Category Archives: Doctor-Patient Communication

Doctor, How Do You Rate?

Posted on May 15, 2015 | 2 comments

As if the challenges of “online professionalism” and Facebook “friending” don’t complicate doctor-patient relationships enough, there is the additional strain of online rating services, where patients rate their physicians along several service-related parameters and then, if they choose, append brief evaluative comments. The physician rating websites that first appeared in the late 1990s – HealthGrades.com, RateMDs.com, WebMD.com, Vitals.com, et al. – are another outgrowth of the patient rights movement of the 1970s. Indeed, taken together these sites are the apotheosis of the consumerist vision of healthcare: We are consumers, our doctors provide services, and we have every right to evaluate their performance in ways that matter to us and presumably to others “in the market” for medical services. And who is to say this is a bad thing? What is wrong with knowing that the wait time for one doctor is unacceptably long or that another spends most of an office visit making eye contact only with his laptop?

There is nothing at all wrong here, as long as we are content with a consumerist orientation toward health care. If doctors are merely the corporeal equivalents of home repair experts, then perusing their star gradings, reading their consumer feedback, and noting if they are “Recognized Doctors” are good things entirely. The problem arises for those patients who persist in viewing their physicians as something more than body-maintenance tradesmen. For them, the rating websites, no less than Facebook and Twitter, have a downside.

For doctors, of course, ratings and comments can be damaging because – excepting only the review/scheduling service ZocDoc^{^[1]} – they are not vetted. They encourage impulsiveness and verbal “acting out” on the part of individuals who may bear a grudge and may not even be patients of the doctor in question. Rare is the physician who cheerfully accepts rating websites because, “though virtually useless for meaningful evaluation of an individual physician,” they “make for refreshing reading” and, taken in the aggregate, may provide useful qualitative data on patients’ needs and preferences.^{^[2]} One wonders how many physicians have the time and inclination to read and ponder patient ratings “in the aggregate” while remaining unconcerned with their own location on the totem pole of patient appraisal.

But my concern here is not for the doctor but for patients in search of more than body work. For them, the rating websites have an insidious long-term consequence, and this has to do with their impact on doctors’ emotional availability to patients and willingness to make this availability the lynchpin of the special friendships associated with medical caring. Never mind that, according to one 2012 study, online ratings of physicians are generally very positive, with rating variations deriving largely from evaluations of punctuality and staff.^{^[3]} To the extent that doctors feel vulnerable – both professionally and financially – to the vagaries of patient feedback, they are forced to devalue that aspect of their professional identities that, in the pre-internet world, was integral to doctoring.

It is a matter, once more, of the caring aspect of care, which over time becomes embedded in meaningful human connections that resist decomposition into discrete units of bodily tune-up and repair, more or less conveniently rendered. This kind of personalized caring, with its procedurally driven, hands-on component, was integral to family medicine through the 1960s, and lives on among a dwindling minority of generalists, especially those who care for underserved, often rural, communities. But for the vast majority of physicians, including frontline primary care physicians, the rating sites have put them on the defensive and, in so doing, rendered mutual the consumerist orientation toward medical treatment (not care) that makes doctors plumbers of the body.

Some doctors who have felt the sting of negative feedback – whether “fake reviews” by fired employees, diatribes by angry patients denied medications they sought but didn’t need, or constructive comments on professional shortcomings – have gone on the offensive. Medical Justice, a member-based “medical identity management” firm launched in 2002, developed a contract to be signed by the patients of its client physicians. Via the contract, which came into use in 2007, patients assigned copyright to any subsequent online review of the physician to the physician being reviewed. In this manner, doctors who received less than flattering feedback could claim copyright infringement and have the offending patient review removed from the rating service. In exchange for the patient’s assignment of copyright, doctors agreed, by contract, not to share the patient’s medical data with marketers. Unsurprisingly, the contracts neglected to inform patients that by law doctors cannot share their confidential data with marketers without the patient’s prior authorization. The “privacy blackmail” contracts were jettisoned at the end of 2011, subsequent to a lawsuit and complaint filed with the Federal Trade Commission by the Center for Democracy and Technology.^{^[4]}

Copyright law is no longer being misused to suppress patients’ rights to evaluate doctors, but physicians and their advocates remain inventively proactive in coping with the prospect of negative ratings. Rather than absorbing body blows to their professional selves, and having learned that courts provide no redress, they have embraced the growing role of physician ratings in medical practice and begun soliciting patient feedback through their own websites. Patients may be contacted by staff and invited to provide positive feedback on one or more of the rating websites.^{^[5]} In a dramatic about face in 2012, Medical Justice began supplying client doctors with iPads to give to patients at the point of leaving the office. Patients are asked to write a review, and the firm makes sure that comments (presumably positive, possibly coerced) are posted on a review site. In the medical free market, there apparently is no defense like a good offense.^{^[6]}

Even when preemptive strategies for garnering positive feedback fall short, there are things to do. In “Responding to Negative Online Comments,” the featured article in a recent issue of MCMS [Montgomery County Medical Society] Physician, a risk management specialist takes physicians down the list. “Don’t panic,” he tells them, and don’t respond immediately or impulsively to negative feedback. “Not all negative comments are worthy of your time to respond,” he continues. “A response may start a chain reaction of negative slurs and comments, potentially leading to litigation.” Clearly false or inflammatory feedback warrants contact with the website administrator in the hope that the site’s content guidelines will effect removal of the offensive posting. But suing a reviewer, he cautions, is a problematic affair, and physicians contemplating such action shuld consult with their attorneys as soon as possible. And there is the otherwise proactive strategy given here as a postscript to negative feedback: “Follow up with positive information about your practice,” but never, he warns, resort to posting fake consumer reviews.^{^[7]}

What’s wrong with this picture? The physician rating websites provide the kind of transparency in health care long urged by consumer groups and the federal government, especially through the Centers for Medicare and Medicaid Services. Such transparency, it is held, will improve the quality and costs of care. But what is the nature of this transparency, and what exactly does it allow us to see? For the vast majority of doctors, those who receive a rating or two or none at all, we see very little. We do not see these men and women as human caregivers bound by professional ethics to reach out to other humans who come to them as needy “petitioners”[8] hopeful that the doctor’s care will restore their damaged humanity. Less grandiloquently, we do not see how willingly these men and women embrace – or fail to embrace – the relational matrix in which care and caregiving traditionally came together. The ratings provide only a black-and-white, two-dimensional x-ray, often tendentiously rendered, of the “bones” that frame a doctor’s activities: office appearance; wait times; staff friendliness; time spent with a particular patient; and the like. And the energy spent soliciting, monitoring, and worrying about patient ratings is energy that might otherwise be deployed caring for patients in conflict-free ways far removed from the commercial world of consumer feedback.

So here, finally, is the payoff: between the Scylla of eviscerated Facebook “friending” and the Charybdis of skeletal patient ratings, physicians, especially general physicians who provide continuing care, are increasingly pulled away from a relational model of caregiving, a trend that all the patient-centered training and empathy workshops in the world cannot reverse. The fact is that the vast majority of physicians today have less energy and/or inclination to give patients in search of something more than body maintenance what physicians have traditionally offered them: a special kind of friendship.

___________________________

[1] ZocDoc, founded in 2007, differs from other rating services. It requires registration by patients and physicians alike, and provides online scheduling of appointments along with physician reviews. But Zocdoc, unlike HealthGrades, et al., only allows reviews from patients who have actually seen a physician through Zocdoc. As such, it is a “closed loop” review system. See O. Kharraz, “Providers should think seriously about leveraging online reviews,” March 12, 2013 (http://www.thedoctorblog.com/providers-should-think-seriously-about-leveraging-online-/reviews/).

[2] S. Jain, “Googling ourselves – what physicians can learn from online rating sites,” N. Engl. J. Med., 362:6-7, 2010.

[3] G. Gao, et al., “A changing landscape of physician quality reporting: Analysis of patients’ online ratings of their physicians over a 5-year period,” J. Med. Internet Res., 14:e38, 2012.

[4] R. Reitman, “Medical justice: Stifling speech of patients with a touch of ‘privacy blackmail’,” May 4, 2011 (https://www.eff.org/deeplinks/2011/05/medical-justice-stifling-speech-patients-touch); E. Goldman, “Medical justice capitulates by ‘retiring’ its anti-patient review contracts,” December 1, 2011 (http://blog.ericgoldman.org/archives/2011/12/medical_justice.htm); R. Lieber, “The web Is awash in reviews, but not for doctors. Here’s why,” New York Times, March 9, 2012 (http://www.nytimes.com/2012/03/10/your-money/why-the-web-lacks-authoritative-reviews-of-doctors.html?_r=0&pagewanted=print).

[5] S. Reddy, “Doctors check online ratings from patients and make change,” Wall Street Journal, May 14, 2014. Cf. C. Ellimootil, et al., “Online reviews of 500 urologists, J. Urology, 189:2269-2273, 2013 and D. B. Bumpass & J. B. Samora, “Understanding online physician ratings,” AAOS Now [American Academy of Orthopedic Surgeons], September, 2013 (http://www.aaos.org/news/aaosnow/sep13/advocacy4.asp).

[6] Lieber, “Web awash in reviews,” op. cit.

[7] J. Hyatt, “Responding to negative online comments,” MCMS Physician (Official Publication of the Montgomery County Medical Society of Pennsylvania), Summer, 2014, 6-8.

[8] This is the language of the influential bioethicist Edmund Pellegrino, for example in Humanism and the Physician (Knoxville: University of Tennessee Press, 1979), 124, 146, 184, and passim.

