I learned the most important lesson of my career while sitting on a toilet seat.
I was fresh out of medical school, just beginning a year of internship, that infamous rite of passage that involves grueling work, sleep deprivation, and an endless stream of sick and dying patients. One night, in the middle of a twenty-four-hour stint in the emergency room, I trudged to the interns' sleeping quarters. Exhausted, I hoped to collapse into unconsciousness for a few hours before returning to duty. But first, I made a detour to the toilet, sat down, and closed the door. When I looked up I saw a graffito staring me in the face, scrawled on the door by some anonymous intern: THE SECRET OF PATIENT CARE IS CARING FOR THE PATIENT. I was jolted. I knew in my heart that this pithy statement was absolutely true. It was seared into my consciousness at that moment and has stayed with me ever since.
I learned years later that this truism originated from Dr. Francis W. Peabody, a legendary superhero of internal medicine during the early decades of the twentieth century. Dr. Peabody was instrumental in setting up the Peter Bent Brigham Hospital, the Rockefeller Hospital, and the Boston City Hospital's Thorndike Memorial Laboratory. He was a World War I Army field doctor and he helped establish the first modern medical school in China. He was an expert on typhoid fever and polio. Both his patients and his students adored him.
At age 45, at the peak of his powers, Dr. Peabody developed incurable metastatic cancer. He died seven months later. During his illness his thoughts turned to what it means to be a physician and a patient, and he delivered a series of lectures on these matters. These talks have become famous. They contain nuggets that should be tattooed in the psyche of every physician. Among them: "Medicine is not a trade to be learned, but a profession to be entered." "The treatment of a disease may be entirely impersonal, the care of a patient must be completely personal." And the comment that was abbreviated on the bathroom wall, "For the secret of the care of the patient is in caring for the patient."
Many healthcare professionals consider Dr. Peabody's comments to be old-fashioned musings from simpler times. Caring, empathy, and compassion are feel-good concepts that can't compete with "real" therapies such as pharmaceuticals and surgical procedures. Even if they could, there's simply no time in busy clinics and hospitals for these "soft" interventions.
This attitude is wrong-headed. When physicians express caring, empathy, and compassion, the duration and severity of illness are often reduced and the body's immune system is stimulated.
In 2009, researchers in the Department of Family Medicine of the University of Wisconsin School of Medicine assessed the impact of physician empathy in 350 subjects suffering from the common cold. The patients rated the level of empathy conveyed by the physicians during their office visit and rated their physical symptoms twice a day. Nasal washings were obtained to determine the level of the immune substance interleukin-8 (IL-8). Patients who were cared for by the most empathic physicians experienced colds that were shorter in duration and less severe, and they had a larger increase in IL-8 levels, when compared with patients cared for by less empathic doctors. The researchers concluded that the effects of empathy are real, they can be measured, and they can make a significant difference.
Medical educators may be waking up to the value of compassion and empathy in healing. In 2006, medical schools in Israel altered their admission procedures to require the presence of compassion and empathy in every entering medical student. High grades and intellectual skills continued to be important, but were judged insufficient to qualify one for admission. "It bothered us," said Professor Moshe Mittelman, head of the admissions committee at Tel Aviv University, "that here and there you meet a doctor about whom you say, 'He may know medicine, but he is not a decent human being.' We are a school that educates people to work in the medical profession, which is not only science but also humanism and dealing with people."
Empathy and compassion have also been emphasized by the World Health Organization as crucial elements in what's being called the "decent care" of persons with HIV/AIDS.
Caring, compassion, and empathy should be part of our current national debate about which therapies work and how we can reduce medical costs. But no one on either side of the political spectrum seems to notice their importance. We should not be surprised. Caring, empathy, and compassion cannot be legislated, and we do not need uncaring politicians to lecture us on the virtues of caring. Instead, we must honor the science validating the healing role of caring, empathy and compassion. We should also trust our personal experience of what helps us heal, and we should seek out physicians who embody healing. How? I have a simple piece of advice: If you feel worse instead of better after leaving your doctor's office, find another one.
Erma Bombeck got it right when she said, "Never go to a doctor whose office plants have died."
~ Larry Dossey, MD
References:
Oglesby P. The Caring Physician: The Life of Dr. Francis W. Peabody. Boston, MA: Harvard University Press; 1991.
Lavizzo-Mourey R. The secret of patient care. The Malcolm Peterson Honor Lecture. National Scientific Meeting, Society of Internal Medicine. Los Angeles, California, April 28, 2006. Available at: http://www.ramcampaign.org/pages/documents/riza_bylined_article.pdf. Accessed September 1, 2009.
Rakel DP, Hoeft TJ, Barrett BP, Chewning BA, Craig BM, Niu M. Practitioner empathy and the duration of the common cold. Family Medicine. 2009; 41(7):494-501.
Mittelman M. Quoted in: Traubman T. Wanted: Medical student, compassionate and personable. Haaretz. http://www.haaretz.com/hasen/pages/RegisterSiteEng.jhtml?contrassI=null&requestid=233637. Accessed 15 April, 2006.
