Our Trip To Africa

 Our trip to Africa might have been the best time we ever had.  She asked me if I wanted to go, and she said if we don’t go now, we’ll ever go.  She said, I’ll pay for it.  I said yes.  It was in 2011.  She had been sober for 8 years.  She hadn’t started on her Alzheimer’s course yet.  My practice was doing very well.  We had built a house in Maui and occupied it, and she had designed a lot of it, and furnished all of it, and that had been, perhaps, her favorite wish.  It was a wonderful trip.

I see it again as I watch the wonderful Out of Africa.  That might be why I cry.  Plus the love story.  I’m such a sucker for love stories.  My friend Mary Lou asked me today if I’m romantic.  I had to say yes, because of course I am.  Very, I’m afraid.  But I’m also 82.  We don’t change that much, but our bodies do, and other things do.  We get better at being alone, maybe.  Who knows.  I barely know about me, how can I know about others.

Taking Care

 “Taking care” is such an important term and concept.  No matter how determined we are to be independent, especially if we have been frustrated by not being well cared for in the past, we want to be cared for.  I'm 82, and I remember when I was a little boy, and my Mommy and my Daddy took care of me.  They cared for me assiduously.  I never doubted for a moment that they would take care of me.  They were so reliable and assiduous in their care that, frankly, it never occurred to me to think about it.  They were there, they would always be there, that's the way it was.

I still miss that.  Not the infantilization, who wants that?  But someone to care for me.  My wife has died and I took care of her until the moment that she died and she knew I took care of her and she thanked me for it and she told me she loved me.  She had not been well cared for as a child.  When it came time to go to college, my parents bundled themselves, me, my three younger siblings into the station wagon with my bags, and we all decamped for Cambridge together.  It was a little embarrassing, and I didn't mind it when they left, but I did dream about my mother as I made this first big dig into independence that I hadn't particularly looking forward to, tell you the truth.  My senior year in high school was great, my friends were great, and I wasn't straining at the bit.

When my wife Ann left San Marino for Cal, her father took her to the airport and she took off for San Francisco with her suitcase and didn't know where she was going, exactly, and didn't know how she would get there, but she was very eager to go and to get there and looked forward to the independence and being away where she had not been well cared for.  She always wondered and worried that she would end up not being cared for, maybe even being a street lady, and I was the happy news that that wouldn't happen to Ann.  I took care of her, her caregivers took care of her, her doctors were attentive, and her kids were concerned and attentive and all three were there for her last days.

Everyone needs to be cared for.  If someone is not personally cared about by whoever is manning the medical care system, then that is a failure of the system and the people in it.  Everyone deserves to be cared about and cared for, everyone.  It's a human right.  If you are sick and worried, you deserve to be cared for.  Now that I am a widower, the one person who cared about me more than about anyone else in the world (except maybe her kids) is gone.  My kids, all five of them, care about me.  I treasure that they do.  I try to be a good person and a good parent, but no one bats a thousand, and I have done well enough that no one has written me off.  If I get toward the end and no one is there to care for me, that will be a shame, but I'll get by.  Meanwhile I have a good doctor who cares for me, who is good, and I'm safe with him until he retires. Then I'll probably be in the soup, but we'll just have to see.  I’m not going to worry about it.

So, on Labor Day I was out in Walnut Creek turning in my laptop at the Apple Store for a new keyboard (I have Apple Care, so it'll be $99, and the experienced tech who helped me was so nice, kind, and patient – you can imagine who he runs into in his job), when I dropped into Lululemon for some slacks – Peter keeps telling me I need some new clothes and he's right.  Lululemon is not aimed at my generation, of course, so even if I don't look my age, there was no one near my age in the store – try Nordstrom's for that, or maybe Saks in the city, where Ann and I used to go and see Thomas up on the third floor, where we were treated like king and queen with the assurance that we would be dropping a few thou.  I was met at the Lululemon door by a saleslady standing there, just waiting for the next customer to come in even though they were fairly busy – they're well organized – who greeted me warmly and personally, got my first name, and helped me find some slacks to try on.  She led me back to the fitting room suite with the two pairs of pants to try on – Pete tells me, go for slim – and turned me over personally and by name to a guy who was to take care of me.  I went to try on my pants and never saw him again.  I didn't have anyone to ascertain that I had chosen the right pair, but I figured I'd just do what I had to do.  I headed out of the suite rather confused, I guess, wondering who I had been handed over to, and a young lady saw my confusion, said my name and asked what she could do.  She warmly directed me to check out, but didn't offer anything else.  I wasn’t going to ask.  They were well organized and upbeat at checkout, fast-moving line, and I was out in a jiffy.  Judgement – they were organized to care, they were coached to care, they showed some caring – but you know they really didn't care, and their system broke down somewhere.  Their system is customer-centric, and the personnel give the simulacrum of caring.  They’re acting.

Then, yesterday, I went to my long time dentist for a problem of tooth #13.  I have gone to him regularly, he is set up industrially — beautifully organized — with maybe 15 or more assistants, runs over 10 bays simultaneously, charges high, makes a fortune.  I had complained about this tooth and the same one on the other side.  He had put a crown on the other tooth, had said that we should probably do the same on this tooth, but then I wondered if he changed his mind because we just let it lie.  But it had begun to bleed when I used the water pik on it and I came in and he said that he was sending me to the periodontist because l had lost bone and needed either a bone graft or extraction and an implant.  Which was very discouraging.  Actually, he didn't say that.  He omitted saying that.  He just said, we have to send you to Doctor Horn, and it was up to me to ask why, as he tried to leave the bay, and then he told me.  Then he was hurrying out of the room again and I said, if we had done something about this tooth earlier, could we have prevented this and he said yes.  His assistant had said in reviewing the chart that Dr. Kami had recommended a crown on tooth #13, but then why hadn't he done it?  She implied it was my fault.  I've always done exactly what he said.  He didn't say anything more when I told him that he had decided to wait on the tooth, just hurried out of the room.  Didn't want to deal with the bad news, for one thing, and the implication of inadequate care, for another.

Did he care?  I guess not.  He always calls at night after a crown or a procedure, he has the form of caring and the procedures of caring, I am always short with him when he calls because I know he has many calls to make.  But when he rushed off without telling me what he was sending me to Doctor Horn for, and he just hurried off, just got out of there, didn't deliver the bad news, just told me where to go, I guess that tells the tale pretty well.