Medicine, Health, and History | A Blog by Paul E. Stepansky, Ph.D.//

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Posted in Doctor-Patient Communication, Patient Rating Services

Tagged Facebook, HeathGrades, medical consumerism, RateMDs, WebMD, ZocDoc

Your Tool Touches Me

Posted on February 8, 2014 | Leave a comment

It is little known that René Laënnec, the Parisian physician who invented the stethoscope at the Necker Hospital in 1816, found it distasteful to place his ear to the patient’s chest. The distastefulness of “direct auscultation” was compounded by its impracticality in the hospital where, he observed, “it was scarcely to be suggested for most women patients, in some of whom the size of the breasts also posed a physical obstacle.”[1] The stethoscope, which permitted “mediate auscultation,” not only amplified heart and lung sounds in diagnostically transformative ways; it enabled Laënnec to avoid repugnant ear to chest contact.

Many women patients of Laënnec’s time and place did not see it that way. Accustomed to the warmly human pressure of ear on chest, they were uncomfortable when an elongated wooden cylinder was interposed between the two. By the closing decades of the nineteenth century, of course, the situation was inverted: The stethoscope, in its modern binaural guise, had become so integral to physical examination that patients hardly viewed it as a tool at all. It had become emblematic of hands-on doctoring and, as such, a sensory extender of the doctor. Even now, the stethoscope virtually stands in for the doctor, especially the generalist or the cardiologist, so that a retiring physician will announce that he is, or will be characterized by others as, hanging up his stethoscope.[2]

It’s easy to argue for the “oneness” of the physician and his or her instruments when it’s a matter of simple tools that amplify sensory endowment (stethoscopes), provide a hands-on bodily “reading” (of temperature or blood pressure), or elicit a tendon reflex (e.g., the reflex hammer). And the argument can be extended without much difficulty to the more invasive, high-tech “scopes” used by medical specialists to see what is invisible to the naked eye. Instruments become so wedded to one or another specialty that it is hard to think of our providers without them. What is an ophthalmologist without her ophthalmoscope? An ENT without his nasal speculum? A gynecologist without her vaginal speculum? An internist without his blood pressure meter? Such hand-held devices are diagnostic enablers, and as such they are, or at least ought to be, our friends.

In “Caring Technology” I suggested that even large-scale technology administered by technicians, and therefore outside the physician’s literal grasp, can be linked in meaningful ways to the physician’s person. A caring explanation of the need for this or that study, informed by a relational bond, can humanize even the most forbidding high-tech machinery. To be sure, medical machinery, whatever the discomfort and/or bodily bombardment it entails, is often discomfiting. But it need be alienating only when we come to it in an alienated state, when it is not an instrument of physicianly engagement but a dehumanized object – a piece of technology.

Critical care nurses, whose work is both technology-laden and technology-driven, have had much to say on the relationship of technology to nursing identity and nursing care. This literature includes provocative contributions that look at where nurses stand in a hospital hierarchy that comprises staff physicians, residents, students, administrators, patients, and patients’ families.

For some CCU nurses, the use of technology and the acquisition of technological competence segue into issues of power and autonomy and they, in turn, are linked to issues of gender, medical domination, and “ownership” of the technology.[3] A less feminist sensibility informs interview research that yields unsurprising empirical findings, viz., that comfort with technology and the ability to incorporate it into a caring, “touching” disposition hinge on the technological mastery associated with nursing experience. Student and novice nurses, for example, find the machinery of the CCU anxiety-inducing, even overwhelming. They resent the casual manner in which physicians relegate to them complex technological tasks, such as weaning patients from respirators, without appreciating the long list of nursing duties to which such tasks are appended.[4] Withal, beginners approach the use of technology in task-specific ways and have great difficulty “caring with technology.”[5] Theirs is not a caring technology but a technology that causes stress and jeopardizes fragile professional identities.

Experienced CCU nurses, on the other hand, achieve a technological competence that lets them pull the machinery to them; they use it as a window of opportunity for being with their patients.[6] Following Christine Little, we can give the transformation from novice to expert a phenomenological gloss and say that as technological inexperience gives way to technological mastery, technological skills become “ready-to-hand” (Heidegger) and “a natural extension of practice.”[7]

Well and good. We want critical care nurses comfortable with the machinery of critical care – with cardiac and vital signs monitors, respirators, catheters, and infusion pumps – so that implementing technological interventions and monitoring the monitors do not blot out the nurse’s “presence” in the patient’s care. But all this is from the perspective of the nurse and her role in the hospital. What, one wonders, does the patient make of all this technology?

Humanizing technology means identifying with it in ways that are not only responsive to the patient’s fears but also conducive to a shared appreciation of its role in treatment. It is easier for patients to feel humanly touched by technology, that is, if their doctors and nurses appropriate it and represent it as an extender of care. Perhaps some doctors and nurses do so as a matter of course, but one searches the literature in vain for examples of nurse-patient or doctor-patient interactions that humanize technology through dialogue. And such dialogue, however perfunctory in nature, may greatly matter.

Consider the seriously ill patient whose nurse interacts with him without consideration of the technology-saturated environment in which care is given. Now consider the seriously ill patient whose nurse incorporates the machinery into his or her caregiving identity, as in “This monitor [or this line or this pump] is a terrific thing for you and for me. It lets me take better care of you.” Such reassurance, which can be elaborated in any number of patient-centered ways, is not trivial; it may turn an anxious patient around, psychologically speaking. And it is all the more important when, owing to the gravity of the patient’s condition, the nurse must spend more time assessing data and tending to machinery than caring for the patient. Here especially the patient needs to be reminded that the nurse’s responsibility for machinery expands his or her role as the patient’s guardian.[8]

The touch of the physician’s sensory extenders, if literally uncomfortable, may still be comforting. For it is the physician’s own ears that hear us through the stethoscope and whose own eyes gaze on us through the ophthalmoscope, the laryngoscope, the esophagoscope, the colposcope. It is easier to appreciate tools as beneficent extenders of care in the safe confines of one’s own doctor’s office, where instrumental touching is fortified by the relational bond that grows out of continuing care. In the hospital, absent such relational grounding, there is more room for dissonance and hence more need for shared values and empathy. A nurse who lets the cardiac monitor pull her away from patient care will not do well with a frightened patient who needs personal caring. A parturient who welcomes the technology of the labor room will connect better with a labor nurse who values the electronic fetal monitor (and the reassuring visualization it provides the soon-to-be mother) than a nurse who is unhappy with its employment in low-risk births and prefers a return to intermittent auscultation.

In the best of circumstances, tools elicit an intersubjective convergence grounded in an expectation of objectively superior care. It helps to keep the “objective care” part in mind, to remember that technology was not devised to frighten us, encumber us, or cause us pain, but to help doctors and nurses evaluate us, keep us stable and comfortable, and enable treatments that will make us better, or at least leave us better off than our technology-free forebears.

My retinologist reclines the examination chair all the way back and begins prepping my left eye for its second intravitreal injection of Eylea, one of the newest drugs used to treat macular disease. I am grateful for all the technology that has brought me to this point: the retinal camera, the slit lamp, the optical coherence tomography machine. I am especially grateful for the development of fluorescein angiography, which allows my doctor to pinpoint with great precision the lesion in need of treatment. And of course I am grateful to my retinologist, who brings all this technology to bear with a human touch, calmly reassuring me through every step of evaluation and treatment.

I experienced almost immediate improvement after the first such injection a month earlier and am eager to proceed with the treatment. So I am relatively relaxed as he douses my eye with antiseptic and anesthetic washes in preparation for the needle. Then, at the point of injection, he asks me to look up at the face of his assistant, a young woman with a lovely smile. “My pleasure,” I quip, slipping into gendered mode. “I love to look at pretty faces.” I am barely aware of the momentary pressure of the needle that punctures my eyeball and releases this wonderfully effective new drug into the back of my eye. It is not the needle that administers treatment but my trusted and caring physician. “Great technique,” I remark. “I barely felt it.” To which his young assistant, still standing above me, smiles and adds, “I think I had something to do with it.” And indeed she had.

[1] Quoted in J. Duffin, To See with a Better Eye: A Life of R. T. H. Laennec (Princeton: Princeton University Press, 1998), p. 122.

[2] Here are a few recent examples: O. Samuel, “On hanging up my stethoscope,” BMJ, 312:1426, 1996; “Dr. Van Ausdal hangs up his stethoscope,” YSNews.com, September 26, 2013 (http://ysnews.com/news/2013/09/dr-van-ausdal-hangs-up-his-stethoscope); “At 90, Gardena doctor is hanging up his stethoscope,” The Daily Breeze, October, 29, 2013 (http://www.dailybreeze.com/general-news/20131029/at-90-gardena-doctor-is-hanging-up-his-stethoscope); “Well-known doctor hangs up his stethoscope,” Bay Post, February 8, 2014 (http://www.batemansbaypost.com.au/story/1849567/well-known-doctor-hangs-up-his-stethoscope)

[3] See, for example, A. Barnard, “A critical review of the belief that technology is a neutral object and nurses are its master,” J. Advanced Nurs., 26:126-131, 1997; J. Fairman & P. D’Antonio, “Virtual power: gendering the nurse-technology relationship,” Nurs. Inq., 6:178-186, 1999; & B. J. Hoerst & J. Fairman, “Social and professional influences of the technology of electronic fetal monitoring on obstetrical nursing,” Western J. Nurs. Res., 22:475-491, 2000, at pp. 481-82.

