In a piece several months ago in the Boston Globe, “Blurred Boundaries Between Doctor and Patient,” columnist and primary care internist Suzanne Koven writes movingly of her patient Emma, whom Koven befriended over the last 15 years of Emma’s life. “Emma and I met frequently to gossip, talk about books and politics, and trade stories about our lives,” she remarks. “She came to my house for dinner several times, and my husband and kids joined me at her 90th birthday party. When, at 92, Emma moved reluctantly into a nursing home, I brought her the bagels and lox she craved – rich, salty treats her doctor had long discouraged her from eating. Here’s the funny part: I was that doctor.”
Koven writes perceptively of her initial concern with doctor-patient boundaries (heightened, she admits, by her status as “a young female physician”), her ill-fated efforts to maintain her early ideal of professional detachment, and, as with Emma, her eventual understanding that the roles of physician and friend could be for the most part “mutually reinforcing.”
As a historian of medicine interested in the doctor-patient relationship, I reacted to Koven’s piece appreciatively but, as I confessed to her, sadly. For her initial concern with “blurred boundaries” and her realization after years of practice about the compatibility of friendship with primary medical care only underscore the fragmented and depersonalized world of contemporary medicine, primary care included. By this, I mean that the quality of intimacy that grows out of most doctoring has become so shallow that we are led to scrutinize doctor-patient “friendship” as a problematic (Is it good? Is it bad? Should there be limits to it?) and celebrate instances of such friendship as signal achievements. Psychoanalysts, be it noted, have been pondering these questions in their literature for decades, but they at least have the excuse of their method, which centrally implicates the analysis and resolution of transference with patients who tend to become inordinately dependent on them.
My father, William Stepansky, like many of the WWII generation, befriended his patients, but he befriended them as their doctor. That is, he understood his medicine to include human provisions of a loving and Hippocratic sort. Friendly two-way extramedical queries about his family, contact at community events, attendance at local weddings and other receptions – these were not boundary-testing land mines but aspects of community-embedded caregiving. But here’s the rub: My father befriended his patients as their doctor; his friendship was simply the caring dimension of his care-giving. What, after all, did he have in common with the vast majority of his patients? They were Protestants and Catholics, members of the Rotary and Kiwanis Clubs who attended the local churches and coached little league baseball and Pop Warner football. He was an intellectual East European Jew, a serious lifelong student of the violin whose leisure time was spent practicing, reading medical journals, and tending to his lawn.
And yet to his patients, he was always a special friend, though he himself would admit nothing special about it: his friendship was simply the human expression of his calling. He did not (to my knowledge) bring anyone bagels and lox or pay visits to chat about books or politics, but he provided treatment (including ongoing supportive psychotherapy) at no charge, accepted payment in kind, and visited patients in their homes when they became too elderly or infirm to come to the office. Other routine “friendly” gestures included charging for a single visit when a mother brought a brood of sick children to the office during the cold season. And when elderly patients became terminal, they did not have to ask – he simply began visiting them regularly in their homes to provide what comfort he could and to let them know they were on his mind.
When he announced his impending retirement to his patients in the fall of 1990, his farewell letter began “Dear Friend” and then expressed regret at “leaving many patients with whom I have shared significant life experience from which many long-term friendships have evolved.” “It has been a privilege to serve as your physician for these many years,” he concluded. “Your confidence and friendship have meant much to me.” When, in my research for The Last Family Doctor, I sifted through the bags of cards and letters that followed this announcement, I was struck by the number of patients who not only reciprocated my father’s sentiment but summoned the words to convey deep gratitude for the gift of their doctor’s friendship.
In our own era of fragmented multispecialty care, hemmed in by patient rights, defensive medicine, and concerns about boundary violations, it is far from easy for a physician to “friend” a patient as physician, to be and remain a physician-friend. Furthermore, physicians now wrestle with the ethical implications of “friending” in ways that are increasingly dissociated from a medical identity. Many choose to forego professional distance at the close of a work day. No less than the rest of us, physicians seek multicolored self states woven of myriad connective threads; no less than the rest of us, they are the Children of Facebook.