Then I had an appointment with our old family therapist just two hours later.  I've been seeing him every other week, he says we're family and I find it helpful.  He is a warm and caring man whom I like a lot, and who certainly knows our history.  I went and worked out at my gym then walked over to his office.  I had been away for August and this was my first week back.  I hadn't checked with him about the appointment, but I kind of knew that I should have, because even when we check the appointments verbally, he often manages to screw it up.  He still keeps his appointments on paper.  But I trusted this time and just showed up, two minutes late. I turned on the switch that signals his office that the next patient is there, and he came out and told me that he wasn't sure when I was coming back and so had booked my time.

Did he care?  More than the others.  It's his system that betrayed him, and my not emailing him, and his inherent disability to schedule.  I was unhappy.  Cognitively I know what happened, but on the other hand, my father would never had made that mistake.  With my father I was always number 1.  But I'm a big boy, I tell myself, and I'll feel better about it in a few days, but for the moment I just got out of there.  Is wanting the same care your father would give you unreasonable?  I guess.  but it shouldn’t be.

Hell, people have strict limits on their caring.

It bothers me that at the description of the Harvard Medical School curriculum section of developing to be a doctor, they say they will teach the students to show empathy – “show empathy” rather than “feel empathy.”  Actually, I think there is an important difference.  Lululemon tries to show caring, but who would mistake that for real caring?  And if HMS wants to teach empathy, they need to do much more in getting students to know and to care about real patients, to get close to them, not just to tell patients that they imagine that the situation is hard on them, that being sick must be hard, to acknowledge their feelings.  That’s necessary but not sufficient.  They are preemptively surrendering to a system set up not to have continuity of the carer, not to have sufficient time and contact.  Caring and time spent knowing is a waste to the measures the leadership used to chart productivity.  Caring isn’t productive to them, it’s an outdated frill.  They assume that as a doctor learning to interact with a patient, that you are new to the patient, not someone who has known the patient for a long time.  There's a difference, guys, there's a difference, and you teach one one way and the other another way, showing empathy versus knowing and caring about the patient and feeling that empathy deeply.  

My dentist does a good job generally, is affable, knows who I am and notably that I have a house in Maui – that fascinated my former ophthalmologist, too, before he missed the diagnosis of my macroadenoma of my pituitary and delayed therapy for six months and could have cost me some of my eyesight because of the pressure prior to surgical extraction, but luckily didn't.  My ophthalmologist always asked about Maui, that was his first question posed, probably jealously.  But when I complained of poor vision he didn't think to do a very easy test of my peripheral vision.  Just stand nose to nose and put your arms out wide and see how wide you can see, or more carefully, just use the machine they have.  It’s not hard — but of course, it’s also not billable.  Did he care?  He never apologized – seemed to act as though it was my fault, or there was no fault because it was finally caught when I insisted that I be checked, and he should be congratulated and I should be grateful.  They just get scared or defensive.  My father would be accusing himself into the night, which wouldn't be helpful, but no one cared more than he did.  And my mother, too, whom I took for granted.  Little did I know.

And these medical offices who sometimes think it shows caring and emotional closeness when they teach their medical assistants to call us by our first names.  A recently graduated medical assistant will be calling a retired professor of medicine in to see the doctor but standing at the doorway and calling to the room at large, “James?”  Then she will set him up in the exam room and say “Dr. Goldberg will be coming in soon.”  The professor who taught Goldberg is “James,” and the former student is “Dr. Goldberg.”  That's not warm caring, people, that's lack of respect.  That’s stupid and careless.  Faking intimacy inappropriately.

Everyone deserves people to care about them.  The financial industry has officially tired of ripping customers off by consenting that their account representatives should act as fiduciaries for their clients, putting their clients' interests above their own and their company's.  Tell that to the company that used to manage Ann's money, who, when Ann wanted to establish a college fund for her granddaughter, put her into a fund with a 5% load, which meant that the company collected a fee, when they could have just as easily chosen a no-load fund, which would have been a better deal for their client, but not for them.  They're just doing their job, ripping off the unknowing and then seeking to defend it when the knowledgeable husband calls them on it.  I’m still pissed, I notice.

But in medicine, where the stakes are high and the connection is intimate, caring, really caring, should be high on the list.  I remember when my pediatrician friend Bob Shimuzu retired, he said he found that now he could relax.  I asked him what had made him not relax when he was in practice.  Worrying about the kids, he said.  I admired that.  Old school.

Think any of those I discussed here worry about me?  Not really, but I guess there’s nothing really to worry about.  Not that I want them to.  But Lululemon didn't win me as a friend, I'm now real disappointed in my dentist who I have always liked and relied on, and I'll relent on my family therapist – he just can't keep a damn schedule, I guess, and it was my fault for relying on him for that.  Nobody bats a thousand.  My ophthalmologist?  Failure, man, failure.

We all need to have people that care about us, but I really don't want to be a burden on anyone.  If they care for me enough to want to do things and it makes them happy when they do – that's the way I felt about Ann – then fine.  But that's all I want, something that works for them.  And not too much.  And, I don't want someone who knows how to show empathy – I want a real friend.  Take that fake stuff and send it out to some clothing store in Walnut Creek.  Act as though you’re empathetic, gin it up.  Not for me, I think.

But what caregivers, like Ann had?  These wonderful professionals that we relied on and whom we made friends with – some of them.  I can accept their caring, they're being paid for it, take it for what it is.  But sometimes, of course, it becomes real.  I'm going to go out to lunch with Ann's chief caregiver, Lai, pretty soon, and it's been over 2 ½ years since Ann died.  My admiration for her is immense.  She was there a lot, and I guess we all got to like each other, and to admire.

It's not an easy subject, but I guess appropriateness and honesty are the hallmarks.  I guess.  I guess there are others, too.

Budd Shenkin

Organizing A Medical School To Teach Humanistic Mediciine

Most medical schools do a very good job teaching scientific biologic medicine (BioM).  When it comes to teaching humanistic medicine (HM), however, the story is not so clear.  It's not clear for a reason – although BioM and HM must go hand in hand in the actual practice of medicine, HM is universally treated less directly and with less intensity.  Most medical schools have some introductory classes during the first year or two of school, and they hope that exposure to “excellent examples” in the clinical rotations will lead their students in the right direction.

(For a decent definition and extensive examples of what HM entails, see here - http://buddshenkin.blogspot.com/2024/06/the-pressing-cogency-of-humanistic.html.)

Let us pose this question: IF A MEDICAL SCHOOL WERE TO TAKE SERIOUSLY ITS RESPONSIBILITY TO PRODUCE GRADUATES WHO WERE WELL PREPARED TO PRACTICE EXCELLENT HM, WHAT WOULD THEY DO?  

How might they organize themselves to accomplish this task?  If you are going to do a job seriously, you want to organize yourself seriously.