[4] C. Crocker & S. Timmons, “The role of technology in critical care nursing,” J. Advanced Nurs., 65:52-61, 2008.

[5] M. McGrath, “The challenges of caring in a technological environment: critical care nurses’ experiences,” J. Clin. Nurs., 17:1096-1104, 2008.

[6] A. Bernardo, “Technology and true presence in nursing,” Holistic Nurs. Prac., 12:40-49, 1998; R. C. Locsin, Technological Competency As Caring in Nursing: A Model For Practice (Indianapolis: Centre Nursing Press, 2005); McGrath, “The challenges of caring,” op. cit.

[7] C. V. Little, “Technological competence as a fundamental structure of learning in critical care nursing: a phenomenological study,” J. Clin. Nurs., 9:391-399, 2000, at pp. 398, 396.

[8] See E. A. McConnell, “The impact of machines on the work of critical care nurses,” Crit. Care Nurs. Q., 12:45-52, 1990, at p. 51; D. Pelletier , et al., “The impact of the technological care environment on the nursing role, Int. J. Tech. Assess. Health Care, 12:35 8-366, 1996.C

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Posted in Doctor-Patient Communication, Medical Instruments, Medical Technology, Old & New, Nursing, Nursing and Gender

Tagged cardiac monitor, catheter, Rene Laennec, respirator, retinology, stethoscope

The Times They Are a-Changin’: Trends in Medical Education

Posted on October 24, 2013 | Leave a comment

Medical educators certainly have their differences, but one still discerns an emerging consensus about the kind of changes that will improve healthcare delivery and simultaneously re-humanize physician-patient encounters. Here are a few of the most progressive trends in medical education, along with brief glosses that serve to recapitulate certain themes of previous postings.

Contemporary medical training stresses the importance of teamwork and militates against the traditional narcissistic investment in solo expertise. Teamwork, which relies on the contributions of nonphysician midlevel providers, works against the legacy of socialization that, for many generations, rendered physicians “unfit” for teamwork. The trend now is to re-vision training so that the physician becomes fit for a new kind of collaborative endeavor. It is teamwork, when all is said and done, that “transfers the bulk of our work from the realm of guesswork and conjecture to one in which certainty and exactitude may be at least approached.” Must group practice militate against personalized care? Perhaps not. Recently, medical groups large and small have been enjoined to remember that “a considerable proportion of the physician’s work is not the practice of medicine at all. It consists of counseling, orienting, extricating, encouraging, solacing, sympathizing, understanding.”

Contemporary medical training understands that the patient him- or herself has become, and by rights ought to be, a member of the healthcare team. Medical educators ceded long ago that patients, in their own best interests, “should know something about the human body.” Now we have more concrete expressions of this requirement, viz., that if more adequate teaching of anatomy and physiology were provided in secondary schools, “physicians will profit and patients will prosper.” “Just because a man is ill,” notes one educator, “is no reason why he should stop using his mind,” especially as he [i.e., the patient] is the important factor in the solution of his problem, not the doctor.” For many educators the knowledgeable patient is not only a member of the “team,” but the physician’s bonafide collaborator. They assume, that is, that physician and patient “will be able to work together intelligently.” Working together intelligently suggests a “frank cooperation” in which physician and patient alike have “free access to all outside sources of help and expert knowledge.” It also means recognizing, without prejudice or personal affront, that the patient’s “inalienable right is to consult as many physicians as he chooses.” Even today, an educator observes, “doctors have too much property interest in their patients,” despite the fact that patients find their pronouncements something less than, shall we say, “oracular.” Contemporary training inherits the mantle of the patient rights revolution of the 1970s and 80s. Educators today recognize that “It is the patient who must decide the validity of opinion from consideration of its source and probability.” Another speaks for many in reiterating that

It is the patient who must decide the validity of opinion from consideration of its source and probability. If the doctor’s opinion does not seem reasonable, or if the bias of it, due to temperament or personal and professional experience is obvious, then it is well for the patient to get another opinion, and the doctor has no right to be incensed or humiliated by such action.

Contemporary medical training stresses the importance of primary care values that are lineal descendants of old-style general practice. This trend grows out of the realization that a physician “can take care of a patient without caring for him,” that the man or woman publicly considered a “good doctor” is invariably the doctor who will “find something in a sick person that aroused his sympathy, excited his admiration, or moved his compassion.” Optimally, commentators suggest, multispecialty and subspecialty groups would retain their own patient-centered generalists – call them, perhaps, “therapeutists” — to provide integrative patient care beyond diagnostic problem-solving and even beyond the conventional treatment modalities of the group. The group-based therapeutist, while trained in the root specialty of his colleagues, would also have specialized knowledge of alternative treatments outside the specialty. He would, for example, supplement familiarity with mainstream drug therapies with a whole-patient, one might say a “wholesome” distrust of drugs.

Contemporary training finally recognizes the importance of first-hand experience of illness in inculcating the values that make for “good doctoring.” Indeed, innovative curricula now land medical students in the emergency rooms and clinics with (feigned) symptoms and histories that invite discomfiting and sometimes lengthy interventions. Why has it taken educators so long to enlarge the curriculum in this humanizing manner? If, as one educator notes, “It is too much to ask of a physician that he himself should have had an enigmatic illness,” it should still be a guiding heuristic that “any illness makes him a better doctor.” Another adds: “It is said that an ill doctor is a pathetic sight; but one who has been ill and has recovered has had an affective experience which he can utilize to the advantage of his patients.”

The affective side of a personal illness experience may entail first-hand experience of medicine’s dehumanizing “hidden curriculum.” Fortunate the patient whose physician has undergone his or her own medical odyssey, so that life experience vivifies the commonplace reported by one seriously ill provider: “ I felt I had not been treated like a human being.” A physician-writer who experienced obscure, long-term infectious illness early in his career and was shunted from consultant to consultant understands far better than healthy colleagues that physicians “are so prone to occupy themselves with the theoretical requirements of a case that they lose sight entirely of the human being and his life story.” Here is the painful reminiscence of another ill physician of more literary bent:

There had been no inquiry of plans or prospects, no solicitude for ambitious or desires, no interest in the spirit of the man whose engine was signaling for gas and oil. That day I determined never to sentence a person on sight, for life or to death.

Contemporary medical training increasingly recognizes that all medicine is, to one degree or another, psychiatric medicine. Clinical opinions, educators remind us, can be truthful but still contoured to the personality, especially the psychological needs, of the patient. Sad to say, the best clinical educators are those who know colleagues, whatever their specialty, who either “do not appreciate that constituent of personality which psychologists call the affects . . . and the importance of the role which these affects or emotions play in conditioning [the patient’s] destiny, well or ill, or they refuse to be taught by observation and experience.” This realization segues into the role of psychiatric training in medical education, certainly for physicians engaged in primary care, but really for all physicians. Among other things, such training “would teach him [or her] that disease cannot be standardized, that the individual must be considered first, then the disease.” Even among patients with typical illnesses, psychiatric training can help physicians understand idiosyncratic reactions to standard treatment protocols. It aids comprehension of the individual “who happens to have a very common disease in his own very personal manner.”

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These trends encapsulate the reflections and recommendations of progressive medical educators responsive to the public demand for more humane and humanizing physicians. The trends are also responsive to the mounting burnout of physicians – especially primary care physicians – who, in the cost-conscious, productivity-driven, and regulatory climate of our time, find it harder than ever to practice patient-centered medicine. But are these trends really so contemporary? I confess to a deception. The foregoing paraphrases, quotations, and recommendations are not from contemporary educators at all. They are culled from the popular essays of a single physician, the pioneer neurologist Joseph Collins, all of which were published in Harper’s Monthly between 1924 and 1929.[1]

Collins is a fascinating figure. An 1888 graduate of New York University Medical College, he attended medical school and began his practice burdened with serious, sometimes debilitating, pulmonary and abdominal symptoms that had him run the gauntlet of consultant diagnoses – pneumonia, pulmonary tuberculosis, “tuberculosis of the kidney,” chronic appendicitis, even brain tumor. None of these authoritative pronouncements was on the mark, but taken together they left Collins highly critical of his own profession and pushed him in the direction of holistic, collaborative, patient-centered medicine. After an extended period of general practice, he segued into the emerging specialty of neurology (then termed neuropsychiatry) and, with his colleagues Joseph Fraenkel and Pearce Bailey, founded the New York Neurological Institute in 1909. Collins’s career as a neurologist never dislodged his commitment to generalist patient-centered care. Indeed, the neurologist, as he understood the specialty in 1911, was the generalist best suited to treat chronic disease of any sort.[2]

Collin’s colorful, multifaceted career as a popular medical writer and literary critic is beyond the scope of this essay.[3] I use him here to circle back to a cardinal point of previous writings. “Patient-centered/relationship-centered care,” humanistic medicine, empathic caregiving, behavioral adjustments to the reality of patients’ rights – these additives to the medical school curriculum are as old as they are new. What is new is the relatively recent effort to cultivate such sensibilities through curricular innovations. Taken together, public health, preventive medicine, childhood vaccination, and modern antibiotic therapy have (mercifully) cut short the kind of experiential journey that for Collins secured the humanistic moorings of the biomedical imperative. Now medical educators rely on communication skills training, empathy-promoting protocols, core-skills workshops, and seminars on “The Healer’s Art” to close the circle, rescue medical students from evidence-based and protocol-driven overkill, and bring them back in line with Collins’s hard-won precepts.

