There’s a new cacophony outside my office, different from the old, discordant tones of our radiotherapy department. A new chief of pediatric oncology has attracted scores of new patients to our medical center. The entire milieu of my workplace has changed.
One sound, though, consistently overcomes all others: crying children who ask, “Why me?” With their question, our young philosophers reach out to us in painful challenge, and although I listen closely, I have yet to hear any parent, nurse, or physician provide a satisfactory response. The grownups remain silent, I among them. I have nothing to say.
But I do have something to learn. As adults, we are socialized and acculturated to wearing masks that hide our fears and suppress our emotions. As I adjust my mask, I sense that the same unanswerable, existential questions posed by our children lurk in the minds of “grownup” patients who sit in my waiting rooms. Yet in reality, if we could listen in on their silence, might we not hear the screams of the child?
Recently, much has been written in medical literature to encourage physicians to “be there” with patients. It’s not just a return to advocating for good bedside manner. The new goal is to prepare doctors to be there without words.
The philosophy, writes palliative care specialist Dr. Paul Rousseau in the Journal of Clinical Oncology, ”can create order out of chaos particularly … when patients and family members seek meaning for their lives.” Similarly, Karen Stanley has written in the Oncologic Nursing Forum that “being there” can constitute an antidote against both physical and emotional abandonment of patients. Stanley maintains that physical abandonment often ensues when active therapeutic options have been exhausted and emotional abandonment occurs when conversations drift to evermore meaningless experiences.
So what does “being there” look like? Usually, we’re talking about just a few minutes. If patients permit me (and almost all do), I hold their hands, too. My point is that it’s an authentic human gesture to be willing to sit next to someone (people know that doctors are super-busy) and just give them the gift of my time. I’ve never met a patient that hasn’t been touched by this synthesis of physicality and spirituality. Patients recognize that it’s completely out of character for an expert physician—whom they came to for explicit answers—to silently announce: “I have nothing to say for the moment, but I still want to be here for you in the moment.” It seems passive, but it’s construed by patients as a very active intervention, and deemed by them to be a reflection of profound concern.
Among medical educators, it is au courant to speak about the growing “empathy deficit” among physicians. In response, a methodical strategy has taken form. The Association of American Medical Colleges has decided to overhaul the Medical College Admissions Test (MCAT) with new sections on social and behavioral sciences to assess the whether applicants are sensitive to cultural differences and in possession of humanistic qualities such as caring. The purpose is not only to send a clear message about prioritization of warmer and fuzzier values but also to attract applicants who are motivated by compassion. My generation of pre-medical students recited the mantra, “Doing well by doing good,” Nowadays, the medical profession seeks to recruit unvarnished do-gooders among its ranks.
Upon beginning their graduate education, today’s medical students can expect to receive a generous helping of coursework in humanities along with meat-and-potatoes physiology and biochemistry. No longer is it unusual for American medical school deans to insist on group seminars designed to develop communication skills as well as independent learning modules predicated on literature, anthropology, creative writing, and art history.
What’s driving the changes?
First, there are the patient satisfaction surveys. Like many others, for nearly a decade, our hospital has been collecting data. Consistently, patients indicate preferences for physicians who are not only professionally competent but also mensches. Several of my patients have quoted the opening line from a keynote address delivered by Rabbi Abraham Joshua Heschel at the 1965 American Medical Association convention: “Distinguished physicians, in order to heal a person you must first be a person!”
There is concern also over the recently described phenomenon of “iPatients” a trendy term that describes the notion that the electronic medical record (EMR) has become the surrogate for the actual patient. In a New England Journal of Medicine editorial entitled “Patient as Icon, Icon as Patient,” Abraham Verghese, a bestselling author and professor of medicine at Stanford University, asserts that today, “interns meet a fully formed iPatient long before they meet the real patient.” In that future shock scenario, doctors can rarely reveal their warmer side because they are interacting with a computer manifestation of a patient. In effect, Verghese is cautioning that touch screens cannot replace touch.
Meanwhile, Dr. Paul Okunieff, director of the cancer center at the University of Florida, represents a view that is labeled practical or cynical, depending on the beholder’s perspective. He points out that patients are less inclined to sue when convinced of having a caring physician in their corner. In fact, by maintaining open lines of communication and implementing a medical-error disclosure program, investigators at the University of Michigan found a significant decrease in the average monthly rates of medical malpractice lawsuits.
Do we have data showing that this reorientation has brought about improvement?
I put that question to Dr. Edward Halperin, Chancellor for Health Affairs and CEO of New York Medical College. A noted medical historian, Halperin underscores that solutions to the problem of physician callousness are not data driven. He predicts that it may take 30 or 40 years to determine whether the kinder, gentler approach is making significant impact on didactic medicine. Halperin reminds us that we’re not talking about quantifiable or even measurable endpoints. He cautioned about a “hidden curriculum” in play, pointing out that most of us learn by modeling our behavior after our mentors. “If a first- or second-year med student is exposed to philosophy, ethics, and poetry but then collides with senior practitioners during the latter two years of training who mutter under their breath and are consistently curt with patients, then what have we accomplished?!”
The use of an electronic interface to gather raw data might, ironically, liberate physicians to explore deeper issues with their patients, says Dr. Clifford Hudis, chief of the Breast Cancer Medicine Service at Memorial Sloan-Kettering Cancer Center and professor at Cornell Medical College. ”The potential benefits of technology are incredible,” exclaims Hudis, also the incoming president of the American Society of Clinical Oncology. He proposes a thought-provoking possibility: “If we have the software to accurately extract objective information such as patient age, chief complaint and occupational history, then it stands to reason that the doctor is freed up to evaluate deeper issues, such as anxiety related to decision-making, that plague the patient.”
Some might critique Hudis by saying computers and gadgets will be off-putting to many patients. But even if that is true right now, every year more young patients (who are all comfortable with smartphones and the like) start to access the medical system and, let’s face it, older patients (less facile with the same gadgets) are dying. Therefore, data acquisition for physicians by virtual sources will likely be embraced.
Absent hard evidence, to what conclusions might common sense channel us? Is it inconsistent for a doctor to be both inherently altruistic toward patients and averse to personal injury law suits? And if Dr. Hudis is correct about the benefits of technology, how many new questions will emerge? Will the “warm and fuzzy” physician be able to ward off pressure from hospital administrators intent on filling any “found time” with more patient throughput?
To me, recommendations to pursue a decidedly kinder and gentler approach seem sensible. I realize, though, that the goal of “being there” is neither within my comfort zone nor easy for me to achieve. (Have you ever tried to sit with a distraught person for any length of time without speaking?) I am willing to believe, however, that there is value to joining my silence with the silence of my patients. Perhaps we can at least be “present,” together, as the deafening quiet gathers, like a storm.
This is part of a series titled “Endoscope: An insider’s look at medicine,” where Dr. Corn will reflect and critique overlooked, controversial aspects of the medical system. We welcome your comments at email@example.com.