FIRST, they would set a formal goal.  Say, formally, that they will seek to ensue that their graduating students excel in HM.  The students are their ultimate test.

SECOND, they would adopt a set of measures, so that if they are going to pride themselves in producing students with excellent training in HM, they can take that pride rightfully.

What are those measures to be?  There are two general measures we have in medical school.
 
One is testing – it's pretty easy to devise tests in BioM, and students face lots of them – the basic science courses have their own written tests, just like college course tests.  It would be possible to devise similar tests for basic HM subjects.  (E.g., “name the three basic types of doctor-patient relationships as described in the Szasz and Hollender paper.”)

A second one is time spent learning under tutelage, as medical students spend months in general surgery, months in internal medicine, etc.  During these rotations, residents and staff teach and observe the students as they perform tasks, and they judge whether or not the student has grasped the basic concepts and skills, and whether or not they need more training.

This second method of measuring is much harder to do in medical school.  For one thing, who is to say that the house staff and attendings know much about HM themselves?  Many don't; in fact, many incarnate excellent counter-examples – they implicit message to students should be, don't be like that!  So what to do?

The answer to this might be, organize the concepts, and organize the teaching staff.

FIRST, the medical school should establish a core list of HM experiences and knowledge for every student, a set of expectations that each student will have been exposed to by graduation.  Have you had a patient that you know will die?  Have you been at the bedside when a patient dies?  Have you been debriefed by a sympathetic teacher to examine what the patient went through, what the family went through, what the staff went through, what you went through?  

That's just one example.  Every medical school should have a core list of experiences that every one of its student will have had by graduation.  The students should know what this list is, and be able to fill it out as their undergraduate career progresses.  If they have trouble filling out some of the needed experiences, they should have a faculty advisor to help them find the missing parts.

SECOND, just as in college we have core requirements for a major, and distributional requirements outside of that major, there should be a set of alternative courses and experiences that involve HM for each student to choose from, so that some wider exposure to the HM side of medicine can be obtained, some windows opened.  There could be mini-courses in narrative medicine (telling the story of the patient so that the patient's malady has some meaning,) spiritual medicine (religion, faith, and higher powers), medical sociology and anthropology (roles of doctors and patients, expectations in different societies), or medicine and illness in literature.  There could also be rotations in particular areas that require HM particularly, such as hospice care or oncology, or visits to patients in non-acute facilities and in their homes.

What the core HM curriculum is and the alternative HM curriculum is would change through the years, but it would be important elements to have.

THIRD, it would be important to assemble a faculty devoted to HM.  It is most likely that scattered among all the doctors and all the officials and all the departments and divisions at the medical school, there are many individuals who are devoted to the ideals of HM.  It is likely that they are not organized, that they know many like souls, but they do not have concerted efforts.  Bringing together these self-identified HM oriented faculty in an advisory body, where they could trade ideas and observations and advise the administration would most likely constitute a great leap forward.

For the didactic and conference courses that are directly devoted to HM issues, there are faculty already teaching some or these courses, and recruiting others should not be hard.  In each clinical department, the odds are that there are departmental members who are interested in and even devoted to the HM mission in medicine.  There might be more in psychiatry than there are in urology, but they are there.  Sometimes older members of the department, or even retired members of the department, will be particularly skilled in HM and eager to pass on their knowledge and experience.  But it could well be helpful for each department to have someone who is specifically implicated to survey the experience each student is having, and help each one get a thorough exposure to HM as seen by that particular department and that particular leader.  There will be variation that way, but that's a good thing.  Let the experiences vary and let the students figure it out!

FOURTH, there needs to be some centralized organization of the HM curriculum.  If it's everyone's responsibility, it's no one's responsibility, says managerial science.  There might be someone in the upper echelons whose responsibility is HM.  This person should be responsible for the HM curriculum, the HM teachers, the HM measurements, and for ensuring that every single student is getting good education in HM.

This HM official would be the one to shepherd curriculum development, to liaise with all the teachers, to meet regularly with students and student groups to get feedback, to organize courses and lectures and dinners and trips – the whole nine yards.

Note: even with increased centralized organization for HM, I am NOT recommending increased bureaucratization and centralized authority.  The administrative center for HM should be called “Support for HM.”  Their call to the departments should be, “What do you need?  How can we help you.”  It is a good plan to have centralized goals and objectives, and decentralized implementation.  

And now, to repeat in different words, because every call to action needs repetition, the “this is what I just said” section.

• There should be a core list of HM experiences and knowledge for every student, a set of expectations that each student will have been exposed to by graduation

This list should be continually adjusted by faculty and student consensus
Each major experience should be followed by debriefing, where reflection with a faculty member or surrogate is pursued
Each student should have a check list of experiences the student has had, and whether or not there has been debriefing and teaching following the experience
The HM knowledge and experience of each student should be measured

• There should be administrative centralization for HM, which would

Continually review and adjust expectations for students
Make liaison with all clinical placements for students to survey and augment HM experiences in the departments
Maintain relationships with all independent HM-related activities to enable student participation
Maintain direct student relationships to monitor and enhance HM student experiences
Coordinate mentor relationships, both faculty and alumni and others

• Each clinical department should have a designated officer for HM, who would both teach directly and be a resource for experiences throughout the department, and a liaison with HMS administration and with other HM departmental officers.   

Diversity of departmental approaches should be nurtured and respected.  This would be a perfect opportunity to utilize more senior departmental doctors, and even retirees.

If a medical school is to be justifiably proud that its graduates have obtained firm mastery of many aspects of HM, just as medical schools are traditionally proud of its graduates' skills with BioM, the medical school needs the structure and the data for that pride.

Excellent medical care needs humanistic medicine as well as biologic medicine to be practiced; they are partners, and HM needs to be taken as seriously as BM.  Organizing for the task is necessary.  I hope the medical schools can take the HM task seriously.

Budd Shenkin

August, 1982, and July, 2024

 

August, 1982, and July, 2024

I think that Kamala might be elected in a landslide. It's too early to tell, but if she were a stock, I'd be a buyer.

I have looked at the stock market since I was in my 20's. I can't say I've had constant success – I haven't – but I made enough to buy my first house when I was 33, and I took formal courses on technical analysis of the stock market at Golden Gate University with the great hank Pruden in the 1980's, and I know something about it.

I've also followed politics since the age of maybe 10. I remember the headlines about the Korean War – Inchon Landing! I remember when Truman fired MacArthur – I supported Truman. I know something about it.

What do the stock market and politics have in common? While both of them have issues of substance that one can seek to understand – they are called “policies” in politics and “fundamental analysis” in the stock market – both of them are governed by popular mass psychology. So, that's where I think the overlap is.

