The Definition, Importance, and Extensive Domain of Humanistic Medicine
What is Humanistic Medicine?
If we are to argue for the importance of Humanistic Medicine (HM), and if we are to understand how it needs to be taught, we first have to find a definition. HM is an appealing term with an elusive definition. We can think of it as a term that contrasts with, and partners with, the science of biologic medicine (BM.) The overall goal of medicine is to help people, to keep them healthy in body and spirit, and to ameliorate and repair their afflictions. BM uses knowledge of biology, HM uses knowledge of caring, communication, feeling, and much else to the same ends. Because it is hard to express a compact definition of HM, we will go on at some length here to get a full sense of it.
An Impressionistic Definition of HM
HM 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 the adopting the proper stance in the doctor-patient relationship, adjusting according to the problem and the personalities, from (a) active-passivity, to (b) guidance-co-operation, and to (c) mutual participation, as described in a classic article. It can be Taking Care of the Hateful Patient. It can be the long-term relationship that develops between a patient and a doctor with meaning for both of them.
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. It can be giving advice that is not strictly medical. It can be being able to call upon literature and philosophy as well as science to help patients. HM is not just a set of principles and boxes to fill out, and generalizations – just as BM needs to be as precisely tailored to individual cases, so HM needs the same precision.
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 caring for the bedridden, turning and cleaning, cheering up, relating, simply being there. It can be tending sensitively to the dying.
It can be all of those things and more.
The Extent of HM
Another way to approach the definition of HM is to list extensive examples of what it covers.
Dealing with serious disease
Knowing how to and when to give bad news, such as a diagnosis of serious disease, of returning cancer, of an untreatable condition.
Knowing when to stop treatment and switch to palliative care
Understanding team medicine in end of life care
Knowing how not to shy away from very sick people
Knowing what to do when there is nothing to be done, how to be there with the patient
Knowing the process of caring for patients by families and caregivers
Knowing how to process death, the family's feelings and your own
Understanding the natural course of life and death, and being able to accept it
Patient relations
Understanding emotional distance, how to be close but still be objective
Understanding the various models of the doctor-patient relationship
Understanding the history of relational expectations; the death of paternalism
Understanding the differences of long-term and short-term patient relationships
Experiencing caring for patients longitudinally
Knowing how to handle difficult patients, patients who provoke you
Understanding clinician anger when patients don't fulfill the sick role properly
Knowing how to be emotionally present for patients
Knowing how to communicate effectively and sensitively
Understanding the power relations between doctor and patients
Understanding the power of projection, how patients need to feel they are in good hands
Treating patients with respect, as a patient with disease, not “the thyroid in 208,” not “a fascinoma”
Knowing when to use first names, when to use Mr. or Ms.
Knowing how to integrate professional demeanor with personal and professional authenticity
Understanding both the commonality of patients, but the differences that culture and finances and faiths and understanding can entail.
How the patient appreciates the full experience of medical care
The effect of practice environment
Effect of telephone system, computer system, making appointments, responses to questions – does the patient experience these steps as “caring,” or not?
The effect of the physical environment
The attitudes and practices of staff
The effect of financing on the therapeutic relationship and sense of caring
The effect of making the patient a prime actor in choosing in a medical marketplace
Impact of giving medical care on the doctor
Understanding psychological defenses of clinicians against the pain of their feelings
Understanding the pressure on caregivers in fields where patients frequently die
Enduring and making sense of disquieting experiences and traumatic confrontations that doctors confront – death, disability, pain, suffering, fear, isolation. The anguish of life.
Understanding the impulse to “do something”
Understanding the impact on the doctor of watching patients suffer
Understanding the concept of moral injury, where and how it occurs
Understanding “burnout,” and how it differs from moral injury
Relationships with other doctors and caregivers
Understanding the strengths and limits of mutual support
Understanding how to support patient in face of perceived shortcomings of other caregivers – and how to interact with deficient caregivers
Understanding how to be a team leader, and how and when to play a supportive role
Understanding how to effect good teamwork
Understanding how clinicians can support each other positively and appropriately
Medical ethics and values
Understanding the basic precepts
the patient comes first
do no harm
confidentiality
respect for patients
all patients are of equal importance
no sex with patients
prohibition on taking advantage of the power differential between doctor and patient
Understanding the challenges to upholding ethics
Understanding the concept of moral injury
Understanding concept of Health Fiduciary (similar to financial fiduciary)
Understanding conflicts that arise from serving 2 masters – employer and network on one side, vs. patient on the other
Understanding moral injury that can result in the doctor inhibited from giving best care to patient
Understanding how to effect joint decision making
Understanding the moral imperative of when to refer a patient
Spirituality and religion in medicine
Understanding, appreciating, respecting, utilizing, and communicating the centrality of meaning, value, and relationship
Understanding the basic theory of applying literary concepts to life stories to convey meaning to life, disease, and death, using plot, characters, and metaphors to examine and illuminate 4 of medicine's central narrative situations: physician and patient, physician and self, physician and colleagues, and physicians and society.
Sociology and anthropology perspectives in understanding medical care
The sick role
The role of the healer
Cultural differences; international differences
Changes over time in American medicine
Evolution of the role of paternalism
New understandings on when to stop treatments
Emergence of palliative care, hospice services
New emphasis on team care
In the end, HM can be understood as the emotional, feeling, and caring aspects of illness and delivering medical care, with emphasis on both care-givers and care-receivers. Does a patient feel cared for, attended to, cared for and cared about, can the patient have confidence in skill and arrangements of a whole system? Does a patient feel like a valued human being, does the patient feel known, or does the patient feel like a cog in a wheel, an input or an output, a thing, a statistic? And the same questions can be asked about the doctors and other care-givers. So much of HM is the essence of caring and being thought about and cherished.
In Sum
As we list the extent of the components of HM, it is astonishing how deep and how far HM's reach is. Many are tempted to view HM as an afterthought – do the important clinical biological work, and be nice about it, smile. It should be obvious how mistaken that is. HM is not peripheral, it is central. It is not just a “natural part of the doctor's personality,” it has to be taught and supported. When HMS students were choosing medicine as a career, a majority had in mind, along with gaining knowledge of scientific curative medicine, being a practitioner of the beneficence of medicine, the kindliness of the doctor, bringing balm to the ill. HM is central to the mission of medicine, and along with BM, it needs to be taught and practiced in medical schools as a highest priority.
Budd Shenkin
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