It is not quite right to observe that these precepts apply equally to Collins’s time and our own. They give expression to the care-giving impulse, to the ancient injunction to cure through caring (the Latin curare) that, in all its ebb and flow, whether as figure or ground, weaves through the fabric of medical history writ large. Listen to Collins one final time as he expounds his philosophy of practice in 1926:

It would be a wise thing to devote a part of medical education to the mind of the physician himself, especially as it concerns his patients. For the glories of medical history are the humanized physicians. Science will always fall short; but compassion covereth all.[4]

[1] Joseph Collins, “The alienist in court,” Harper’s Monthly, 150:280-286, 1924; Joseph Collins, “A doctor looks at doctors,” Harper’s Monthly, 154:348-356, 1926; Joseph Collins, “Should doctors tell the truth?”, Harper’s Monthly, 155:320-326, 1927; Joseph Collins, “Group practice in medicine,” Harper’s Monthly, 158:165-173, 1928; Joseph Collins, “The patient’s dilemma,” Harper’s Monthly, 159:505-514, 1929. I have also consulted two of Collins’s popular collections that make many of the same points: Letters to a Neurologist, 2^nd series (NY: Wood, 1910) and The Way with the Nerves: Letters to a Neurologist on Various Modern Nervous Ailments, Real and Fancied, with Replies Thereto Telling of their Nature and Treatment (NY: Putnam, 1911).

[2] Collins, The Way with Nerves, p. 268.

[3] Collins’s review of James Joyce’s Ulysses, the first by an American, was published in The New York Times on May 28, 1922. His volume The Doctor Looks at Literature: Psychological Studies of Life and Literature (NY: Doran, 1923) appeared the following year.

[4] Collins, “A doctor looks at doctors,” p. 356. Collins’s injunction is exemplified in “The Healer’s Art,” a course developed by Dr. Rachel Naomi Remen over the past 22 years and currently taught annually in 71 American medical colleges as well as medical colleges in seven other countries. See David Bornstein, “Medicine’s Search for Meaning,” posted for The New York Times/Opinionator on September 18, 2013 (http://opinionator.blogs.nytimes.com/2013/09/18/medicines-search-for-meaning/?_r=0).

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Posted in Doctor-Patient Communication, General, Medical Education, Psychiatry in Medicine

Tagged doctor patient relationship, Joseph Collins, medical history, neurology, patient-centered medicine

Exit the Family Doctor

Posted on June 13, 2013 | Leave a comment

WHERE’S the good old family doctor, with

his microscopic bills,

With his bag of plasters, powders, and those

evil-tasting pills?

How our troubles used to lighten and our

aches and pains abate,

When his shabby horse and buggy tied up

at the old front gate!

________

Now it’s Doctor This for measles and it’s

Doctor That for mumps,

And it’s Doctor What-You-Call-Him when

it’s just a case of dumps;

If it’s only common colic, just as plain as

plain can be,

To a hospital you’re hustled for some

surgicality.

________

Comes the twentieth century doctor in a

spotless limousine,

Sealed hermetically in it — clothed “germproof”

to microbes keen.

Or, more truly, this great doctor will not

come at all to you —

In an office he’s receiving—”Office hours

from one to two.”

________

And it’s Doctor This for left eye and it’s

Doctor That for right,

And it’s Doctor What-You-Call-Him if

you’re crosswise in your sight;

When you need some fancy glasses just

to see more than you ought,

To Berlin you’re shipped instanter to that

famous Doctor Whaught.

________

He can amputate bad tempers, he can

make good folks of bad,

He’ll immune you from diseases that you

never could have had.

Yes, time’s come when it’s expected, just

to keep you ” middling fair,”

You must know the specialistic docs of

all the kinds there are.

________

Oh, it’s Doctor This for ” eetises” and

Doctor That for ” ites,”

And it’s Doctor What-You-Call-Him when

you’re seeing things o’nights.

Each will treat one ” error ” only,

will these modern unionists,

Then divide your woes with twenty other

waiting specialists.

— The Washington Post, February 17, 1910, p. 6.

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Posted in Doctor-Patient Communication, Family Doctors, Then & Now, General Practice

Naming the Pain

Posted on August 29, 2012 | 1 comment

I always begin my “Medicine and Society” seminar by asking the students to identify as many of the following terms as they can and then to tell me what they have in common: nostalgie; railway spine; soldier’s heart (aka effort syndrome or Da Costa’s syndrome); puerperal insanity; neurasthenia; hyperkinetic syndrome; irritable bowel syndrome; ADHD; chronic fatigue syndrome; and fibromyalgia.

The answer, of course, is that they are not diseases at all but broadly descriptive syndromes based on self-reports. In each and every case, physicians listen to what patients (or, in the case of children, parents or teachers) tell them, and then give a diseaselike name to a cluster of symptoms for which there is no apparent biomedical explanation.

The fact that such conditions have existed throughout history and the appreciable symptomatic overlap among them surprise some students but not others. I like to point out especially the virtual mapping of neurasthenia, a syndrome “identified” by the pioneer American neurologist George Beard in 1869, on to contemporary notions of chronic fatigue syndrome and fibromyalgia. For Beard the symptoms of neurasthenia include mental and physical fatigue, insomnia, headache, general muscular achiness, irritability, and inability to concentrate. What have we here if not the symptoms of chronic fatigue syndrome and fibromyalgia, with the only difference, really, residing in the biomedically elusive cause of the symptoms. Whereas neurasthenia was attributed by Beard and other nineteenth-century neurologists to nervous weakness, i.e., “debility of the nerves,” the contemporary variants are ascribed to a heretofore undetected low-grade virus.

The same mapping chain applies to stomach and digestive discomfort. Long before the arrival of “irritable bowel syndrome,” for which there has never been a basis for differential diagnosis, there were terms like enteralgia, adult colic, and that wonderfully versatile eighteenth- and nineteenth-century medical-cum-literary condition, dyspepsia. Before children were “diagnosed” with ADHD, they were given the diagnosis ADD (attention deficit disorder) or MBD (minimal brain dysfunction), and before that, beginning in the early 1960s, the same kids were diagnosed with hyperactivity (hyperkinetic syndrome). Military medicine has its own chronology of syndromal particulars. Major building blocks that lead to our understanding of combat-related stress and its sequelae include PTSD, during America’s war in Vietnam; combat fatigue and war neurosis during WWII; shell shock and “soldier’s heart” during WWI; and nostalgie during the Napoleonic Wars and American Civil War.

The functionality of neurasthenia and its modern descendants is that they are symptomatically all-inclusive but infinitely plastic in individual expression. It is still a blast to read Beard’s dizzying catalog of the symptoms of neurasthenia in the preface to Modern American Nervousness (1881). Here is a small sampling:

Insomnia; flushing; drowsiness; bad dreams; cerebral irritation; dilated pupils; pain, pressure, and heaviness in the head; changes in the expression of the eye; asthenopia [eye strain]; noises in the ears; atonic voice; mental irritability; tenderness of the teeth and gums; abnormal dryness of the skin, joints, and mucous membranes; sweating hands and feet with redness; cold hands and feet; pain in the feet; local spasms of muscles; difficulty swallowing; convulsive movements; cramps; a feeling of profound exhaustion; fear of lightning; fear of responsibility; fear of open places or closed places; fear of society; fear of being alone; fear of fears; fear of contamination; fear of everything.[1]

This same model, if less extravagant in reach, pertains to chronic fatigue syndrome and fibromyalgia. Any number of symptoms point to these conditions, but no single clustering of symptoms is essential to the diagnosis or able to rule it out. In the world of global syndromes, the presence and absence of specific symptoms serve equally well as diagnostic markers.[2]

As many historians have pointed out, the development and marketing of new drugs plays a significant role in the labeling (and hence medicalizing) of these syndromes. From time immemorial, young children, especially boys, have had a hard time sitting still in school and focusing on the task before them. But it was only with the release of Ritalin (methylphenidate) in the early 1960s that these time-honored developmental lags (or were they simply developmental realities?) were gathered into the diagnosis “hyperkinetic syndrome.”

Psychiatry has been especially willing to accommodate the drug-related charge to syndromize new variants of existing syndromes. “Panic disorder” became a syndrome only after Upjohn released a new benzodiazepine, alprazolam, for which it sought a market within the broad universe of anxiety sufferers. Conveniently, the release of the drug in 1980 coincided with the release of the 3^rd edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM), which obligingly found a place for “panic disorder” (and hence alprazolam) in its revised nosology. DSM-III was no less kind to Pfizer; it helped the manufacturer find a market for its newly released MAOI antidepressant, phenelzine, by adding “social phobia” to the nomenclature.[3]

Critics write about the creeping medicalization of virtually every kind of discomfort, dis-ease, despondency, dysfunction, and dysphoria known to humankind.[4] As a society, we are well beyond medicalizing the aches and pains that accompany everyday life. We are at the point of medicalizing life itself, especially the milestones that punctuate the human life cycle. This is the viewpoint especially of French social scientists influenced by Foucault, who seem to think that the “medicalization” of conception (via, for example, embryo freezing) or the “pharmacologization” of menopause via hormone therapy takes us to the brink of a new de-naturalizing control of biological time.[5]

I demur. What we see in medicalization is less the “pathologization of existence”[6] than a variably successful effort to adapt to pain and malaise so that life can be lived. The adaptation resides in the bi-level organizing activity that fuels and sustains the labeling process. It is comforting to group together disparate symptom clusters into reified entities such as neurasthenia or chronic fatigue syndrome or fibromyalgia. It is also comforting, even inspiriting, to associate with fellow sufferers, even if their fibromyalgia manifests itself quite differently than yours. All can organize into support groups and internet self-help communities and fight for recognition from organized medicine and society at large. These people do something about their pain. And they often feel better, even if they still hurt all over. If nothing else, they have accessed a collective illness identity that mitigates self-doubts and alienation.[7]

But there may be other ways of adapting to chronic pain amplified, all too often, by chronic misery that veers into psychiatric co-morbidity. The problem with adapting to nonspecific suffering by labeling, medicalization, support groups, self-help literature, and the like is the pull to go beyond living with pain to living through the illness identity constructed around the pain. For some there are other possibilities. There is psychotherapy to address the misery, which may or may not prove helpful. There is the stoic resolve, more typical of the nineteenth century, to live with pain without collapsing one’s identity into the pain and waiting for the rest of the world to acknowledge it.[8] There is the pursuit of symptomatic relief unburdened by illness identity and the existential angst that accompanies it. And there is a fourth way that leads back to my father’s medicine.

