In 1927, just months before he died of inoperable cancer when he was only 46 years old, Dr Francis Peabody, chief of the Harvard medical service at Boston City Hospital and the Thorndike Medical Laboratory, wrote in “The Care of the Patient” in JAMA (the Journal of the American Medical Association):
“The most common criticism made at present by older practitioners is that young graduates have been taught a great deal about the mechanism of disease, but very little about the practice of medicine—or to put it more bluntly, they are too “scientific” and do not know how to take care of the patient.
“The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy, and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the care of the patient is in caring for the patient. (italics mine).”
Advocating the importance of the house call, Peabody advocating seeing patients in their own environment:
“”The clinical picture’ is not just a photograph of a man sick in bed; it is an impressionistic painting of the patient surrounded by his home, his work, his relations, his friends, his joys, sorrows, hopes, and fears.”
Fifty years later, in 1977, Dr. George Engel published his classic thesis advocating the biopsychosocial model of medicine as a means of diagnosing and treating patients—as opposed to the biological model used by so many physicians today. The same year, Dr. Engel asked in “The Care of the Patient: Art or Science” ?
Today. many long years after Peabody and Engel—and too many short uncommunicative MD-patient visits--, James C. Harris of Johns Hopkins recalls their work and discusses the importance of patient-centered treatment in caring for patients in “Toward a Restorative Medicine—The Science of Care” in JAMA in April of 2009.
Now, three new books are trying to attack these non-communicative problems bedevilling patients. Their approaches represent three points of view. The first, ONLY TEN SECONDS TO CARE: Help and Hope for Busy Clinicians
is by a physician, Wendy Schlessel Harpham (Philadelphia: ACP Press, 2009), who writes from her own experiences..Harpham is an internist, a veteran of chronic indolent lymphoma which still limits her energies, and a patient advocate.
As a doctor-patient, she tries to tell practicing physicians, residents, and medical students what it feels like from the other side of the bedside. Her book is filled with stories illustrating ways for doctors to make life easier for patients. Although her advice to physicians on caring for patients is succinct and compassionate, I’m not sure how many rushed and rushing MDs will follow her lead—until they themselves get sick..
The second BREAKING THE CYCLE: How to Turn Conflict into Collaboration When You and Your Patients Disagree
By George F. Blackall, PsyD, Steven Simms, PhD, and Michael J. Green, MD (Philadelphia: ACP Press, 2009) implicitly and explicitly asks whether the much-maligned “difficult patient” blocks good patient care—or whether it is the difficult doctor who is the root of medical conflict. Although the authors’ stance implies helping physicians overcome their own attitudinal problems with patients, the WALL ST JOURNAL review tends to put the onus on patients by asking, “Are you a difficult patient?”
BREAKING THE CYCLE is a valuable little book because it describes the cycle of conflict between patients and physicians, delineates unproductive cycles in relationships, talks about ways to build collaboration and prevent impasses with patients, and ways of responding to difficult medical relationships. It is unique in talking about ways physicians—and patients are forced to deal with the devils of chronic disease and the crises in the ICU. It reminds physicians that many patients have trouble describing their problems. Patients are older. Physicians usually are younger. Patients look forward to the visit and pour too much into their stories. Doctors want to move on to the next patient. Time is everyone’s enemy. So, too, is greed, which often limits the doctor’s time. Although primarily intended for physicians and staff, we will all someday be patients, we all need our doctors—and they—if they would succeed and avoid burnout—need us.. “Doctor” means “teacher” and it is up to doctors to teach patients how to get what they want from the physician by zeroing in on the major problem spurring their medical visit. to the physician.
Kudos to the American College of Physicians’s ACP Press for recognizing the invidious conflicts inherent in the doctor-patient relationships. But brickbats for charging $39.95 for this paperback with its dated references. The price will drive away many patients, medical students, residents, and even practicing MDs who might benefit from its good advice. Surely, it will make patients wonder.
HOW PATIENTS SHOULD THINK: 10 Questions to Ask Your Doctor about Drugs, Tests, and Treatment by Ray Moynihan and Melissa Sweet (New York: Pegasus Books, 2009) is a lot less expensive at $15.95 and an exceedingly valuable guide—but for patients only . Some of Australian journalists Moynihan and Sweet’s advice is rooted in a healthy skepticism for unhealthy patients but the premise is conflict-building. But advising, “[I]t can be a mistake to sit back and hand over control for our health care” tends to oversimplify. Asking questions is helpful but a chip on your shoulder is not. The oversimplified guide to questions in each chapter may help and may not. The message is that patients should write down their questions and offer them in a way that opens the doors to information. Warnings about the “dangers” of screening are dangerous in themselves. The value of these questions is in the best way of concluding the visit with necessary information before the examining room door is shut.
Despite these clarion calls for communication, despite many physicians—and lots of patients—begging for better relationships between those two unequals, doctors and patients, not much has changed. One of the best books crossing the Rubicon between doctors and patients in Jerome Groopman’s HOW DOCTORS THINK (Boston: Houghton Mifflin, 2007)., reviewed in this blog. If I were sick, I’d get on a plane for Boston and sit on Dr. Groopman’s doorstep till he saw me.