The relationship between doctor and patient has fascinated me ever since medical school. I grew up in an era when diagnosis was king because there were so few therapeutic tools. Penicillin was first used in a clinical trial in 1930, though not applied widely until well after I was born in 1935. Since radiology and blood testing were rudimentary by today's standards, the paramount skill was the physician's ability to glean from the patient by observation, listening, and a careful examination the information needed to make a diagnosis. Of course, this took time, perhaps 30 minutes or more.
The clinical teacher in medical school that I remember best was a community-practice neurologist who gave a series of lectures to the class. He showed us how to look at people, their gait, their stance, how they move, how they speak, and more in order to perceive clues to neurological disease. He could mimic a person with a stroke realistically. He said he used to stand on the corner of State and Madison in Chicago, a very busy downtown intersection, and try to diagnose neurological problems by watching people go by.
Although on occasion we still see such personal, non-technical attention to diagnosis, the approach is more often radically different today; it is not unusual for imaging and blood tests to be done before the patient is ever seen, an approach that tells us far less about the patient than it tells us about the doctor.
How to explain the uneasiness that this change causes in me isn't easy. At times I dismiss myself as just another old-time curmudgeonly doc who extols “the good old days” and hasn't moved ahead with the times. But I have just read a book that has helped me crystallize the virtues of the old way: “William Carlos Williams and the Diagnostics of Culture,” by Brian Bremen (Oxford University Press, 1993).
Dr. Williams is a renowned American poet (1883-1963) who had a full-time general practice in his hometown of Rutherford, NJ, for his entire professional career, taking care of patients mostly of the lower economic class. He made house calls and wrote some of his poems in a horse drawn carriage on the way to a from a patient's house (before he switched to an automobile).
Bremen shows how Williams's practice, particularly the diagnostic approach of that era, was fundamental to his poetry, because he saw poetry in the people and in the process of pulling together the jigsaw pieces that led to a diagnosis.
Bremen says that practicing medicine in that environment gave Williams a “modicum of financial security he needed to survive and the wealth of artistic material he needed for his writing by giving him the opportunity to make an empathic contact with some romantically more ‘authentic’ member of the community through an act of diagnosis.”
Williams explained this in his autobiography thus: “I lost myself in the very properties of their minds: for the moment at least I actually became them, whoever they should be, so that when I detached myself from them at the end of a half-hour of intense concentration over some illness which was affecting them, it was as though I was reawakening from a sleep. For the moment I myself did not exist, nothing affected me… I knew it was an elementary world that I was facing, but I have always been amazed at the authenticity with which the simple-minded often face that world when compared with the tawdriness of the public viewpoint exhibited in reports from the world at large. The public view which affects the behavior of so many is a very shabby thing compared to what I see every day in my practice of medicine.”
In a sense, the process of diagnostics was enlarged from its search for a medical diagnosis to an entry into the deeper recesses of the patients' worlds and words. Bremen says, “It is the act of diagnosis that is at the core of both Williams's medicine and his poetry.”
It would be hard to imagine such a statement describing a modern day physician, who is often shielded from the patient by technology. But the works of Oliver Sachs, Richard Seltzer, Abraham Verghese, and a few others in our own age come close to the marrow of the doctor-patient relationship.
The potential sacrifice of this deeper knowledge and understanding of patients due to science and technology was foreseen long ago. In the mid-1700s during the Enlightenment's dissection and elevation of science, Jean D'Alembert wrote that agriculture and medicine were the first sources of useful knowledge, “both the most primitive knowledge and the source of all other knowledge,” that grow out of the need to support and maintain the body. But he expressed dismay that “these branches of knowledge have been stifled and overshadowed” by the “physico-mathematical” sciences because they cannot be reduced to algebraic or geometric “truths”; such reductions, he said, are merely “intellectual games to which Nature is not obliged to conform.”
I am not saying that we should all become poets (though that is far from the worst thing I could wish for our profession) or stop using the technology (though overuse is scandalous). But I believe that with the technical age we have often lost something precious; we have methods of diagnosis that are (ultimately) more accurate, but often at the cost of losing a much more comprehensive understanding of our patients and their circumstances. Partly, this is due to the time it takes; a five-minute visit per patient—that is indirectly caused by a terrible reimbursement system that does not reward listening to patients—is not going to allow this depth of understanding.
Oncologists are among the least likely to have a longer conversation with patients because the diagnosis is often established (by surgeons and pathologists) before the patient is referred and seen.
The best opportunity for the “long talk” mostly occurs when a course of therapy is contemplated and discussed with the patient. That is the opportunity to spend some extra time with the patient as Dr. Williams did, in order to, in a sense, “become the patient” for a brief period of time to have a deeper and broader understanding of the patient's world, fears, desires, strengths, and weaknesses on their own terms. Such an encounter rewards both in many ways.
Along the same lines, if you haven't seen it, go to http://on.ted.com/aKEP to hear a wonderful talk by Dr. Abraham Verghese on the importance of touch and ritual in a patient encounter.