In the post-WWII era, there were no support groups or self-help literature or internet communities to validate diffuse syndromal suffering. But there were devoted family physicians, many of whom, like William Stepansky, were psychiatrically oriented and had the benefit of postgraduate psychiatric training. A caring physician can validate and “hold” a patient’s pain without assigning the pain a label and trusting the label to mobilize the patient’s capacity to self-soothe. He or she can say medically knowledgeable things about the pain (and its palliation) without “medicalizing” it in the biomedically reductive, remedy-driven sense of our own time.

Primary care physicians who listen to their patients long enough to know them and value them become partners in suffering. They suffer with their patients not in the sense of feeling their pain but in the deeper sense of validating their suffering, both physical and mental, by situating it within a realm of medical understanding that transcends discrete medical interventions.

Am I suggesting that fibromyalgia sufferers would be better off if they had primary care physicians who, like my father, had the time and inclination to listen to them in the manner of attuned psychotherapists? You bet I am. The caring associated with my father’s medicine, as I have written, relied on the use of what psychoanalysts term “positive transference,” but absent the analytic goal of “resolving” the transference (i.e., of analyzing it away) over time.[9] Treating patients with chronic pain – whether or not syndromal – means allowing them continuing use of the physician in those ways in which they need to use him.

A parental or idealizing transference, once established, does two things. It intensifies whatever strategies of pain management the physician chooses to pursue, and it provides the physician with relational leverage for exploring the situational and psychological factors that amplify the pain. Of course, the general physician’s willingness to be used thusly is a tall order, especially in this day and age. It signifies a commitment to holistic care-giving over time, so that issues of patienthood morph into issues of suffering personhood. My father’s psychological medicine – of which contemporary notions of patient- and relationship-centered care are pale facsimiles — could not eliminate the pain of his syndromal sufferers. But it provided them with a kind of support (and, yes, relief) that few contemporary sufferers will ever know.

[1] G. M. Beard, American Nervousness, Its Causes and Consequences (NY: Putnam, 1881), pp. viii-ix.

[2] K. Barker, “Self-help literature and the making of an illness identity: the case of fibromyalgia syndrome (FMS),” Social Problems, 49:279-300, 2002.

[3] D. Healy, The Anti-Depressant Era (Cambridge: Harvard University Press, 1997), pp. 187-189.

[4] E.g., Peter Conrad, The Medicalization of Society: On the Transformation of Human Conditions into Treatable Disorders (Baltimore: Johns Hopkins, 2007).

[5] A. J. Suissa, “Addiction to cosmetic surgery: representations and medicalization of the body,” Int. J. Ment. Health Addiction, 6:619-630, 2008, at p. 620.

[6] R. Gori & M. J. Volgo, La Santé Totalitaire: Essai sur la Medicalization de l’Existence (Paris: Denoël, 2005).

[7] Barker, “Self-help literature and the making of an illness identity,” op. cit.

[8] There are some powerful examples of such adaptation to pain in S. Weir Mitchell’s Doctor and Patient, 2^nd edition (Phila: Lippincott, 1888), pp. 83-100.

[9] P. E. Stepansky, The Last Family Doctor: Remembering My Father’s Medicine (Keynote, 2011), p. 86. More than a half century ago, the American psychoanalyst Leo Stone wrote of “the unique transference valence of the physician.” Patients formed transference bonds with their analysts partly because the latter, as physicians, were beneficiaries of “the original structure of the patient-doctor relationship.” Small wonder that Stone deemed the physician’s role “the underlying definite and persistent identity which is optimum for the analyst.” L. Stone, The Psychoanalytic Situation: An Examination of Its Development and Essential Nature (NY: International Universities Press, 1961), pp. 17, 15, 41.

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Posted in Doctor-Patient Communication, Family Doctors, Then & Now, Medicalization

Tagged ADD, ADHD, chronic fatigue syndrome, doctor patient relationship, fibromyalgia, George Beard, hyperactivity, neurasthenia, S. Weir Mitchell, William Stepansky

Pathways to Empathy?

Posted on May 18, 2012 | 2 comments

Dipping into the vast[1] literature on clinical empathy, one quickly discerns the dominant storyline. Everyone agrees that empathy, while hard to define, hovers around a kind of physicianly caring that incorporates emotional connection with patients. The connection conveys sensitivity to the patient’s life circumstances and personal psychology, and gains expression in the physician’s ability to encourage the patient to express emotion, especially as it pertains to his medical condition. Then the physician draws on her own experience of similar emotions in communicating an “accurate” empathic understanding of how the patient feels and why he should feel that way.

Almost all commentators agree that empathy, whatever it is, is a good thing indeed. They cite empirical research linking it to more efficient and effective care, to patients who are more trusting of their doctors, more compliant in following instructions, and more satisfied with the outcome of treatment. Patients want doctors who give them not only the appointment time but the time of day, and when they feel better understood, they simply feel better. Furthermore, doctors who are empathic doctor better. They learn more about their patients and, as a result, are better able to fulfill core medical tasks such as history-taking, diagnosis, and treatment. Given this medley of benefits, commentators can’t help but lament the well-documented decline of empathy, viz., of humanistic, patient-centered care-giving, among medical students and residents, and to proffer new strategies for reviving it. So they present readers with a host of training exercises, coding schemes, and curricular innovations to help medical students retain the empathy with which they began their medical studies, and also to help overworked, often jaded, residents refind the ability to empathize that has succumbed to medical school and the dehumanizing rigors of specialty training.[2]

It is at this point that empathy narratives fork off in different directions. Empathy researchers typically opt for a cognitive-behavioral approach to teaching empathy, arguing that if medical educators cannot teach students and residents to feel with their patients, they can at least train them to discern what their patients feel, to encourage the expression of these feelings, and then to respond in ways that affirm and legitimize the feelings. This interactional approach leads to the creation of various models, step-wise approaches, rating scales, language games (per Wittgenstein), and coding systems, all aimed at cultivating a cognitive skill set that, from the patient’s perspective, gives the impression of a caring and emotionally attuned provider. Duly trained in the art of eliciting and affirming emotions, the physician becomes capable of what one theorist terms “skilled interpersonal performances” with patients. Seen thusly, empathic connection becomes a “clinical procedure” that takes the patient’s improved psychobiological functioning as its outcome.[3]

The cognitive-behavioral approach is an exercise in what researchers term “communication skills training.” It typically parses doctor-patient communication into micro-interactions that can be identified and coded as “empathic opportunities.” Teaching students and residents the art of “accurate empathy” amounts to alerting them to these opportunities and showing how their responses (or nonresponses) either exploit or miss them. One research team, in a fit of linguistic inventiveness, tagged the physician’s failure to invite the patient to elaborate an emotional state (often followed by a physician-initiated change of subject), an “empathic opportunity terminator.” Learning to pick up on subtle, often nonverbal, clues of underlying feeling states and gently prodding patients to own up to emotions is integral to the process. Thus, when patients don’t actually express emotion but instead provide a clue that may point to an emotion, the physician’s failure to travel down the yellow brick road of masked emotion becomes, more creatively still, a “potential empathic opportunity terminator.” Whether protocol-driven questioning about feeling states leads patients to feel truly understood or simply the object of artificial, even artifactual, behaviors has yet to be systematically addressed. Medical researchers ignore the fact that empathy, however “accurate,” is not effective unless it is perceived as such by patients.[4]

Medical educators of a humanistic bent take a different fork in the road to empathic care giving. Shying away from protocols, models, scales, and coding schemes, they embrace a more holistic vision of empathy as growing out of medical training leavened by character-broadening exposure to the humanities. The foremost early proponent of this viewpoint was Howard Spiro, whose article of 1992, “What is Empathy and Can It Be Taught?” set the tone and tenor for an emerging literature on the role of the humanities in medical training. William Zinn echoed his message a year later: “The humanities deserve to be a part of medical education because they not only provide ethical guidance and improve cognitive skills, but also enrich life experiences in the otherwise cloistered environment of medical school.” The epitome of this viewpoint, also published in 1993, was the volume edited by Spiro and his colleagues, Empathy and the Practice of Medicine. Over the past 15 years, writers in this tradition have added to the list of nonmedical activities conducive to clinical empathy. According to Halpern, they include “meditation, sharing stories with colleagues, writing about doctoring, reading books, and watching films conveying emotional complexity.” Shapiro and her colleagues single out courses in medicine and literature, attendance at theatrical performances, and assignments in “reflective writing” as specific empathy-enhancers.[5]

Spiro practiced and taught gastroenterology in New Haven, home of Yale University School of Medicine and the prestigious Western New England Psychoanalytic Institute. One quickly discerns the psychoanalytic influence on his approach. The humanistic grounding he sought for students and residents partakes of this influence, whether in the kind of literature he wanted students to read (i.e., “the new genus of pathography”) or in his approach to history taking (“The clues that make the physician aware at the first meeting that a patient is depressed require free-floating attention, as psychoanalysts call it.”).

