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.