A lot of technical analysis works off charts – in fact, technicians are sometimes called “chartists.” The chart of stock prices shows a picture of popular opinion of what a stock is worth through a time period. Technicians try to make use of these charts to find common elements through time to be able to recognize recurrent phenomena. In other words, standard pictures that you can recognize that you have seen before.

I remember August, 1982. There had been a long decline in the market; there had been a stubborn inflation and then a rise in interest rates engineered by Paul Volker at the Fed, with the intention of producing a recession that would cool prices down. You can see it in the first half of this chart.

Opinion on stocks was negative, and prices reflected that negativity. In fact, opinions were so negative that some technicians (but not fundamentalists) were predicting a stock market rise, although they didn't know when, because when opinion swings strongly one way, that's a contrarian sign that there is a reversal in the future. You just don't know when.

But for here, let's just concentrate on the decline – prices were going down. They kept going down and down, everyone got depressed, and finally, even the most optimistic started to get depressed. They capitulated to pessimism – that's the technical analysis official term for what happens at such a time, capitulation. There is no one left to sell stocks, because everyone has already done so, and the last sputter is the capitulation.

And then, all of a sudden, very suddenly and unexpectedly, something happened, and prices turned around on a dime and started to shoot up. They shot up fast. Volume climbed – everyone started to pile in. No one knew why, but there it was in front of you. Mass psychology sees big changes fast. And that chart shows what the turnaround looks like. It's not tentative – not only do prices start to rise, but they do it on big volume (lots of shares traded,) out of seeming nowhere.

So, my thesis is that we could change the x-axis (the abscissa) from the first years of the 1980s to the last year or two in the 2020's, and change the y-axis (the ordinate) to Democratic popularity and “good job” ratings, and we then have picture of political mass psychology.

The popularity of Biden and the Democrats was constantly tending downward. The final event in this series was the June 27th debate. What a horror show! I was watching it alone on my blue leather couch in the TV room, and within three minutes I said – “Disaster!” Confused and slate white, mouth agape, words hard to find, Biden looked about 95 years old. He shuffled. He kind of rallied later, but the damage was done, and everyone could see it. The Democrats were cooked – put a fork in them. Even Trump didn't quite know what to do, the breakdown was so complete. His choice of JD Vance just over two weeks later reflected the capitulation; Trump thought he had it won, so he might as well get a fire-breather.

Not so fast, old man, not so fast. The last sputter of a bear market can be deceptive. Unlike the stock market, here we can discern a clear change that led to the public perception change – Biden withdrew and Kamala stepped in with authority – with great authority! How she has grown! Poised, confident story-telling, taking her time as she builds to the climax, the wind clearly in her sails. Hey, man, that was the bottom! The debate was the bottom. Look at what's ahead. It's not tentative, the financial contributions to Kamala are the equivalent of stock volume, which tracks enthusiasm – it's a bottom followed by a breakout to the upside.

So, we could trace some of the fundamentals – all the issues of the Democrats are more popular than those of the Republicans, for instance, they just have to be recognized by the people.. But the charts will tell us if we have identified it correctly. In the stock market it's the earnings that come in later, after the turn, the fundamentals follow the technicals. Politically now, the chart predicts that the polls will turn, more money will roll in, more endorsements, some good debates, etc. That will come. But right now, we're just looking at the chart, and if thing go as I think they will, we're looking at our first woman president next year, and preservation of the Biden legacy, and the much hoped-for political demise of Trump. Personally, I think it could well be a landslide.

But, in both stock market and politics, you never really know. As they say in sports, that's why they play the game. And to quote my father quoting an old English apothegm, “There's many a slip twixt the cup and the lip.”

Budd Shenkin

Bad Night?

 

The debate Thursday night was a disaster for Biden. He was tongue-tied, he got lost, he looked really old. The Democrats have a problem. There is still, barely, time to change horses, but probably only if Biden himself calls it quits, which he obviously is not ready to do.

Then there would be the awful brouhaha with Kamala. She would be the “obvious” choice in terms of placement as VP, but not in the hearts of her countrymen. To me, she has the permanent vision of superficiality. She's sharp, she can hold her own on stage, but her campaign for President was a disaster in terms of organization, and in terms of her self-presentation. She didn't have a firm grasp of issues – for instance, beyond saying “single payer health care system,” she had almost no idea of what it entailed, her allegiance to that idea was purely political, where does it place me. Ask her about it, and it's a void. Her vision is very narrow. And let's not even go to her chronic inability to manage an office at any level, and think how could she organize the office of the President. Talk about disaster.

But if you go to the other natural contenders, and if they are victorious, the self-proclaimed vital center of the Democratic party, black women, (which I don't believe, by the way) take a hike over being disrespected, decry racism, and damn the consequences for democracy. So, that's a wonderful scenario.

Foreseeing these and other complications, the Democrats shy away and proclaim the Thursday Disaster “a bad night.” We all have them, says Obama. It's time we have his back as he has had ours, says Newsom – who must be ultra-loyal in public to preserve his viability, of course, and at the same time he shows off his verbal abilities – it's a subtle show, but not too subtle.

But was it just “a bad night” that anyone could have had? Tim Miller says, convincingly to me, that "a bad night" minimizes it.

What's confusing is this:

Biden has a basic disability with language, stuttering being only one part of it.  He has difficulty getting from thought to verbal expression; you can see him getting frustrated with it.  He doesn't organize his thoughts well – that's why he always resorts to a list of numbered points – “that's one, and now, number two....” You could even call it an expressive aphasia. As with so many people with disabilities, he has found workarounds to get around it all his life, and it's so interesting that he has chosen a field where his disability is right in the center of what he has to do -- verbal expression and politics are inseparable.  It's like if someone with congenitally stiff and deformed fingers decided to become a graphic artist.  It's a constant struggle, and the battle line varies, sometimes it gets overcome, and sometimes it overcomes you. So, if you view his performance as a battle with disability, "bad night" could capture it.

But then there is aging.  His thoughts might be as clear as they always were, but the aging process seems palpable in his appearance.  It's a job that ages you, that makes the natural decline more severe, more precipitous. Obama's whitening hair didn't really bother anyone, but he was at the top of the aging ramp. That's hardly Biden's position.  So you have to wonder, is he really being propelled in an increasingly downward slope?  This year, OK, he's very functional - but 4 years????

It's that latter construction of the events of last Thursday that are most frightening - beyond figuring out whether or not he can beat Trump. And meanwhile, just by the way, whoever prepped him did a crappy job, overloaded him. He needed a little Marco Rubio “set speech,” rather than trying to be ultra-verbal and ultra-adaptable, being able to cut and paste his thoughts seamlessly as the occasion demanded. He needed less “if he says this, say that,” and more “just say this.” Someone was teaching a singles-hitter to go for the fences.

