Sunday, February 23, 2014

Some thoughts on healing

Late last year, I led a session for our MS1 students in which we discussed the idea of healing.  We used this article as a jumping off point in the discussion.  The article goes through a process of defining healing, but the core concept is that of healing as a transcending of suffering.

Healing is a complicated issue.  Not everyone heals the same way, at the same pace, or to the same level.  Healing can be fast or slow, complete or incomplete and it can be very hard to recognize how to heal.  The traumas and the stresses that people face can be so severe that it might be difficult to identify the best way forward, and to determine what steps need to be taken.  Sometimes these steps might be harmful, might create problems of their own.  Sometimes when in the depth of a crisis we strike out, or we lapse too far inwards.  The hope is that we can find some way to move past those harmful actions and find a true way forward--even if that way is diminished.

Healing is made more difficult because of what people heal from.  If they are healing from a physical suffering, an emotional injury, a loss of control or some loss of wholeness, they will heal differently.  Until we can accurately identify the source of the suffering, then the path to healing will be extremely difficult.

I think this is an important reason why people seek medical care as part of their healing.  Sometimes we can help, with medications, or surgery, or some other treatment.  Often times, our role in healing is simply our presence helping patients and families through the difficult times, advising and treating where we can, and bearing witness and sharing in the process.  The assurance that someone will be there to care and to help may be an important step in peoples' healing.

Monday, February 17, 2014

What is the Value of the Doctor/Patient Relationship?

(In response to Abraham Verghese's TED talk)

Verghese's talk centers on the process of the physical exam, but I think the central themes are that of ritual and connection.  In the healing relationship that physicians (should?) attempt to develop with our patients, the ritual and roles of healer and patient--those who are present to aid and to care and those that are seeking assistance and caring--enhance the physician's presence to beyond a source of a prescription or a recommendation for a treatment.  Instead, the ritual helps establish a connection between the two parties, and the connection enhances the benefit of any recommended treatment be it medication prescriptions, physical therapy, or counseling.  If a great deal of illness is suffering, then it is the trust between patients and physicians that helps the dyad seek to overcome that suffering.

I have long held tight to the concept of the "therapeutic use of self", that as healers we can use our presence to be an important part of helping patients heal in some form.  Verghese's closing--that physicians will not abandon our patients, that we will see them through whatever trial--beautifully summarizes this idea.

Unfortunately, we are in a situation in healthcare where it is very difficult to live up to Verghese's ideal.  I certainly cannot give 1 hr for a patient to tell me their history, and then another 1 hr visit just for the physical.  Our office gives us 20 minutes for each visit (whether a new or an established visit), and this is generous: many other offices give 10-15 minutes.  I can try to approximate Verghese's approach by taking advantage of the continuity of care primary care offers: I can see patients back repeatedly, and even if I cannot gather all this information at once or develop the desired connection as quickly, I can still work to gain my patient's trust and to preserve the healing relationship heading forward. 

In a healthcare system that rewards productivity, physicians will be pushed to be productive.  Often this means seeing more patients, ordering more tests, sending for more studies…and often times the therapeutic use of self is left aside in the hustle.

Relationships are critically important, and so are patients' expectations and experiences.  In the case of research around the placebo effect it appears that how much benefit a patient receives from certain interventions depends on their experiences.  If we as physicians are caring, kind, patient, and truly interested, might we enhance this benefit?

I believe the issue at hand is that we have a healthcare "system" that is not a system, and that does not really care about "health".  If we cared about health, we would emphasize the importance of the doctor/patient interaction, we would give the time needed to allow this relationship to develop and be supported, and we would find a better way to value the work being done.

Sunday, February 16, 2014

A Change in Course (and, hopefully, a renewal)

Looking back at this blog, I am embarrassed at how long it has been since I have updated it.  Life has gotten so busy that I hardly ever think to jot down any thoughts here, even if I should have some thought I think worth sharing.

Now that the ACA has been protected by the Supreme Court, by a Presidential election, and by a finally effective roll-out, I don't feel that I need to tout the law's benefits as loudly as I have been...and I appreciate those of you who have stuck through me during all this time.

I am hoping to bring this blog back to its original intent: to speak about medicine, and healing, and the challenges and rewards of working with medically-underserved communities.

In the past year, I have also become increasingly interested in the intersection of evidence-based medicine and patient-centered care.  I suspect that some of those thoughts will come into discussion on this blog.

Since my last post I have been teaching more.  I am teaching students in our school's honors program that prepares students to work with medically-underserved communities after they complete their training, and I am teaching the entire medical school class about the important elements of the doctor/patient relationship.  I hope that my increased engagement there will renew my energy and desire to share ideas here.

I am also helping teach a "Medicine and Literature" course on our undergraduate campus.  As part of that class, we have an active discussion board.  In order to get this blog back online, and to avoid doing the double work that would quickly end this attempt to restart things, I will start by cross-posting some of my thoughts from that discussion here.

Hopefully, you will see more on this blog soon.  Thanks to all those who might have been bearing with me.