Humanistic Medicine Defined, and Why We Need To Teach It

Humanistic Medicine, and Why We Need To Support Teaching It

I

This is the age of amazing medical advances – I personally have had my own share of medical gifts of life and limb that former generations could only dream of, and the odds are that you, the reader, have had your own. The touch of modern medicine is everywhere. But in this age of scientific advance, there are unforeseen consequences. Just as the scientific doctor has advanced, so has the role of traditional healer, the practitioner of humanistic medicine, been partially eclipsed.

That is a shame. Because as much as we welcome the newly empowered doctor as scientist with miracle cures in the pocket, we still need the doctor as humanist, a tradition that goes back for millennia in human history. Scientific and humanistic medicine are both necessary; one does not go without the other.

Let's be more specific about what Humanistic Medicine is. “Humanistic medicine” encompasses a lot. It can mean interviewing patients to find out where they're at, how best to reach them, how to be empathetic. It can be befriending patients, even while being a professional. It can refer to adopting the proper stance according to the problem, as indicated by the classic article on the doctor-patient relationship by Szasz and Hollender, a relationship that can go from (a) active-passivity, to (b) guidance-co-operation, and to (c) mutual participation. It is part of the art of medicine to determine which situations and which patients require (a), (b), or (c).

It can mean becoming wise, as old time doctors were reputed to be, rabbi-like. It can be becoming attuned to the cycles of life, from birth to death, knowing when and how to intervene and when to let nature take its course, to acquiesce. It can be giving advice that is not strictly medical. It can be being able to call upon literature, philosophy, art and other forms of wisdom to help patients and give them perspective.

It can mean being part of a team that works with patients when curing is not an option. It can be helping patients navigate so they can do things they really want to do, when it becomes very hard. It can be giving patients and families bad news in a sensitive manner, different for each practitioner and each family. It can be caring for the bedridden, turning and cleaning, cheering up, relating, simply being there. It can be tending sensitively to the dying patient, and the families of the sick and dying patient, in all their variety.

Humanistic Medicine is that part of medicine, the softer side.

II

If you look at the medical miracles of modern life, it's understandable that an unintended consequence of its rise would be to put the traditional role of caring in the shade. The new possibilities of curing are so exciting as well as demanding. There is so much more science to master. It can be overwhelming in its difficulty and obvious importance. The time for learning to care can be crowded out.

In addition, it's not clear that medical schools and large research institutions were ever very good at teaching the softer side of medicine, the feeling side, the relational side, the empathetic side, the long term supportive side. The role of the scientist has taken over the medical turf, and the humanistic doctors are not the top recruits for medical schools, which think of themselves as research institutions. Curing has crowded out caring.

And that is a shame, because caring for and caring about the patient, and relating intimately to the patient and the family, and caring for the chronically ill, is as important as it ever was. Even when doctors could do very little to cure patients, they still rendered important services by being there. They always coordinated care for patients with ongoing illnesses, and for patients who were dying.

Caring for people, moreover, is not only important for patients, but for the doctors as well. It's hard to be a doctor. It's hard work to tend to patients, it's hard to prepare and learn so much and to keep learning all your life, it's hard just physically to work all that time including nights, and nowadays, of course, it's hard to cope with the corporations that run medicine. It's a very hard job.

But more than in most jobs, medicine can have so much meaning. You are doing so much, you have all the expectations on you, and when you meet them, when you actually do your job and help people in this most important aspect of people's lives, their health – talk about satisfaction in your work, few things match medicine, at least when things go right. So for all the difficulty of the job, there is a lot of upside.

Humanistic medicine is not a frill. Most doctors who have been in practice know how fulfilling it is to both patient and doctor when the softer requirements of medical care are fulfilled. And most doctors who have been practicing for a while realize how hard it has been to achieve that status of the wise and sensitive and caring physician. When you have been at it a while, you realize how important it is that humanistic medicine be taught and emphasized, perhaps more consciously than ever.

III

And, on a personal note, this all came home to me in spades over the last few years as my wife was afflicted with Alzheimer's. I had tried as best I could in a long career in primary care pediatrics to be that practitioner of humanistic medicine that I've advocated here. It was a long slog, I had a lot to learn, although I tend naturally towards being empathetic, which was a help. In pediatrics, I did have some bad diagnoses to deliver, and I did better at that as time went on. I tended to people's personal lives. I tended to try to put things in perspective. I wasn't a “Just the facts, ma'am” practitioner. But still, it wasn't easy.

And then I sat with my wife as our neurologist delivered the diagnosis, "I'm afraid it's Alzheimer's," a direct and caring face to face encounter, a heartfelt “I'm sorry.” She didn't at all shy away from the direct, personal connection while giving bad news. I was able to tell her, our neurologist, that we liked her very much as a doctor and ask her if she could schedule us for periodic visits a few times a year even if there was little she could do, because she was our doctor. She said yes, and told me later she had learned something from me and that she was scheduling her patients more frequently, just to give them care, if not prescriptions.

I cared for my wife as she needed more and more care, as I had to drive her everywhere, to the hairdresser, to take her shopping for clothes she would never wear and books she would never read, help her in showers, I had to help her in the bathroom, I had to prepare meals on an ever more restricted menu of things she would eat. I had to get care for her, thank God I found our Angelicare agency with professional caregivers, wonderful giving people, based in nearby Vallejo, all from the Philippines, eventually 24/7 care when Ann couldn't get out of bed and they had to keep her clean, which wasn't easy, but they did it so well in a way that I never could have. She never had a bedsore. The nurses came from hospice, as did the aide who washed her body and her hair twice a week as she was in the hospice-supplied hospital bed. We had to give her more and more medicines to control her neurological symptoms, especially when the seizures came. What I didn't see in pediatrics was professionals who take over when they know their patient is going to die, prepared to see that happen and move on to the next dying patient.

And then the final days, the kids assembled, sitting with her when she couldn't eat or drink anymore, I sat by her side and held her arm as she took her last breaths and gradually her heart stopped.

I realized that although primary care pediatrics had prepared me for some of all this, a lot actually, my training had left out a lot. I had never sat with a patient for a long time to see what it was like – I mean, it would take 12 hours of sitting there to really absorb it, and more than that, longitudinally. In med school and in residency I had never learned to give a dreadful diagnosis properly, and as a result I had botched some of those instances in practice. I had never sat with someone as they died – my only direct death encounters were after the fact, although one time at the Mass General ER a patient had coded in the radiology suite and the staff doc had taken me with him and as the patient wasn't responsive he opened the chest and massaged the heart manually and urged me to do the same, which I did. But that wasn't caring for a patient and then being there for the death, the way the movies of old-time doctors show that that's what used to happen.

So, it occurred to me that our training left out a bunch of stuff on the humanistic side. And that's why I'm writing this.

 

Budd Shenkin