Dossey L. Universal access to compassion and empathy: A cornerstone of decent care. In: Restoring Hope: Decent Care in the Midst of HIV/AIDS. (Ted Karpf, J. Todd Ferguson, Robin Swift, and Jeffrey V. Lazarus, eds.) New York, NY: Palgrave Macmillan; 2008: 121-128.
It won't be until medicine returns to a focus on making people well and helping them stay well that the flaws in this system have any hope of repair.
As a physician who no longer participates directly with managed care and HMO's, I can share first hand that all of my patients get more of me. I no longer need to see a truckload of patients every day. The office atmosphere is quiet and calm. I am relaxed, have lots of time to listen to my patients as well as share my thoughts and recommendations in a thorough manner and have seen a huge improvement in therapeutic outcomes. Is empathy and compassion part of the healing process? Absolutely! It is an essential component. Without it, we have a system of intervention devoid of health care.
That's why I pay for insurance each month.
Sure I could bank the $400 a month and pay cash to the doctor. But patients without insurance are charged up to four times as much should there be any labs, tests or hospital stays or surgery. They pay a lot more for prescriptions too. For what an emergency or hospital stay would cost, you couldn't cover by saving for it. And should you have something serious, debilitating or long term, you have to have insurance. And you can't predict appendicitis or cancer.
Oh, so you don't get paid what you're worth, your work load is too much and you're not appreciated? Welcome to my world. I'm a teacher. And guess what? Despite the pay, the work load and the complaints....teachers still care about their students. They care enough to work beyond the contract day and pay for instructional supplies out of their own pockets. They also take extra classes and training on their own time paid for out of their own pockets.
You're welcome.
Why does an annual physical cost at least $400 when a Nurse Practitioner can do the same thing just as well and get paid less?
If physicians as a whole were a truly caring lot, then they would be banging down the doors of Congress demanding universal health care coverage. Sure you would probably be paid less than you want, but if you care about your patients and people in general, then don't you want to see everyone have an equal opportunity to receive treatment without fear of losing their home and life savings? Think about it.
Here are two simple mandatory questions that need to be asked by your primary doctor during every patient visit. If your doctor does NOT ask these - find another doctor.
TWO SIMPLE MANDATORY MEDICAL HISTORY QUESTIONS
Proposed by Dr. Rick Lippin, June, 2002
Propose that all health care providers (especially primary care providers) ask adult * patients two simple questions when taking the medical history during every patient visit. Using the JCAHO model for pain (JCAHO’s so called 5th vital sign) patents would report levels from 1 to 10. The questions are simply:
“ How are things at work?”*
“ How are things at home?”
1= “couldn’t be better”
10= “couldn’t be worse” (in crisis stage)
The answers to these questions could then lead to referrals and standardized tests for further diagnostic workup for stress and depression and they would not “burden” the primary care providers with a requirement to do a full exploration of the problems very likely to be elicited
* for students substitute word “school” for “work”
Dr. Rick Lippin
Southampton,Pa
I am lucky that I can pay him up front. Many people can't. But it is worth it because my annual physical lasts TWO HOURS. It is around $400. We take time to go over everything in detail. At least, if there is a crisis, "my" doctor knows me well enough to keep all the specialists going the same direction.
My insurance company has denied coverage on some tests or parts of tests. Most confoundedly, the anesthesia on a colonoscopy/endoscopy. Like I'm going to do that AWAKE??
Those crooks and PROFITEERS always get away with huge over-charges and
constant whittling down of your benefits.
Seems like a faulty business plan to me. If we are to believe medicine is simply a business.
Not..."How are you, Mr X", but really truly, "how are ya?"
Be the patient's friend first, then their doctor. It's okay not to have an encyclopedic knowledge of every disease and ailment known to man. You can go research that stufff later on your own time. The doctor's time with the patient is his/her time, not the doctor's time. For doctors, it's about the numbers, the money, the test results, etc. For the patient it's about "Am I going to live or die, or suffer, and if Im going to suffer, how much?"
Most MDs, unless they are psychiatrists spend far too much time on the body below the neck and don't care about what is going on between the ears. How that can possibly be is beyond me, because it has long been accepted that a person's mental and emotional state directly affects his/her physical health.
So, if people come away with nothing, the one thing you can do is insist your doctor call you by your first name, and try your best to have a real "How are ya?" conversation that has nothing whatsoever with the diagnostic process
I think she did well through this surgery because of his skill, AND because she felt he truly cared about her. She looked forward to his daily visits during recovery and he would come in and sit on the edge of the bed and seem to have nowhere else he would rather be at that moment.
Compassion is not something that can be taught, but it is certainly something that can be modeled. This was a teaching hospital, and I hope his marvelous example inspired his students to try to walk in his footsteps.
I wish you the best.
I fail to see how the change of focus constitutes a higher reimbursement.