Carl Ellenberger, MD
For fifty years, I have read the prestigious New England Journal of Medicine, full of rigorously peer-reviewed and authoritative scientific articles with big words like "Imatinib, Peginterferon Alfa-2a," and sophisticated statistics I may not fully comprehend. During my career, the understanding of human disease, diagnostic precision, and treatment have greatly advanced while the "practice of medicine" in the US, transformed into the colossal industry of "Healthcare," has made some people healthier and others -- especially corporate executives and investors -- wealthier.
Lately I have started reading non-scientific articles in the NEJM like The Virtues of Irrelevance, Narrative and Medicine, and Rethinking the Social History, reminding me that, despite all these new developments, the doctor-patient bond remains the most important step in the process of care, just as it had to be for Hippocrates in 400 B.C.E.
The Virtues of Irrelevance makes the simple case for a doctor to begin a conversation before probing the medical problems:
"I like your necklace [shoes, pin, etc] ...."
showing interest in the person as well as the illness. I have also seen that strategy turn strangers in restaurants into friends.
Narrative medicine seeks each patient's story, as would doctors William Carlos Williams, Oliver Sacks, Abraham Verghese, and Atul Gawande. (see * below)
"... not only is diagnosis encoded in the narratives patients tell of symptoms, but deep and therapeutically consequential understandings of the persons who bear symptoms are made possible in the course of hearing the narratives told of illness."
See how hard it is to read medical articles? That excerpt is 'medicalese' for, "Our stories reveal who and how we are." You can't, for example, adequately understand most chronic pain, headache or backache without hearing the stories of those who have it.
Rethinking the Social History is a manifesto for "social medicine" (not "socialized medicine," a political term deriding Medicare) that
"…elucidates how patients' environments influence their attitudes and behaviors and how patients' agency -- the ability to act in accordance with their free choice -- is constrained by challenging social environments.
Translation: how and where we live affects our health. Your doctor needs to know.
As a consumer of healthcare (formerly called a patient), I can't dismiss the reality that doctors work on a tight schedule dictated by their payers (insurance companies or employers) who can financially penalize (or fire) them if their 'clinical volume' falls short.
Seated in the exam room in a paper gown I answer opening questions like, "What are your concerns?" as the doctor examines and enters data on a screen, checks boxes, and periodically looks in my direction. He may send me for tests or up the chain of specialists. Later his office may call with results and instructions, sometimes the sole "product" of the services I hope my insurance will pay for.
Some physicians seem to avoid personal questions fearing they might run the conversation into overtime. I may remain silent for the same reason, even when my physician is a former colleague. That's unfortunate because more problems than you might think can be addressed by reaching a better understanding than by pills or injections.
When I do encounter a physician who wants to connect (most recently a podiatrist), I wonder if that behavior comes from his or her character rather than from medical education. As conservatories may not teach musicians how to behave on stage, medical schools may not teach doctors how to listen to patients. Such skills certainly don't come though incentives from payers. I hope that when my failing parts can no longer be repaired or replaced my doctor will be one of the more human ones. (see Gawande's Being Mortal)
In my childhood doctors were thought to be the best educated and wise members in a community. Maybe that's why I admire those with non-medical interests, such as the writers mentioned above. I wonder whether their broader perspective of the human condition makes them better doctors, especially if it extends beyond playing golf, collecting wine, or watching football. When I once suggested to one of my mentors that medical trainees read more widely, novels or poetry perhaps, he answered, "No evidence for that...."
Has making music made me a better doctor? That's difficult to measure. It helped me pay for (and survive) medical school, enlarged my network of friends and colleagues, and helped me understand the problems musicians have brought to me like dystonia (July 21, 2013), but I have no way of measuring outcomes in those cases or in others. Some may have assumed that music distracted me from medical work. Indeed, I never was a "high-performance" practitioner like an an ophthalmologist I worked with who saw 100 patients a day! But in my view quality trumps quantity, though the latter is easier to measure and reward.
I do not believe that advances in medical science require educators to stuff ever more information ("the material") into student doctors' heads. In fact, the reverse may be true; now information is in very accessible clouds. The mind is freed to connect with patients and 'apply the material.' And maybe acquire wisdom.
"...wisdom, which is almost always another name for humility, lies in accepting one's own inevitable share in human fallibility." (Marilynne Robinson: When I Was a Child I Read Books)
*Doctor/writers mentioned above
Oliver Sacks: The Man Who Mistook His Wife For A Hat: And Other Clinical Tales, Awakenings
Abraham Verghese: Cutting for Stone, My Own Country: A Doctor's Story, etc
Atul Gawande: Complications, Being Mortal, etc
William Carlos Williams: The Doctor Stories and any edition of Collected Poems
