Kirsten Patrick is Deputy Editor at CMAJ
Rising awareness of the toll that physician burnout is taking on our profession and our healthcare services has inspired numerous organizational physician wellness initiatives and resilience courses aimed at individual physicians. Yet, as experts discuss the relative merits of the system-level approach vs. the individual-wellness-training approach to addressing burnout, one key element seems to be all-but ignored: the healing power of the relationship between physicians and the patients they serve.
Dr. Tom Hutchinson, in his book, Whole Person Care: Transforming Healthcare (Springer International Publishing AG, 2017), suggests that we have lost touch with “the interior processes of healing and growth in the individual patient and the practitioner that give meaning to illness and to healthcare,” and in so doing we have created healthcare systems that fail us all. If you are looking to rediscover some meaning in your medical career, read this short but powerful book.
Before physicians become medical students it’s likely they are asked, more than once, “Why do you want to become a doctor?” I was asked this question in my medical school interviews. Many would-be physicians are required to write lengthy personal statements outlining their reasons for wanting to join the medical profession. I’m sure most of us say something virtuous yet heartfelt about wanting to heal/help people who are sick.
Yet in the process of learning the science and practice of medicine, and often because of the culture of our profession, we start to lose sight of what it means to be a physician and what is truly required of us. We confuse knowing with evidence, practice with treatment, and healing with curing. Aligning ourselves with guidelines, targets, algorithms performance expectations and hierarchy, we forget that much of what supports the healing of others comes from within us and must be discovered rather than learned. We burn out. And as we give our all, trying to rise to all that is expected of us, we wonder why patients don’t seem to appreciate our efforts. “The increasingly external focus of medical practice and teaching has displaced a complementary internal focus,” writes Dr. Hutchinson.
In Whole Person Care, Dr. Hutchinson draws on his decades of experience as a nephrologist and palliative care physician, as well as a decade and a half of co-developing and teaching the McGill University medical school’s program in Whole Person Care. He begins with a brief history of the evolution of the medical profession, pointing out that healers have long existed in many cultures and our pivot towards a focus on the biomedical model, evidence-based decision-making and health care efficiency are relatively modern developments. He doesn’t dismiss these important advances, but readers are encouraged to examine how they have affected the quality of the relationship between physician and patient that is essential to healing.
Healing. A key focus of Whole Person Care. But what is it? According to Hutchinson, healing “begins with getting people in touch with what gives their life energy, hope…” because “to deal with illness, or indeed life, we…need the sense of our own value as persons…” We need to deliberately see the patient behind the disease. As physicians, working to meet targets and standards, it’s all too easy to see only the illness and not how it affects the patient. Yet, cure or no cure, patients are deeply affected in ways non-physiological by their experience of disease. There may be a cure but there is not always healing.
I entered medical school when I was 18 years old, in a country where you apply straight from high school and the training is a run-through 6 years. Anticipating second year was all about anticipating meeting the body: the cadaver that we had to dissect. But in the year before I went in to second year, the Department of Family Medicine was given the go-ahead to offer an elective course aimed at helping students understand early in training that patients have context…that they are people, not just bodies with diseases. I applied to be in the first cohort to try the new touchy-feely course, which many looked down on because it meant we got to do a slightly reduced physiology course with the physiotherapy and occupational therapy students as a trade-off to create the time. In hindsight I see that this course taught something akin to whole person care as defined by Dr. Hutchinson in his book. One exercise involved the course facilitators taking video recordings of us conducting mock consultations, after which we critiqued our approach. They compared these videos of us second-year, non-clinical students with videos recorded during an identical exercise undertaken with fifth-year students on their family medicine rotation. It was clear to anyone who watched those videos that the second-year students with relatively little medical knowledge were ‘better’. Lacking clinical information, we relied on our inherent humanity to talk to the ‘patients’ we were faced with; we had empathy in spades while the fifth-year students were mentally distracted by their desire to ‘work out the diagnosis’.
No, I’m not implying that it’s better to be a nice doctor than a well-educated one. But genuine empathy and its value in the service we provide as physicians has come to be underrated. We’ve started to fear having too much empathy. Some might even suggest that, while showing empathy is good for patients, being emotionally empathic may be risky for physicians’ wellbeing. Articles about ‘cognitive’ empathy – learning to see things from another’s point of view – have suggested that if emotional empathy is too risky then cognitive empathy may do the job just as well. Whole Person Care makes a good case for turning again to true empathic engagement as an antidote to physician burnout and lack of professional fulfillment.
Dear Warren thank you for your beautiful reflection on the review of my book on whole person care. It appears that you have lived more fully than I have the values I espouse in my book.
Thank you for your kind words, Tom. You took the time and made the effort to articulate these ideas in detail, and lay the groundwork for others to follow, and for that you deserve our gratitude and respect. My comments are simply an abbreviated distillation of your accomplishment.
When I was a medical student in 3rd year at McGill, having transferred after two years at UBC, and feeling bewildered by the unrealistic, mutually exclusive expectations imposed by multiple inpatient services on us beginners regarding what we needed to explore or ask patients in our clinical encounters, I took a 3 month “sabbatical” under the protective wing of Donald Bates, head of the History of Medicine Dept. I explored our “complete history and physical” process, and found that ideas about what it should contain ranged from massive questionnaires and multiple test procedures all the way to a short series of open-ended questions — all generating more or less the same results.
In other words, getting all technical/clinical on patients didn’t seem to work better than simply asking them to share what they knew. The primary purpose of the medical interview, in fact, boiled down to establishing a rapport with patients.
I didn’t write a book about it, but i did write a paper, published in the CMAJ in 1974 (link below).
In it I suggested that there were two goals underlying an encounter with a patient: “1) knowing why the patient has come, in whatever terms, whether medical or not, and 2) knowing the fundamental person and his [those were the days when all humans were male!] way of life, i.e. occupation, socioeconomic situation, past social record, personality, diet, etc.”, adding later on that it was important to place “a more explicit emphasis on satisfying the emotional needs of the patient, based on the documented pragmatic value of this emphasis in terms of patient cooperation.”
Today I am by no means so coldly “instrumental” in my analysis of relations with patients as I was then — in my fulsome ignorance — and would add further, and without hesitation, that such an approach leads to greater satisfaction for the physician as well.
As a solo practitioner for nearly 40 years in a small town, and one who has incorporated psychotherapy into a full-service practice as well, getting to know patients in all their complexity and humanity is enormously satisfying. Certainly I could have burnt out long ago had I restricted myself to more mechanistic, formally limited approaches — especially the popular but intellectually barren processes such as “10 minutes per visit” and “one problem per visit” and “no sharing of clinical test results without an office visit” and “no prescription renewals without an office visit”, and the stultifying stream of superficial encounters they are likely to generate.
I was never overly interested in specialization because the broad outcome of speciality work, especially surgical, is an inevitable emphasis on repetitive procedural interventions, often with the patient’s personal life seen as either opaque, if he or she is cooperative, or as an obstruction if he or she is disruptive, questioning or anxious.
Your friends are then your colleagues, and your patients, in all their rich and glorious diversity, inevitably become your “work”.
As a generalist, my patients can be, in a certain manner, my friends and my companions along the road of life, with my great privilege being to have access to their private world of complexity, suffering, and triumph, with a responsibility to do what I can to alleviate the bad bits, and facilitate the good bits. I can speak to them of values, and preferences, and work with them on informed decision-making, compromise, communication and the exploration of options, done respectfully and with give and take on both sides.
Much like I do with myself and my friends and family.
We should all be granted such a meaningful path in life.