A variant of the “humanist” approach accepts the cognitivist assumption that empathy is a teachable skill but veers away from communications theory and cognitive psychology to delineate it. Instead, it looks to the world of psychotherapy, especially the psychoanalytic self psychology of Heinz Kohut. These articles, most of which were published in the 90s, are replete with psychoanalytic conceptualizations and phraseology; they occasionally reference Kohut himself but more frequently cite work by psychoanalytic self psychologists Michael Basch and Dan Buie, the psychiatrist Leston Havens, and the psychiatrist-anthropologist Arthur Kleinman.

Authors following a psychoanalytic path to empathy assign specific tasks to students, residents, and clinicians, but the tasks are more typically associated with the opening phase of long-term psychotherapy. Clinicians are enjoined to begin in a patiently receptive mode, avoiding the “pitfalls of premature empathy” and realizing that patients “seldom verbalize their emotions directly and spontaneously,” instead offering up clues that must be probed and unraveled. Empathic receptiveness helps render more understandable and tolerable “the motivation behind patient behavior that would otherwise seem alien or inappropriate.” Through “self-monitoring and self-analyzing,” the empathic clinician learns to rule out endogenous causes for heightened emotional states and can “begin to understand its source in the patient.” In difficult confrontations with angry or upset patients, physicians, no less than psychoanalysts, must cultivate “an ongoing practice of engaged curiosity” that includes systematic self-reflection. Like analysts, that is, they must learn to analyze the countertransference for clues about their patients’ feelings.[6]

There is a mildly overwrought quality to the medical appropriation of psychoanalysis, as if an analytic sensibility per se – absent lengthy analytic training – can be superadded to the mindset of task-oriented, often harried, clinicians and thereupon imbue them with heightened “empathic accuracy.” Given the tensions among the gently analytic vision of empathic care, the claims of patient autonomy, and the managerial, data-oriented, and evidence-based structure of contemporary practice, one welcomes as a breath of fresh air the recent demurrer of Anna Smajdor and her colleagues. Patients, they suggest, really don’t want empathic doctors who enter their worlds and feel their pain, only doctors who communicate clearly and treat them with courtesy and a modicum of respect.[7]

And so the empathy narratives move on. Over the past decade, neuroscientists have invoked empathy as an example of what they term “interpersonal neurobiology,” i.e., a neurobiological response to social interaction that activates specific neural networks, probably those involving the mirror neuronal system. It may be that empathy derives from an “embodied simulation mechanism” that is neurally grounded and operates outside of consciousness.[8] In all, this growing body of research may alter the framework within which empathy training exercises are understood. Rather than pressing forward, however, I want to pause and look backward. Long before the term “empathy” was used, much less operationalized for educational purposes, there were deeply caring, patient-centered physicians. Was there anything in their training that pushed them in the direction of empathic caregiving? I propose that nineteenth-century medicine had its own pathway to empathy, and I will turn to it in the next posting.

[1] R. Pedersen’s review article, “Empirical research on empathy in medicine – a critical review,” Pat. Educ Counseling, 76:307-322, 2009 covers 237 research articles.

[2] F. W. Platt & V. F. Keller, “Empathic communication: a teachable and learnable skill,” J. Gen Int. Med., 9:222-226, 1994; A. L. Suchmann, et al., “A model of empathic communication in the medical interview,” JAMA, 277:678-682, 1997; J. L. Coulehan, et al., “’Let me see if I have this right . . .’: words that help build empathy,” Ann. Intern. Med., 136:221-227, 2001; H. M. Adler, “Toward a biopsychosocial understanding of the patient-physician relationship: an emerging dialogue,” J. Gen. Intern. Med., 22:280-285, 2007; M. Neumann et al., “Analyzing the ‘nature’ and ‘specific effectiveness’ of clinical empathy: a theoretical overview and contribution towards a theory-based research agenda,” Pat. Educ. Counseling, 74:339-346, 2009; K. Treadway & N. Chatterjee, “Into the water – the clinical clerkships,” NEJM, 364:1190-1193, 2011.

[3] Adler, “Biopsychosocial understanding,” p. 282.

[4] Suchmann, et al., “Model of empathic communication”; Neumann, “Analyzing ‘nature’ and ‘specific effectiveness’,” 343; K. A. Stepien & A. Baernstein, “Educating for empathy: a review,” J. Gen. Int. Med., 21:524-530, 2006; R. W. Squier, “A Model of empathic understanding and adherence to treatment regimens in practitioner-patient relationships,” Soc. Sci. Med., 30:325-339, 1990.

[5] H. Spiro, “What is empathy and can it be taught?”, Ann. Int. Med., 116:843-846, 1992; W. Zinn, “The empathic physician,” Arch. Int. Med., 153:306-312, 1993; H. Spiro, et al., Empathy and the Practice of Medicine (New Haven: Yale University Press, 1993); J. Shapiro & L. Hunt, “All the world’s a stage: the use of theatrical performance in medical education,” Med. Educ., 37:922-927, 2003; J. Shapiro, et al., “Teaching empathy to first year medical students: evaluation of an elective literature and medicine course,” Educ. Health, 17:73-84, 2004; S. DasGupta & R. Charon, “Personal illness narratives: using reflective writing to teach empathy,” Acad. Med., 79:351-356, 2004; J. Shapiro, et al., “Words and wards: a model of reflective writing and its uses in medical education,” J. Med. Humanities, 27:231-244, 2006; J. Halpern, Empathy and patient-physician conflicts,” J. Gen. Int. Med., 22:696-700, 2007.

[6] Suchmann et al., “Model of empathic communication,” 681; Zinn, “Empathic physician,” 308; Halpern, “Empathy and conflicts,” 697.

[7] Halpern, “Empathy and conflicts,” 697; A. Smajdor, et al., “The limits of empathy: problems in medical education and practice,” J. Med. Ethics., 37:380-383, 2011.

[8] V. Gallese, “The roots of empathy: the shared manifold hypothesis and the neural basis of intersubjectivity,” Psychopathology, 36:171-180, 2003; L. Carr, et al., “Neural mechanisms of empathy in humans: a relay from neural systems for imitation to limbic area,” Proc. Natl. Acad. Sci., 100:5497-5502, 2003; G. Rizzolatti & L. Craighero, “The mirror-neuron system,” Ann. Rev. Neurosci., 27:169-192, 2004; V. Gallese, et al., “Intentional attunement: mirror neurons and the neural underpinnings of interpersonal relations,” J. Amer. Psychoanal. Assn., 55:131-176, 2007.

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Posted in Doctor-Patient Communication, Empathy, Medical Education, Psychoanalysis

Tagged Heinz Kohut, Howard Spiro, patient-centered medicine, self psychology

Empathy, Psychotherapy, Medicine

Posted on March 27, 2012 | 1 comment

What passes for psychoanalysis in America these days is a far cry from the psychoanalysis Freud devised in the early years of the last century. A sea change began in the 1970s, when Heinz Kohut, a Vienna-born and Chicago-based psychoanalyst, developed what he termed “psychoanalytic self psychology.” At the core of Kohut’s theorizing was the replacement of one kind of psychoanalytic method with another. Freud’s method – which Freud himself employed imperfectly at best – revolved around the coolly self-possessed analyst, who, with surgeon-like detachment, processed the patient’s free associations with “evenly hovering attention” and offered back pearls of interpretive wisdom. The analyst’s neutrality – his unwillingness to become a “real” person who related to the patient in conventionally sympathetic and supportive ways – rendered him a “blank screen” that elicited the same feelings of love and desire – and also of fear, envy, resentment, and hatred – as the mother and father of the patient’s early life. These feelings clustered into what Freud termed the positive and negative transferences.

Kohut, however, found this traditional psychoanalytic method fraught with peril for patients burdened less with Freudian-type neurotic conflicts than with psychological deficits of a preoedipal nature. These deficits gained expression in more primitive types of psychopathology, especially in what he famously termed “narcissistic personality disorder.” For these patients – and eventually, in Kohut’s mind, for all patients – the detached, emotionally unresponsive analyst simply compounded the feelings of rejection and lack of self-worth that brought the patient to treatment. He proffered in its place a kinder, gentler psychoanalytic method in which the analyst was content to listen to the patient for extended periods of time, to affirm and mirror back what the patient was saying and feeling, and over time to forge an empathic bond from which interpretations would arise.

Following Kohut, empathy has been widely construed as an aspect, or at least a precondition, of talking therapy. For self psychologists and others who draw on Kohut’s insights, the ability to sympathize with the patient has given way to a higher-order ability to feel what the patient is feeling, to “feel with” the patient from the inside out. And this process of empathic immersion, in turn, permits the therapist to “observe” the patient’s psychological interior and to comprehend the patient’s “complex mental states.” For Kohut, the core of psychoanalysis, indeed of depth-psychology in general, was employment of this “empathic mode of observation,” an evocative but semantically questionable turn of phrase, given the visual referent of “observe,” which comes from the Latin observare (to watch over, to guard). More counterintuitively still, he sought to cloak the empathic listening posture in scientific objectivism. His writings refer over and over to the “data” that analysts acquire through their deployment of “scientific” empathy, i.e., through their empathic listening instrument.