But there is a downside to this diffusion of connective energy. When, as a society, we construe the friendship of doctors as extramedical, when we pull it into the arena of depersonalized connecting fostered by social media, we risk marginalizing the deeper kind of friendship associated with the medical calling: the physician’s nurturing love of the patient. And we lose sight of the fact that, until the final two decades of the 19th century, when advances in cellular biology, experimental physiology, bacteriology, and pharmacology ushered in an era of specific remedies for specific ailments, most effective doctoring – excluding only a limited number of surgeries – amounted to little more than just such friendship, such comfortable and comforting “friending” of sick and suffering people.
And this takes us back to Suzanne Koven, who imputes the “austere façade” of her medical youth to those imposing 19th-century role models “whose oil portraits lined the walls of the hospital [MGH] in which I did my medical training.” Among the grim visages that stared down from on high was that of the illustrious James Jackson, Sr., who brought Jenner’s technique of smallpox inoculation to the shores of Boston in 1800, became Harvard’s second Hersey Professor of the Theory and Practice of Medicine in 1812, and was a driving force in the founding of MGH, which opened its doors in 1821. Koven cites a passage from the second of Jackson’s Letters to a Young Physician (1855) in which he urges his young colleague to “abstain from all levity” and “never exact attention to himself.”
But why should absence of levity and focal concern with the patient be tantamount to indifference, coolness, the withholding of physicianly friendship? Was Jackson really so forbidding a role model? Composing his Letters in the wake of the cholera epidemic of 1848, when “regular” remedies such as bleeding and purging proved futile and only heightened the suffering of thousands, Jackson cautioned modesty when it came to therapeutic pretensions. He abjured the use of drugs “as much as possible,” and added that “the true physician takes care of his patient without claiming to control the disease in all cases.” Indeed he sought to restore “cure” to its original Latin meaning, to curare, the sense in which “to cure meant to take care.” “The physician,” he instructed his protégé,
“may do very much for the welfare of the sick, more than others can do, although he does not, even in the major part of cases, undertake to control and overcome the disease by art. It was with these views that I never reported any patients cured at our hospital. Those who recovered their health before they left the house were reported as well, not implying that they were made so by the active treatment they had received there. But it was to be understood that all patients received in that house were to be cured, that is, taken care of” [Letters to a Young Physician, p. 16, Jackson’s emphasis].
And then he moved on to the narrowing of vision that safeguarded the physician’s caring values, his cura:
“You must not mistake me. We are not called upon to forget ourselves in our regard for others. We do not engage in practice merely from philanthropy. We are justified in looking for both profit and honor, if we give our best services to our patients; only we must not be thinking of these when at the bedside. There the welfare of the sick must occupy us entirely” [Letters to a Young Physician, pp. 22-23].
Koven sees the Hippocratic commitment that lies beneath Jackson’s stern glance and, with the benefit of hindsight, links it to her friendship with Emma. “As mutually affectionate as our friendship was,” she concludes, “her health and comfort were always its purpose.” Indeed. For my father and any number of caring generalists, friendship was prerequisite to clinical knowing and foundational to clinical caring. It was not extramural, not reserved for special patients, but a way of being with all patients. And this friendship for his patients, orbiting around a sensibility of cura and a wide range of procedural activities, was not a heavy thing, leaden with solemnity. It was musical. It danced.
In the early 60s, he returns from a nursing home where he has just visited a convalescing patient. I am his travelling companion during afternoon house calls, and I greet him on his return to the car. He looks at me and with a sly grin remarks that he has just added “medicinal scotch” to the regimen of this elderly gentlemen, who sorely missed his liquor and was certain a little imbibing would move his rehab right along. It was a warmly caring gesture worthy of Osler, that lover of humanity, student of the classics, and inveterate practical joker. And a generation before Osler, the elder Jackson would have smiled. Immediately after cautioning the young physician to “abstain from all levity,” he added: “He should, indeed, be cheerful, and, under proper circumstances, he may indulge in vivacity and in humor, if he has any. But all this should be done with reference to the actual state of feeling of the patient and of his friends.” Just so.
Copyright © 2012 by Paul E. Stepansky. All rights reserved.
Medicine, Health, and History 