So we'll see. Best scenario – Bad Night! Bad Preparation! Bad Cold!

Let's stick with that. I'm not going with worst scenario this time around. Been there....

Budd Shenkin

Losing A Friend

I met my friend Mary Lou about a year ago, when Rich Ash, who I had hired as our medical director at Bayside Medical Group, who had lost his wife to cancer about a year after I lost my wife to Alzheimer's, invited me to walk around the 2.7 miles of the Lafayette Reservoir with him and two of his friends from his gym, Mary Lou and Marcia, every Saturday morning at 6:45 AM. It's pretty dark then in winter, and pretty light in summer. I said yes with trepidation – pretty early! But now I'm not only used to it, but it's a mainstay of my life. We walk at a 19 minutes per mile pace, we talk, usually paired off to me with Mary Lou and Rich with Marcia – rumor has it they talk about their dogs a lot. Early on I thought it would be great to eat breakfast afterwards, and we found Millie's American Kitchen in Lafayette, which opens at 8 AM on weekends and is perfect. It's an about 10 table restaurant, run by owners Victor and Aimee, intimate but well-lit and happy place and really good food. It's usually Mary Lou and me, Marcia is not a breakfast person, and Rich usually runs off to his puppy now become dog, but he's come I think twice. We're regulars, so Vic and Aimee expect usright when they open at 8, we have our table set up for us, and we order the same thing every week, and I think it's fair to say that Vic and Aimee have become friends. Just a few weeks ago when we got there Victor said that they had some news for us but he would let Aimee tell us, and she didn't say anything but just showed us the fourth finger on her left hand and there was a diamond. We congratulated them both – they were radiant – and Aimee said, well, it only took nine years. She's awfully cute, with a baseball cap and about 15 colored pens in her apron which seem to be gone by the end of the shift.

So Mary Lou and I sit there in our comfortable corner table and talk, careful not to stay too long if there's a line up outside, but it's not unusual for us to arrive at eight sharp and go around nine-thirty. That's usually the only time we see each other during the week, although once or twice we've had lunch on another day, and once I took her to the ballet and we had dinner first down on College Avenue at King Yen, where I have eaten for about 25 years or so. Mary Lou is really comfortable to talk to, we are both good at accepting each other for who we are, and there is much to admire about her. She is always busy, doing things for other people, Rotary Club, her church, giving to her daughter Kelly's 501 (c) 3 clothes and furniture and sundries recycling store at King's Beach in Tahoe, and she walks the reservoir maybe three days a week and works out at the gym which keeps her ultra-slim and healthy, and she's always doing something with community or church spirit.

We talk about this and that and you never know exactly where it's going to go. We had walked around the reservoir today, I forget what we talked about, it was just her and me because Rich was jet-lagged and Marcia had something to do, it was a gorgeous day and I felt so good and strong and not too heavy. I almost ordered something different from my farro oats and fruit on the side but I stuck with what I know and then got an English muffin just because I was feeling good. We were the only ones in the restaurant to start with and Vic and Aimee shared their distress at Biden's debate performance, and wondered what he would do not just a couple of months from now but for four years after that, and we agreed that he shouldn't have run again. Mary Lou spent all day yesterday writing and addressing get out the vote and vote Democratic postcards.

Eventually, after we finished eating and I was just sipping my decaf and we had talked about other things, I told her of a difficult phone call I got a few days ago. I told her, as a warm up, once again about how lucky I was to have such a great high school class at Lower Merion High (yup, Kobe went there after we did, a lot after we did.) We were smart, athletic, fun loving, compatible, school sports and pick up sports, and our poker games. Poker on the weekends, pretty much every weekend, at rotating houses, at our peak so many players that we need two tables. Mixed, Jews and gentiles, about half at the top of the class, all together in high school where we have started the second phase of life, having metamorphosed from being kids to being early or pre-adults, but enough adult that we remember so much of those days, while elementary school and junior high is more of a blur. We were all together, such friends! Such friends. Some didn't play poker, John Raezer didn't and Jon Gross didn't, but they were still friends, close friends. Lynn Sherr didn't, but she was such good friend. Barb Geyer didn't, but her, too. Half of us were in Special English with Mrs. Hay, the first real college type class where we sat in a circle and read Plato and Darkness at Noon, and Shakespeare and Tragedy and Freedom and Responsibility and John Stuart Mill and such other stuff, it was like college. Johnny Fish didn't play cards either, but he came to the games to be friendly, and when the game was at my house he sat over to the side and looked at our bird books – Fish knew all the birds – and my little sister Emily fell in love with him and hoped he'd wait for her.

So it was Fish who called me this week. He lived in Bala-Cynwyd, and there was a little alley behind his house and just across the alley, maybe literally a stone's throw, lived John Bernard. Fish was about 5'7”, maybe he'd claim 5'8” but I'd dispute it, and Bernard was about 6'3” and bulky. They were athletic as were we all. Fish went on to be soccer captain at Brown, and poker players Ed Packel and Bill Strong were co-captains at Amherst, and they weren't even the best players on our team – they claimed that Tom Harrison was, but he wasn't part of our friendship, our group. But Fish and Bernard most certainly were in the heart of our group, Bernard an avid poker player. Bernard went on to Swarthmore and then Harvard law, came back to Philly and worked at Ballard-Spahr for decades. Frankly, for such a smart guy, although he had a fine career as a Philadelphia lawyer, I was disappointed in him – he was very smart, and an independent thinker. When we passed around our papers so we could read each other's in Special English, I thought that Bernard was a better writer than I was, and I vowed to do better, which I did, although it took lots of effort and years, years. But Bernard really was quite smart, and yet I thought maybe he didn't connect with a mission, although maybe I'm wrong there. His mission was often sports, and especially baseball. When it came time to retire they asked him to stay on and emphasized that he would make a lot of money, but he told me that he just really didn't care about the money, that he just wanted to go to baseball games and see his kids, and actually just after he retired he told me he had lost 50 pounds. I was in Philly for some reason and made a point of seeing him. We walked from somewhere to somewhere else and we were somewhere near Broad Street near the Ritz-Carlton where Ann and I tended to stay, and he did confide to me, as a doctor, that he wondered what he should do about constipation and I advised Metamucil. He was so healthy he took hardly any pills at all, which I was amazed at, because I take so many, along with Metamucil for regularity of the aging.

