Imagine you come home to discover your door broken in. Your desk has been knocked over, papers are strewn about, and it doesn’t take long to notice your valuables are gone. You phone the police and follow the appropriate procedures. Hours later, the burglar has been tracked down, and all of your belongings have been recovered. How comfortable would you feel in your home that night?
This is the analogy Dr. Abraham Verghese uses to explain the “art of medicine” to his medical students at Stanford University, illustrating the difference between treating a disease and treating the patient. Determining there was a break-in is the “diagnosis” and the recovery of belongings is the “cure.”
Both are essential steps in properly treating a disease, but neither has anything to do with healing. “What we’ve lost sight of in Western medicine is that there is a sense of violation,” says Verghese. “Addressing the molecular, genetic, scientific underpinnings of a disease doesn’t take away that violation — that still requires a certain kind of nurturing.”
This concept isn’t new. Before massive strides in medical research and technology, the doctor-patient relationship was an “active ingredient” in healing, write D.M. Dixon, K.G. Sweeney and Denis John Pereira Gray in the British Journal of General Practice. But it’s something many experts feel has been on the decline: Rapid developments in diagnostic testing combined with over-stressed health care systems have led to more structured, standardized care and less time spent fostering the doctor-patient relationship.
What else has been lost as a result of this shift? Studies have shown a decrease in history-taking and physical-examination skills, which can result in diagnostic errors. As Dr. Christopher A. Feddock points out in his 2007 article, “The Lost Art of Clinical Skills,” in the American Journal of Medicine, it can also lead to a decline in clinical reasoning.
The deterioration of these skills goes with an increased reliance on imaging and diagnostic testing — a recognized problem in Canada. When doctors spend so much time focusing on test results, they can disassociate the human being from his or her medical record, says Verghese.
Plenty of doctors would like to spend more time fostering their patient relationships, Verghese adds, and teaching interpersonal competencies is a priority in medical schools here and in the United States. But Dr. Walter Wayne Weston, a professor emeritus of family medicine at Western University in London, Ont., and long-time advocate of patient-centred care, says those efforts are often undermined once students enter clinical training in hospitals.
When they see frenetic residents running from patient to patient and relying on diagnostic testing, just stopping to ask a question such as “What else do I need to know about you to take care of you?” is seen as a luxury.
Conversations about the ripple effects of an illness are also often sidestepped — a gap that some independent organizations have started to fill. MJ DeCoteau founded Rethink Breast Cancer in 2001 to draw attention to the discussions that should be taking place between health care professionals and younger breast cancer patients, such as what fertility options are available for someone undergoing treatment.
Rethink has also issued care guidelines to prompt conversations about early menopause, financial strain and where to find additional support, such as counselling. Similarly, Parkinson Society Canada created the first national clinical guidelines in 2012, in partnership with neurologists and other specialists, aiming to improve the quality of care received by those diagnosed with Parkinson’s.
But even as these gaps are being filled, Dr. Arthur Kleinman, a medical anthropologist at Harvard, warns something much larger is being lost: a doctor’s moral responsibility to the patient. “We are losing the deep involvement of the physician in caregiving, and this has always been central to the medical role,” says Kleinman, who is also a psychiatrist. “Once caregiving is lost, the physician becomes a highly paid mechanic.”
It’s a feeling quite familiar to Toronto family physician Dr. Nalya Jessamy. She realized early on that dealing strictly with “fixing” a physical problem wasn’t satisfying; she needed to feel a human connection with her patients. She spent the first nine years of her career at a community health centre, which opened her eyes to how factors like employment, housing and mental health impact the experience of illness.
That led Jessamy to become certified to practise psychotherapy, which helps her dig deeper with her primary care patients — she’s able to ask the right questions, build trust and provide emotional support.
“The mind and body are so connected,” she says, adding that repeat visits, specialist referrals and over-testing can often be avoided by gauging the context of a patient’s experience. “It goes a long way for all of us to feel heard and understood.”