TEACHING THE HUMAN SIDE OF MEDICINE
Many patients, students, and friends have expressed doubt that the hu- man side of medicine can be taught. “Either you have it or you don’t,” they say. Unequivocally I declare: “The human dimensions of medicine and how to apply that knowledge can be taught—by drawing upon students’ own experiences, by modeling the relationship, and by thoughtful exami- nation of the infinite number of medical transactions.”
My undergraduate, semester-long course at Macalester College, “Semi- nar in the Human Side of Medicine: What It’s Like to Be a Patient; What It’s Like to Be a Physician,” meets in a two-hour weekly session, with dis- cussions, weekly papers, and a term paper. Together the students and I ex- plore the essence of that part of medicine, seen from the standpoint of the patient and the physician. Let me parse the title of the course.
The course is a seminar, not a lecture course. That means that there is an intimacy between my students and me, which allows for open and open-ended discussion. Nonetheless, there are a framework and an agenda to the discussions, which this book approximates. During the seminar meetings, we often tell stories from our own lives and use these stories as data for our discussion.
The human side of medicine: The theme of the course, and of this book, is that medicine, while technical in many of its methods, is a human profes- sion, about people. While illness may be defined in terms of an abnormal organ or organ system, it is ultimately about human distress, and the sci- ence of it is only part of the method of inquiry and action. It does not always help the patient when the physician presents technical information with- out providing context, comfort, compassion, and continuity—all human dimensions of medicine.
What it’s like to be a patient takes priority in the subtitle over what it’s like to be a physician. The primary axiom of the course and of my practice and professional life is “the patient is the center of the drama,” not the doctor, not the hospital, not the insurance company or other institution. The task of the physician is to appreciate what it’s like to be in the patient’s situation, to clearly define the patient’s needs, and then to help the patient meet those needs. That is where we begin the course.
The composite life of a physician, what it’s like to be a physician, cannot be ignored by anyone considering a career in medicine. Being a physician means dealing not simply with illness but with people with illness, having Introduction xxxiii to interpret and decode their stories in order to define their problems be- fore one can suggest and provide a remedy. That is a very stimulating and satisfying activity. What it’s like to be a physician is more than what the doctor does all day. It means knowing how to plan our day to make best use of time, to integrate our professional and personal lives and provide balance, to set limits, to attend to our family, and to share some of the emotional burdens. Being a physician is intense work, filled with complex decisions (most of which become second nature with experience), and we can be easily se- duced into allowing our professional activity to overtake our personal life.
We begin the course with a story of one patient’s experience with illness.
To this we add stories from the students’ experiences, for almost all students have had experience with either their own or a close family member’s en- counter with a more than trivial illness. We learn from stories. Sometimes we miss all their lessons. Sometimes we unconsciously alter them by how we listen or how we retell them. But this does not negate the point that one of the joys and opportunities of being a physician is being privy to stories and the discovery that is involved.
I like to use the photograph on page xxxiv when I teach the course.
“Take three minutes to study the photo,” I tell the students, “and then take ten minutes to write a story about it.” All they know for sure is the caption: “Home health nurse examining a patient in his home, Madison County, NC.” Each of the students’ stories, of course, is different, focusing variously on the man, the woman, the nurse, or all three. The students construct sto- ries of differing acute and chronic illnesses; the man’s various losses—health, independence, income, and ultimately life; and the impact of his illness on the man, the woman in the doorway, usually called “his wife,” and the nurse. Some notice the photo of the serviceman on the bookshelf in the background, and construct yet another story. Some notice the walker in the foreground. Others notice the modesty of the dwelling.
After the students read their stories to the whole class, I tell them what the phogorapher, Rob Amberg, told me. “The woman to the right is the man’s daughter. He was 94 years old when the photograph was made, and he had been living with her and her husband for a number of years. The home health nurse made regular weekly visits with him. That work is in- credibly rewarding. The nurses play a vital role in our very rural, often iso- lated community, acting not only as interpreters between patients and clinic doctors, but also as a strong social connection. Most of the nurses end up being good friends with their patients. Both the man and his daughter are long gone, and, while I’m sure he would be flattered to be thought so young, I suspect she would be equally upset to be thought so old,”
Home health nurse examining a patient in his home, Madison County, North Carolina. Shot for Southern Exposure magazine. Photographer: Rob Amberg. Copyright © 1984.
The photograph is but a moment in these people’s lives. The point of the exercise is to demonstrate that we unconsciously construct stories about people from scant knowledge of the facts and then draw conclusions from those stories. The less we know for sure, the more inaccurate our infer- ences. Especially as physicians and other health care professionals, we need to know as much of the story as possible to make valid decisions and do our jobs well.
I have set out to write a sweet book, full of patients,’ students’, and physi- cians’ stories and reflections. It represents the cumulative wisdom of all my teachers—my professors, my colleagues, my family and friends, and my pa- tients and students. Much of what I do and much of who I am as a physician and teacher is derived from what I have learned from them.
I’ll begin chapter 1, after presenting the medical history, by telling a story. Then I will identify the issues, address the role of the doctor-patient relation- ship, and finally ask, “What did I learn?”