We had a great class, the class of 1959, a large number of us stayed in touch, if not actually, then in spirit, and since email appeared as a technology, about 10 or 15 of us are in email connection. I'm tempted to go into all that we achieved in life, which I'm very proud of, but I'll hold off. Lynn was a nationally known newscaster for ABC, lawyers (Bernard and Birkhead), and doctors (Fish and me) and two math professors (Packel and Gross) and writer (Seidman) and economist-financial analyst (Raezer) and professor of 19^th century French literature at Sarah Lawrence (Angela Schrode), sports business person (Strong), founder of Pushcart Press (Henderson), initiator and godfather of the University of Michigan lacrosse program (DiGiovanni), and there was Ricky Shryock who was the best hitter you ever saw (Lafayette) and so loved by everyone, and other people and stuff I'm forgetting. I'm so proud of them. It reminds me of those movies where you see what became of them – Animal House, Stand By Me, American Graffiti.

So, I knew that Bernard had had his problems recently. Bernard and Gross and Raezer had been having periodic lunches and then Bernard came out with something that sounded pretty anti-Semitic and Gross is a religious Jew with strong Israel attachment and he said he couldn't associate with Bernard anymore and Raezer, ever the conciliator, tried to patch it up but couldn't. Then Bernard called Raezer a few times and Raezer said that Bernard wasn't making sense. Then Fish called me to tell me that he thought Bernard was getting demented. And then this last week Fish called me and said he had bad news and I braced myself and told me that John Bernard had died a few days ago. Norman Ezebil had been visiting him in a facility where he was and it was Norman who got in touch with Fish. We don't know what's up with Bernard's wife Esther, his second wife, another lawyer at Ballard Spahr, after his first wife had died, and we don't know if we'll hear about arrangements, about funeral, about memorial service. When my father died and we had a service just maybe two or four days after he died, somehow Raezer and Bernard got wind of it and just showed up, the two of them. Raezer had told Bernard, we should go. I'll never forget that, they just showed up, and afterward, it was such a moving event when all four of us kids talked and then others went up to talk, afterward, Bernard and Raezer came up to me, Raezer at 6'1”, Bernard at 6'3”, and they looked down at me (5'9”) and said how nice the service was, and they meant it, it was moving. Like you'd expect it to be boring, maybe some clergyman who didn't know him reporting on what surviving family had to told him. I'd love to somehow return some of the favor to Bernard, can't go to Philly now, probably, but at least do something, but probably won't be able to, because Esther keeps her distance, it looks like. Maybe Ezibil will know; we'll see.

So, after Fish's call I emailed everyone on our list and told them and everyone wrote back immediately, it makes us all so sad, and Birkhead said he's the first one of the poker group to die. Which isn't actually true, because John Tracy, ol' Mother-man Tracy, died a few years ago, as we know because his ex-wife and classmate organizes our reunions, probably we won't have another but maybe we will, but anyway, it's what we live with now because we've made it to our 80's. Who'd a ever goddamn thunk it, sitting around the able and calling the game of Itsy-Bitzy-with-a-tiddle, which I think Bubble Leidman introduced. It probably wasn't Bumbo Bray, another in and out member of the group. Gosh we had a lot of guys who played, some core, some now and again. My parents saw them all; I think they were so happy to see this great group, what a high school class, they all knew my parents. I guess Jon Gross hasn't emailed, he had to be so offended by what Bernard said, although maybe it could be chalked up to dementia – that's what I'd like to do, but I really don't know. I think it's a valid attribution, I'd like it to be, but I wasn't there.

I sat there at Milly's American Kitchen as the time went by, it was probably about 9 by this time, and I started telling Mary Lou about it, about Fish's call and the rest, and when I said “John Bernard” I couldn't help it, for the first time, I cried. I told her that after I had emailed everyone I saw that Raezer's email had bounced back so I called him, and he had already heard. It was good I called him anyway, because his wife Sally had just had her successful lower abdominal operation and John was very happy for that. He's had a rough go of things, heart arrhythmia and two weeks in the hospital which has left him weak and his balance is unsteady and his beloved daughter Julie is coming to the end of her road with her brain tumor, so we're in very close touch and we reassure each other continually that we love each other. Mary Lou believes in an afterlife but I don't, I think it's just like before you were born, nothing, so all we can do is tend to each other while we're alive and be kind and help one another and be friends and do what you can do despite all your deficiencies and be grateful that we have life even if it's only for an instant, but I had to cry and Mary Lou put her hand on my arm and I couldn't help crying and it was good I did because holding it in isn't the healthiest thing to do. We assured each other, Mary Lou and I, that we each try to do the best we can, and I told her very sincerely that she is always helping other people and she assured me that I was, too. But I thought of those poker games, and how talented John was, although he was definitely more thinking than feeling, but with a good sense of humor. One time Bernard asked Fish how he felt about the President of Brown calling for reparations and Fish said that he didn't want to pay the money and Bernard congratulated him on his principled response and I still laugh about it today. But who couldn't honor a choice of baseball over continuing his legal career, distinguished as it was, and making more money. That obit cite, by the way, came from Lynn, who wrote her memoirs in Outside the Box and had a few pages on our class with the same pride and celebration and description that I feel, that we all feel.

Mary Lou said that it's funny, she grew up in Hannibal, Missouri, the same Hannibal of Mark Twain, but moved to Naples, Florida for 11^th and 12^th grades and she knows almost no one from Hannibal but still has friends from Naples – where she was homecoming queen one year, I think, or some queenly honor like that. Sure, I said, it's high school. If you want to know where someone is from and they have moved around, ask them about high school, because that's really where we're from, those mid-teen years, that's where we're from. That's where we form ourselves, where we're first spending significant time away from parents, peer grouping, coping with maturing and fighting with our hormones as they push us one way and the other, playing sports and having class plays and finding things to do with each other and, significantly, playing poker. Where you're from is where you went to high school, and when you get older, you will increasingly suffer loses, until you yourself are one of the losses, and it will be a good sign of life if you can cry.

Budd Shenkin

The Pressing Cogency of Humanistic Medicine

 

Practicing medicine has always been a partnership of scientific biological medicine (BioM) and caring for the patient, or Humanistic Medicine (HM.) While BioM has soared to almost magical heights, many wonder if HM has withered, or at least not kept pace. Patients are in awe of the BioM advances, but they complain about not having the caring relationship with doctors they wish for, of having compressed visit times, of being treated by doctors who hardly know them. And doctors complain about being on treadmills, of feeling like factory workers, of not having time to relate to patients and to care for them as they want to. Patients get resigned to impersonality, and doctors experience burnout, alienation, and even moral injury.

That is not the full picture, of course. But it probably has enough truth to it that we should look closely at HM to understand what it is in full and why it is important, and to understand what is needed to make HM an effective part of medical practice.