I was Heinz Kohut’s personal editor from 1978 until his death in the fall of 1981. Shortly after his death, I was given a dictated transcript from which I prepared his final book, How Does Analysis Cure?, for posthumous publication. Throughout the 80s and into the 90s, I served as editor to many senior self psychologists, helping them frame their arguments about empathy and psychoanalytic method and write their papers and books. I grasped then, as I do now, the heuristic value of a stress on therapeutic empathy as a counterpoise to traditional notions of analytic neutrality, which gained expression, especially in the decades following World War II, in popular stereotypes of the tranquilly “analytic” analyst whose caring instincts were no match for his or her devotion to Freud’s rigid method.

The comparative perspective tempers bemusement at what would otherwise be a colossal conceit: that psychoanalytic psychotherapists alone, by virtue of their training and work, acquire the ability to empathize with their patients. I have yet to read an article or book that persuaded me that empathy can be taught, or that the yield of therapeutic empathy is the apprehension of “complex psychological states” that are analogous to the “data” gathered and analyzed by bench scientists (Kohut’s own analogy).

I do believe that empathy can be cultivated, but only in those who are adequately empathic to begin with. In medical, psychiatric, and psychotherapy training, one can present students with instances of patients clinically misunderstood and then suggest how one might have understood them better, i.e., more empathically. Being exhorted by teachers to bracket one’s personal biases and predispositions in order to “hear” the patient with less adulterated ears is no doubt a good thing. But it assumes trainees can develop a psychological sensibility through force of injunction, which runs something like: “Stop listening through the filter of your personal biases and theoretical preconceptions! Listen to what the patient herself is saying in her voice! Utilize what you understand of yourself, viz., the hard-won fruits of your own psychotherapy (or training analysis), to put yourself in her place! Make trial identifications so that her story and her predicament resonate with aspects of your story and your predicament; this will help you feel your way into her inner world.”

At a less hortatory level, one can provide trainees with teachers and supervisors who are sensitive, receptive listeners themselves and thus “skilled” at what self psychologists like to refer to as “empathic attunement.” When students listen to such instructors and perhaps observe them working with patients, they may learn to appreciate the importance of empathic listening and then, in their own work, reflect more ongoingly on what their patients are saying and on how they are hearing them say it. They acquire the ability for “reflection-in-action,” which Donald Schön, in two underappreciated books of the 1980s, made central to the work of “reflective professionals” in a number of fields, psychotherapy among them.[1] To a certain extent, systematic reflection in the service of empathy may help therapists be more empathic in general.

But then the same may be said of any person who undergoes a transformative life experience (even, say, a successful therapy) in which he learns to understand differently – and less tendentiously – parents, siblings, spouses, children, friends, colleagues, and the like. Life-changing events — fighting in wars, losing loved ones, being victimized by natural disasters, living in third-world countries, providing aid to trauma victims – cause some people to recalibrate values and priorities and adopt new goals. Such decentering can mobilize an empathic sensibility, so that individuals return to their everyday worlds with less self-centered ways of perceiving and being with others.

There is nothing privileged about psychotherapy training in acquiring an empathic sensibility. I once asked a senior self psychologist what exactly differentiated psychoanalytic empathy from empathy in its everyday sense. He thought for a moment and replied that in psychoanalysis, one deploys “sustained” empathy. What, pray tell, does this mean, beyond denoting the fact that psychoanalysts, whether or not empathic, listen to patients for a living, and the units of such listening are typically 45-minute sessions. Maybe he simply meant that, in the nature of things, analysts must try to listen empathically for longer periods of time, and prolongation conduces to empathic competence.

Well, anything’s possible, I suppose. But the fact remains that some people are born empathizers and others not. Over the course of a 27-year career in psychoanalytic and psychiatric publishing, I worked with a great many analysts and therapists who struck me as unempathic, sometimes stunningly unempathic. And those who struck me as empathic were not aligned with any particular school of thought, certainly not one that, like self psychology, privileges empathy.

Nor is it self-evident that the empathy-promoting circumstances of psychotherapy are greater than the circumstances faced day-in and day-out by any number of physicians. Consider adult and pediatric oncologists, transplant surgeons, and internists and gerontologists who specialize in palliative care. These physicians deal with patients (and their parents and children) in extremis; surely their work should elicit “sustained empathy,” assuming they begin with an empathic endowment strong enough to cordon off the miasma of uncertainty, dread, and imminent loss that envelops them on daily rounds. Consider at the other end of the medical spectrum those remaining family doctors who, typically in rural settings, provide intergenerational, multispecialty care and continue to treat patients in their homes . The nature of their work makes it difficult for them not to observe and comprehend their patients’ complex biopsychosocial states; there are extraordinary empathizers among them.

When it comes to techniques for heightening empathy, physicians have certain advantages over psychotherapists, since their patients present with bodily symptoms and receive bodily (often procedural) interventions, both of which have a mimetic potential beyond “listening” one’s way into another’s inner world. There is more to say about the grounds of medical empathy, but let me close here with a concrete illustration of such empathy in the making.

William Stevenson Baer graduated from Johns Hopkins Medical College in 1898 and stayed on at Hopkins as an intern and then assistant resident in William Halsted’s dauntingly rigorous surgical training program. In June, 1900, at the suggestion of Baer’s immediate supervisor, Harvey Cushing, Halsted asked Baer to establish an orthopedic outpatient clinic at Hopkins the following fall. With no grounding in the specialty, Baer readied himself for his new task by spending the ensuing summer at the orthopedic services of Massachusetts General Hospital and the Boston Children’s Hospital. At both institutions, many children in the orthopedic ward had to wear plaster casts throughout the hot summer months. On arrival, Baer’s first order of business was to alter his life circumstances in order to promote empathy with, and win the trust of, these young patients. To wit, he had himself fitted for a body cast that he wore the entire summer. His sole object, according to his Hopkins colleague Samuel Crowe, was “to gain the children’s confidence by showing them that he too was enduring the same discomfort.”[2]

Psychotherapists are generally satisfied that empathy can be acquired in the manner of a thought experiment. “Bracket your biases and assumptions,” they admonish, “empty yourself of ‘content,’ and then, through a process of imaginative identification, you will be able to hear what your patient is saying and feel what she is feeling.” Baer’s example reminds us that illness and treatment are first and foremost bodily experiences, and that “feeling into another” – the literal meaning of the German Einfühlung, which we translate as “empathy” – does not begin and end with concordant memories amplified by psychological imagination.[3] In medicine, there is an irremediably visceral dimension to empathy, and we shall consider it further in the next posting.

[1] Donald A. Schön, The Reflective Practitioner: How Professionals Think in Action (NY: Basic Books, 1983); Donald A. Schön, Educating the Reflective Practitioner (San Francisco: Jossey-Bass, 1987).

[2] Samuel James Crowe, Halsted of Johns Hopkins: The Man and His Men (Springfield, IL: Thomas, 1957), pp. 130-31.

[3] The imaginative component of empathy, which is more relevant to its function in psychotherapy than in medicine, is especially stressed by Alfred Margulies, “Toward Empathy: The Uses of Wonder,” American Journal of Psychiatry, 141:1025-1033, 1984.

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Posted in Doctor-Patient Communication, Family Doctors, Then & Now, Primary Care, Psychoanalysis, Psychotherapy

Tagged Donald Schoen, empathy, Harvey Cushing, Heinz Kohut, self psychology, William Baer, William Halsted

A Musical Offering

Posted on February 24, 2012 | Leave a comment

“There is no doubt in my mind that the study of music aids in the study of medicine. The study of one appears to potentiate the other.” ~ F. William Sunderman, M.D., Musical Notes of a Physician (1982)

My father, William Stepansky, whose lifelong passion for violin and string chamber playing is recorded in The Last Family Doctor, holds a singular status in the history of World War II. He was the only GI in the US Army to join his infantry division at the D-Day staging area in the dripping heat of Yuma, Arizona with a violin in tow. Wiser minds prevailed, and he sent the violin home, but not before knowledge of his unlikely traveling companion spread throughout the unit. Here he is in army fatigues playing violin in Germany in the final year of World War II. The violin in question, a fine mid-eighteenth-century instrument by the Prague maker Thomas Andreas Hulinzky (1731-1788), was the gift of a group of GIs who retrieved it in the vicinity of the famous Hohner Factory in Trossingen, Germany in early 1945. Apparently knowing about the violin-toting kid from South Philly who was a surgical tech, they brought the “liberated” fiddle back to his surgical clearing station and offered it to him – but only on condition that he play it for them then and there.

He obliged them, and the Hulinzky became his violin for the next half century, the instrument that provided his four sons with childhoods suffused with Bach, Mozart, Beethoven, Schubert, Mendelssohn, Brahms, and a host of later Romantics. We learned standard repertoire through my father’s practicing and chamber rehearsals and performances. And we played with him ourselves – two pianists, a violinist, and a cellist. Here is a family trio in action in 1976; this one includes David Stepansky (piano), Alan Stepansky (cello), and William Stepansky (violin).

Why the violin mattered so much to our father and how it entered into the kind of medicine he practiced – I forego these precious bits of biography here. But I cannot resist commenting on Danielle Ofri’s recent piece, “Music Teachers for Doctors?”, since it stimulates memories of growing up with a gifted physician-musician in a remarkably musical household.

Picking up on a recent article by the internist Frank Davidoff, Ofri suggests that the critical feedback that performing musicians receive throughout their careers from “teachers, audiences, critics and their own ears” exemplifies the kind of “coaching” that, in parallel fashion, might aid physicians in the “performance” of clinical medicine. Senior colleagues who observe physicians as they actually practice medicine and provide “detailed feedback,” she suggests, might play the same energizing motivational role as music teachers and coaches who relentlessly critique their students’ performance skills and spur them to higher levels of artistry.

