctors to be human. This means that doctors themselves need to come to terms with their inherent fallibility as human beings. They need to be free to discuss with colleagues mistakes that they have made…. Both doctors and patients need to remember that being human involves grieving over mistakes and losses, and physicians should not be expected to be immune from feeling that pain.” One young man hopes for “a more open environ- ment for the physician by holding regular conversation hours in clinics and hospitals, where the physicians would sit together to discuss their stories of when they were humbled by medicine.”
Benefits for the physician go beyond financial ones. Another student wrote: “In the medical field there are intellectual and social benefits that can be as attractive as economic compensation…. [Among these benefits are] var- ied opportunities to get involved in continuing education programs,…a supportive and fertile environment within a research community,… [and] accessibility to mentors and peers. The fact that problems and challenges are not always solved in the same manner opens opportunities for diverse thinking and . . . creativity.”
A student described the uniqueness of the medical profession:
As one physician told me, after a while the illnesses one sees become familiar and, perhaps, no longer as interesting in themselves as they once were. But the way in which the patient experiences and describes his or her illness, on the other hand, is always unique and thus always potentially edifying. This fact is what can keep the practice of medicine interesting and fulfilling for the physician and, as a conse- quence, make the physician more effective and durable.
The overlap in patients’ needs and those of physicians is no coincidence, and that in itself is a lesson. For both patients and physicians, the themes are recurring: simple humanity, relationship and partnership, the ability to listen and learn from each other, and the time to do it. Our ongoing task as physicians and teachers is to validate and reinforce these themes. When values such as these are present at the beginning, they are worth preserv- ing. Patients and students should accept nothing less.