 

Definition

There is no agreed definition of HM. Most definitions, however, have concentrated on the traits of the doctor (or other health care professional), as typically here: “the physician’s attitudes and actions that demonstrate interest in and respect for the patient and that address the patient’s concerns and values. These generally are related to patients’ psychological, social, and spiritual domains.” There are two problems with this definition. One, it specifies process rather than outcome. Two, it is too narrow; although the doctor is certainly a prime mover in HM, HM is the concern of the whole medical care team and system, not just the doctor.

Stated as an outcome rather than a process, the key characteristic of HM is the feeling the patient has of being a known and recognized individual who is being sensitively cared for and treated as a fellow human being. It's helpful to think of what it is not – it is not the feeling of being treated as a cog in a wheel, as an input or an output, a thing, a statistic, or (God forbid) a revenue source. It is the feeling of being understood and being put first, not last.

It is also important to recognize that, while the major intent of HM is better care for the patient, HM also serves the caregivers, including the designers and managers of the system. Giving personalized care is immensely satisfying to the givers. HM is a two-way street; it gives meaning to both sides. This is the way humanity works.

Two Types of HM Services

Medicine is both similar to and different from general commercial services. Like other services, good customer care can make patients feel they have been thought about and cared for – appointments may be easy to make, phone trees may not be excessive and talking to a human easy, waiting times may not be excessive, service personnel can be ingratiating and efficient, décor may be accommodating, prices might be reasonable, etc. Some of the BioM advances have made customer care in medicine more difficult – there are more specialists and services to visit, more treatments to decide among, patients can feel lost as clinicians don't coordinate well, their key PCP might not be the hub of the relationship they need, etc. Much of this is under the control of managers rather than clinicians, just as in other industries.

But medical services are also special, and like no other. Patients and clinicians can be under tremendous pressure, because medicine literally gets to the heart of our existence – life, death, disease, disability, anxiety, anguish. Contact is intimate, conditions are dangerous, touching, frightening, and sometimes miraculous. The depth of emotions touched in medicine are like no other. “Playing God” is not a joke. Conditions and care can be harrowing – sometimes patients have to be warned that they might not wake up from a procedure. The dependence of patients on the skill and caring of the medical team is total, the stakes sometimes the very highest. In addition, the variety of medical situations, and the variety of patient personalities, backgrounds, emotional needs, family and social support, etc. can be excruciatingly complex and highly charged. So it has been well recognized over millennia that special emotional accompaniment is needed in medicine. Unlike the general customer care part of HM, human interaction is required for this part, the assurance of someone who cares a great deal and knows how to show that caring is priceless. People need to be cared for, and it's never one size fits all.

Even the most determinedly independent people need and want to be cared for. Medical services need to take account of both general customer care and special medical care in order to produce the best results of HM. In the end, attending to these requirements will produce situations where both patients and caregivers feel the deep satisfaction of the caring phenomenon.

The Extent and Complexity of HM Services

While formulating general definitions of HM are important, in-depth understanding of the importance and difficulty of HM requires specifics.

HM is about feeling. Empathy and kindness are essential in all medical relationships, but to what extent that ideal can be realized varies with circumstances. In depth personal knowledge and feeling is much more possible in long-term primary care or chronic illness relationships, but even in shorter term relationships, chances for emotional closeness may be possible. It is actually quite amazing how one short visit can imbue a patient with the feeling of being understood and being cared for by the sensitive and experienced clinician.

It can take long experience to differentiate which of the three classic doctor-patient relationships is appropriate and possible for each situation - activity-passivity, guidance-cooperation, and mutual participation. Some patients and clinicians will be most comfortable with close emotional distance, others with more formal relationships. Sometimes there isn't a match and a transfer of caregiver has to be made. Knowing how to communicate clearly, to elicit patient responses about their feelings and how to “show empathy” is one thing. How to be genuine and authentic and not just acting the part is another. Too much involvement and not enough distance can be exhausting and dangerous to the well-being of the caregiver. Finding spiritual equipoise can be a lifelong struggle in the specialties where death and suffering are constants. See Figure 1.

Making HM decisions and relating in the circumstances of severe disease can require even greater HM skill. See Figure 2.

Discussions of HM frequently ignore the often substantial impact of giving HM on doctors and the other caregivers. See Figure 3.

Since care is usually delivered by teams, HM roles need to be established for the team. See Figure 4.

Sometimes reaching out to other disciplines can be very helpful in providing tools for understanding and giving perspective to our current ways of providing HM. Educating professionals is different from educating technicians, and providing a liberal academic view of HM can deepen the professional in ways that are deeply satisfying and helpful. See Figure 5.

Of course, not everything one needs to know about HM can be reduced to a list of spreadsheet points. But just by reading over these elements of HM, it should be immediately obvious how important HM is, and how difficult it is. And we can also appreciate that progress in BM has made HM even more essential. With more medical capability comes more necessity to explain and more choices to make, more clinicians are involved with every case, and it is now even more difficult for patients to have it all make sense and for them to feel cared for.

Requirements to Implement HM Services

It is incomplete to talk about what HM is, without addressing what needs to be done to implement HM in practice. It is tempting to think that aware and trained physicians will simply ply their trade and all will be well. Not so fast.

Implementing HM is just like implementing any program: (1) the leaders of the enterprise need to place a high priority on the task; (2) management and clinicians need to be capable of doing the job, (3) managers and clinicians need to have the internal and external incentives to do the job; and (4) the necessary time and materials need to be provided.

Prioritization

If HM is integral to the medical mission, then every organization that provides or finances medical services should have HM as a primary priority. The efforts and budget of each organization should reflect that priority. That can be difficult. Payment and productivity measures are based on the RBRVS system of RVUs, and RVUs recognize only BM services. HM services are “assumed” as part of the clinical duties, which are neither measured nor paid for. Since they are unpaid and unmeasured, time spent on HM tends to be viewed by management as waste rather than valued service. HR is treated as the stepchild of medicine, more of a constraint than an objective.

Although the obstacles are substantial, committed and imaginative leadership can make inroads. If enterprise leadership declares HM a prime enterprise goal, and management rouses itself with imagination and skill and involves clinicians and even patients in redirecting their practices at every level, progress is possible. In the long run, however, RVUs will need to change for HM to be properly recognized.