It’s a bit difficult to understand precisely what Ofri and Davidoff mean by the term “performance.” It seems to be a catchall for clinical competence, of which creative problem solving; emotional engagement; collaborative sensibility; and enthusiasm for the work are all components. The greater one’s allotment of these attributes, the better one “performs” clinical medicine.

Davidoff, who observes that most musicians “perform almost exclusively in groups,” is especially taken with the interactive and cognitive yield of group performance. It inculcates a better sense of “teamwork,” of the “specialization” associated with one’s particular instrument, and of the importance of clinical improvisation, i.e., the wherewithal to deviate from established protocols in response to the needs of “particular patients in particular contexts.” Ofri, for her part, sees clinical coaching modeled on musical coaching as especially relevant to the creeping complacency, the mid-career “plateaus” to which all-too-human physicians are subject. Musical-cum-clinical coaching would remind physicians that the quest for “performance” excellence is never ending; it might goad them to further career growth and renewed satisfaction in their work.

Between these two contrasting emphases, I am more aligned with Davidoff, though I question whether the value of group performance is best thought of in terms of an interactional concept such as “teamwork” or a cognitive skill such as improvisation. The improvement to which “good enough” doctors should seek ongoing feedback is of a different sort. What they could really use is a dose of the sensibility associated with chamber music playing, for ensemble work feeds into the art and craft of dialogue, of give and take, of respectful recognition of different voices moving together in accord with the anatomical blueprint provided by a composer.

Rather than provide “coaches” who give physicians feedback to improve their clinical “performance,” let’s take them right to the medicomusical locus itself. To wit, let’s make instrumental training and chamber performance an integral part of postgraduate clinical training. And, by way of bringing this utterly fanciful notion back down to earth – or at least within earth’s orbit – let’s give physicians “continuing education” credit both for playing in musical ensembles and for taking seminars and workshops on how to listen to chamber music.

But let’s play out the original fantasy. What a boon to patients if doctors were obliged to make music among themselves. Better still if they made music with nonphysicians and best of all if they made music with current or former patients. In so doing, they might build up tacit knowledge relevant to caring for people rather than diagnosing and treating illnesses. From chamber playing, they would learn about harmonious interchange, about counterpoint (as Davidoff points out), about respecting intelligent voices other than their own. Tacit knowledge – the concept comes to us from the Hungarian-British scientist and philosopher Michael Polanyi – by its nature resists articulation among those who possess it. But, speaking from the outside, let me say that the tacit knowledge I have in mind hovers around the art of doctor-patient communication, of learning to converse with patients in a manner more responsive to individual illness experiences. Here is my claim: Chamber music holds the promise of broadening, however tacitly, the physician’s sense of dialogic possibility when he or she is with patients.

Consider chamber music as a special kind of narrative journey. It is not the hero’s journey that culminates in individual redemption and rebirth but the journey of individual voices conjoined in pursuit of something communal, call it musical truth. Individual voices assert their authority; they take the lead when called on, enabling other voices to play their supportive roles with greater sensitivity and more perfect ensemble.[1] The voices interweave and interpenetrate; they invade musical space only to make graceful exits; they weave exquisite filigrees around the melodic inventiveness of others; they learn to yield melodic pride of place, only to reclaim it once again as transformed by other voices. Out of the dialogue emerges a tapestry whose separate threads merge in single-minded purpose. This interpretive solidarity, this playing together, is hemmed in by a composer’s intentions, framed by the compositional traditions and performance practices of a particular time and place. Absent any single voice, the journey can not be undertaken; there is no tapestry to be woven.

What have we here if not a musical analogue of the kind of narrative competence associated with patient- and relationship-centered medicine? Interweaving, interpenetrating, entering and exiting, listening to other voices, yielding to other voices, hearing differently because of other voices – aren’t these things at the heart of narrative medicine?

This was the medicine that my father practiced long before scholars decided to study “narrative medicine” as a kind of medicine. As a violinist, he was especially drawn to Bach, but also to the early and late Romantics, and he could shape a phrase with the same warmth and control with which he helped patients reshape the personal stories they brought to him. He was a charismatic listener who encouraged his patients to bring him their stories. But he always listened as their doctor, with the quiet authority to decide on a course of treatment and reassure them all was in hand – because all was in his mind. He was, after all, the first violinist, the leader of the quartet. He knew the score, and he was comfortable taking the lead, both with other chamber players and with his patients.

My father was a man of great modesty and reserve, but his violin always soared with controlled passion. Just so in medicine: his personal reserve never diminished the polyphonic textures and expressive sonorities of his medicine, of how he listened to and conversed with his patients and then proceeded to doctor them.

_________________

My father’s model for a life of medicine and music was F. William Sunderman. One of Philadelphia’s premier internists, Sunderman was an accomplished medical researcher at Pennsylvania Hospital. During the 1930s, he developed new methods for measuring blood cholesterol, glucose, and chloride and invented the Sunderman Sugar Tube. During the war, he served as Medical Director of the Manhattan Project, where he developed an antidote for the nickel carbonyl piosoning to which the first atomic bomb assemblers were prone.

Among Philadelphia’s literati, however, Sunderman was best known for integrating medicine and music into a single exemplary life. The side-by-side entrances of his four-story brownstone at 2210 Delancy Street bore complementary aluminum plaques, one adorned with a caduceus, the other with a lyre and singing bird. To the former came his patients; to the latter the musicians – eminent scientists and physicians among them – who joined him regularly for chamber music. Sunderman’s passion for the violin, which in his case was embodied in a collection of exquisite instruments – a Gagliano, a Vuillaume, a Guarnarius – was fast becoming part of Philadelphia’s cultural landscape.

What must Sunderman have thought when, in the fall of 1947, a young war veteran recently graduated from Philadelphia College of Pharmacy wrote him and requested an audience. The young man, a Jewish immigrant whose parents fled the Russian Pogroms in 1921, knocked on Sunderman’s “musical” door with his GI-liberated Hulinzky in hand. He announced without fanfare: “I want to be like you. My life will be medicine and music.” And without further ado, my father played for him. And Sunderman was impressed, both with the young man and with his playing. And so he endorsed the violinist-pharmacist-serviceman’s application for admission to Philadelphia’s Jefferson Medical College.

Among the area musicians who joined Sunderman for chamber playing on a regular basis was a young cellist and Harvard graduate (class of ’32). At Harvard, Robert U. Jameson not only played cello but rose to the presidency of the Pierian Sodality, the forerunner of the Harvard-Radcliffe Orchestra. (In 1941, nine years after Jameson’s graduation, the Orchestra performed his orchestration of Edward Ballantine’s “Variations on Mary Had a Little Lamb.”) Now in the real world, Jameson made his living teaching English at The Haverford School on Philadelphia’s Main Line. An extraordinary teacher who seemed to know his students from the inside out and hence to understand exactly what they needed (viz., how to “coach” them), Jameson remained a devotee of cello throughout his life. In the mid-1970s, in failing health but still in the saddle at Haverford, he counted among his students a remarkably gifted young cellist. The two bonded, and the teacher became admiring of his student and warmly supportive of his career aspirations.

The young man played the Saint-Saens Cello Concerto at his teacher’s memorial concert in the spring of 1978, one cellist saluting another, and then moved on to the Curtis Institute, Harvard, and the New York Philharmonic, where he served as Associate Principal Cellist. The cellist, my brother Alan Stepansky, is now Professor of Cello at the Peabody Conservatory and Manhattan School of Music and a performer and teacher of international stature.

A decade earlier, in the late 1960s, this same Robert U. Jameson took in hand another student who showed promise as a writer but was in need of the kind of disciplining a chamber-music-playing English teacher could provide. Jameson, a student, like all cellists, of Bach’s Cello Suites, helped him harness luxuriant adolescent prose and understand that restraint is the handmaiden of passion, indeed, that it is the better part of a writer’s valor. I was that student. Did Mr. Jameson’s love of cello and chamber playing enter into his understanding of language and his ability to impart, perhaps tacitly, the elements of well-wrought narratives? Did his instrument help make him the teacher and mentor he was? Who’s to say it didn’t.

[1] The importance of taking the lead in chamber playing and the manner in which a strong leader enables other players to provide support “with greater sensitivity and more perfect ensemble” – this insight and this wording come from my brother Alan Stepansky.

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Posted in Doctor-Patient Communication, General, Medicine and Music, Medicine in WWII, Narrative Medicine

Tagged chamber music, F. William Sunderman, music and medicine, narrative medicine, patient-centered medicine, physician-muscians, William Stepansky

My Doctor, My Friend

Posted on January 10, 2012 | Leave a comment

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 90^th 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 19^th 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 19^th-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.

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Posted in Doctor-Patient Communication, Nineteenth-Century Medicine, Primary Care, Psychoanalysis

Tagged doctor patient relationship, primary medical care, William Stepansky

Category Archives: Doctor-Patient Communication

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Exit the Family Doctor

Naming the Pain

Pathways to Empathy?

Empathy, Psychotherapy, Medicine

A Musical Offering

My Doctor, My Friend

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A Gift to Children During the Pandemic

Blogs for Thinkers

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Websites Extraordinaire

The Legendary Red Medicine

A Revolution In A Tube

A Low-Tech Wonder

How’s Your Blood Pressure?

It Wasn’t Pretty But It Got The Job Done

The Mighty B-D “Empire”

Organotherapy, anyone?