Management Capabilities

Do managers and system designers know enough to make customer care comport better with HM objectives? Managers are driven by notions of “economy,” but without taking into account the implications of “economy” on HM, “economy” can frequently entail reducing HM services. Managers will have to change their calculations, and HM will need to receive proxy values. For instance, managers might favor phone banks over local contacts with trusted and experienced staff, but that can be false economy. Likewise for central patient scheduling for standard appointment times, likewise for not leaving time available to see the PCP, rather than an ad hoc replacement. PCP's might be allowed to see their hospitalized patients, and these could be paid visits for HM services, rather than stigmatized as “social visits.” Managers will need new measurements and new HM awareness.

Clinical Capabilities

A glance at the figures offered in this paper may indicate how difficult mastering HM is. Most clinicians will admit that they are still learning HM to their last day in practice. HM training will need to be increased in training programs, so HM can be a true partner of BioM. HM is taught didactically much less intensively than BioM pre-clinically, and during clinical rotations, instead of conscious inculcation of best HM practices by senior clinicians, it is usually hoped that HR will be “picked up” by osmosis. The schools should probably create lists of what situations should be experienced and then discussed, and keep track; overt expectations are better than passive hopes, and well-processed experience is essential.

If ideal HM is taught and experienced in training, it is more likely that clinicians will demand the same in practice from themselves and from the organizations.

Incentives

Idealism is the foremost incentive that will drive HM in practice. Hoping to help people is a prime motivation in applying to medical school. If trainees see that HM is a prerequisite of doing good, they will seek to build it in their practices; they will demand it. It's possible that patients will prefer organizations where HR is intensively practiced, and it is possible that clinical recruitment to organizations might also prosper where HM is a priority.

It's true that HM receives no financial increment at present. The culture of a practice, however, leads to peer inducements. Leadership can create an atmosphere where HM is in the air. It is true that money is usually the most potent motivator, but even without financial incentives we can expect that leadership and culture can impel personnel to fulfill HM ideals. Recognition, reinforcement, and leadership can help produce a culture that favors HM. But it would also help if there were RVUs that also made HM individually profitable.

Time and Materials

Official priorities, knowledge, and incentives can all be present, but if managers and clinicians do not have the time to practice HM, and if they don't have the space to meet with patients, or the staff help to contact and serve the patients, or if they are not paid for their HM services, if the system does not make it easy to contact other doctors on a case for a “warm handoff,” then HM will not be well-practiced. The budget must reflect a high priority placed on HM.

Conclusion

While it is complex, HM is definable. While BM is of ultimate importance in curing, the caring provided by HM is a worthy partner. Humanistic care is not a frill, it is not an add-on, it is an essential, not only for the patient, but for every caregiver on the team. HM is not simple to teach, nor to learn, nor to implement in practice. HM might start with being nice and kind, and for caretakers to put themselves in the patients' shoes, but it might end in dealing with the meaning of life. Training programs need to start the process of teaching it, every care delivery organization needs to tend to it, and every clinician need to insist on it. Medicine has two hearts, science and caring, and both have to beat strongly if medicine is to fulfill its goal of tending to the patient's body and soul.

Budd Shenkin

Figure 1

Patient relations
	Understanding how and when to employ the various models of the doctor-patient relationship
	Knowing how to be emotionally present for patients, understanding emotional distance, how to be close but still be objective; developing one’s own style of relating to patients
	Being able to empathize with patients, learned from study, experience and practice, knowing how to communicate empathy appropriately in different circumstances
	Understanding and adhering to boundaries of patient relations
	Being able to adapt to different patient needs of relationships and caring style
	Knowing how to integrate professional demeanor with personal and professional authenticity
	Knowing how to elicit and communicate information effectively and sensitively
	Understanding the power relations between doctor and patients, and not using it inappropriately
	Treating patients with respect, as a patient with disease, not “the thyroid in 208,” not “a fascinoma”
	Understanding the power of projection, how patients need to feel they are in good hands
	Knowing how to handle difficult and provocative patients
	Understanding clinician anger when patients don't fulfill the sick role properly
	Understanding how to adopt different styles for short-term and long-term patient relationships
	Understanding both the commonality of patients, but the differences that culture and finances and other circumstances present
	Understanding the history of relational expectations, different national and cultural expectations, and how relationship expectations have changed over time, with patient independence emergent, and paternalism in decline

Figure 2

Severe Disease
	Knowing how to and when to give bad news, such as a diagnosis of serious disease, returning cancer, untreatable condition.
	Knowing when to stop treatment and switch to palliative care, involving and listening to the patient and family, but showing leadership
	Understanding how to cohere in 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 how to comfort families of the dying
	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
	Knowing how to adapt to belief systems and values of the patient to put life and death in perspective
	Knowing how to employ narrative medicine to help give share a meaning for the patient’s life
	Knowing how to integrate into present care physicians and caregivers who have treated the patient in the past, especially PCPs

Figure 3

Impact of HM on the caregiver Understanding the disquieting feelings of caregivers in confronting death, disability, pain, suffering, fear, isolation. The anguish of life and death. Understanding psychological defenses of clinicians against the pain of their feelings and intimations of their own vulnerability to disease and death. Understanding the pressure on caregivers in fields where patients frequently die Enduring and making sense of disquieting experiences and traumatic confrontations that doctors  Understanding the impulse to “do something,” the difficulty of “giving up.” 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 Understanding moral injury that can afflict the doctor inhibited from giving best care  Understanding conflicts that arise from serving 2 masters – employer and network on one side, the patient on the other Understanding concept of Health Fiduciary (similar to financial fiduciary), where doctor is charged with tending solely to the patient’s welfare, and how their own inadequacies may haunt the caregiver

Figure 4

Relationships with otherdoctors and caregivers Establishing common team understanding of patient’s and family’s psychological caring needs;assigning HM roles Understanding the strengths and limits of mutual support,how clinicians can support each other positively and appropriately 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 and let others lead

Figure 5

HM Adjunctive Tools & Perspective
	Narrative medicine	Use techniques of fiction to craft a story of the life and illness, make sense of it all
	Spiritual medicine	Understand structure of meaning to patient, putting religion, illness and life in perspective
	Literature of Medicine	See how healers experience their lives and cases, see the experience of illness and death in literary characters, giving increased depth to the understanding of our place in the world
	Sociology of medicine	Understand roles (e.g., the “sick role”), expectations of attitudes and behavior in medical care relationships
	Anthropology of medicine	Understand how different societies understand illness, the healer role, religious processes of cure
	History of medicine	Understand role of the doctor when little could be done, how caring predominated over curing, beliefs of health that now seem strange to us, how patient autonomy has now become more the norm than paternalism
	Medical payments	Understand how payments shape behaviors, how caring has been under-recognized and underpaid
	Health Care organization	Understand how different organizational modes - the staff model, the group practice, vertical integration, use of hospitalists - affect modes of connecting to patients