Saturday, June 22, 2024

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


Wednesday, June 19, 2024

A Sad Boy And An Angry Mother

 

I don't remember the details, it happened when I had been maybe 20 years in practice, so I had gotten fairly good at the job. I always like the well visits, especially the teen visits. There was no formula for that, you just had to be prepared for whatever might happen. Sometimes I fumbled – like one time when a boy told me he was gay, hadn't told his parents, just chose me to come out to. I did my best to reassure, reassure that telling his parents would be a good step and I could help if necessary, but I wasn't sure-footed. Or another time when a teenage boy came with his mother, and he had gotten his girlfriend pregnant, and she didn't want an abortion. His mother wanted him to marry the girl, but the boy wasn't on board for that. The Mom asked me if I could tell him what to do. That's a pretty tough assignment. I kind of stumbled through it. Pediatrics is sometimes harder than people think.

So, this one time, I came into the exam room with a maybe 14 or 15 year old boy and his mother. The pediatric exam rooms can be small – this one was maybe what, 7 by 11? Narrow. High examination table on one side (pediatrics) with a counter and sink along the same wall, a couple of plastic chairs opposite them on the other narrow wall, a window at the end. The boy might have been sitting on the exam table, or standing by it, and the Mom was at the end of the room by the window. Usually I would see the teenager alone, but this time the two of them were together. Both were dark-haired and maybe Mediterranean or Armenian, I don't know, not that it matters, Oakland is one of the most diverse cities in the country. But there was some kind of tension in the air. They were probably in there together because there was something they wanted to talk about. We would have acceded to that, we weren't rigid, there were reasons for everything, and it was our job to be flexible. I liked these meetings.

So, I remember kind of sizing up the situation as I walked in. I said, so how are things? The boy was just starting to get a mustache, I think, and he had his head down the way boys that age do when they are doing something difficult and they are still immature, and he kind of murmured, “Ah, not so good.”

“Not so good?” I said. “What's wrong?”

And he looked toward his mother and murmured, “She's mad at me all the time.”

I looked over toward her myself, then I looked back at him. “What is she mad at you about?”

“Everything,” he said. “Homework.”

I looked back at her and she was a little tense, but she was unapologetic, and she said something like, “He won't do it. He won't settle down.”

We must have said a couple more things, but there it was, they had brought their problem to their pediatrician, who was me. So, as I said, I had racked up a fair amount of experience in practice by this time, and I thought with all this practice my batting average was rising, so I took on the challenge. So I turned to the boy and I said, “So she's mad at you a lot. And that's upsetting, right?”

“Yeah,” he said.

“Do you think she doesn't like you?” I said.

“I think she hates me,” he said.

So I looked over at her, and she didn't know what to say. She just looked forlorn.

“Because she's mad at you,” I said.

He nodded.

“You know,” I said, “I can see that it feels like that, but I don't think she hates you. I think she loves you. But I think she's yelling at you because she's afraid.”

He looked up in surprise. His eyes asked me to explain. I turned to his Mom and said to her, “Do you love him?”

“Of course I love him,” she said. The boy looked at her and heard her. I turned back to him.

“She loves you, but the reason she is getting mad at you is that she is afraid for you.”

His eyes said to me, “Why is she afraid for me?”

“She's afraid,” I said, “she's afraid that if you don't do your work for school, if you don't take it seriously, that you won't be able to go on to college, and your life will be hard for you, and she's afraid you will grow up to hate your life. She's afraid for you.”

I looked over to her, and she was relieved that it was explained the way she had wished it would be. That's why she was in the exam room with him.

I looked back to him. His head was up now, he was looking over to his mother, he wasn't afraid an afflicted anymore. I don't know if he looked inspired, but at least he felt loved.

When they left the exam room, they were walking together. They were together. I have no idea how things worked out, but at least something was cleared up. If things hadn't turned out better after that, they would have been back, that I'm pretty sure of. I thought I had gotten another solid hit, maybe not a homer, but a double anyway.


Budd Shenkin

Friday, May 24, 2024

A Day in the Life - My Car, Rock and Roll, Moving On

This year, my friends and I have generally allowed that the Warriors failure to make the playoffs was foreordained. Several of us were hot on the Knicks, especially the two graduates of Columbia. But Philly boys like me had more trouble with the Knicks – it's just so hard to root for NYC teams! – despite the three Villanova guys. Needless to say, we can't root for the Celtics ever. So I'm kinda going for Indiana, kinda like Minnesota – anyway, it's an interesting playoffs this year. But then one of the Knicks fans wondered how I was going onto rooting for other teams. So I answered him.

A mark of fandom is to be able to move on!

Believe me, I'm much more interested in having gotten my tire fixed today and getting my stolen car back into shape (2011 Infinity M56S.)  I was avoiding it, and now I'm re-embracing it.  I love my car - the guys at the dealer all say, it's the Cadillac of their line, and if I'm getting rid of it to let them know to bid on it.  Do I dare fall in love with it again?  

As I sat getting it fixed, using my computer, in came a black grandmother, very heavy, and her two teen granddaughters.  We talked about how she was lucky to be able to get into the dealer right away, because her car was failing on the highway as she drove from Modesto to San Jose - turned out to be a faulty battery terminal, and they fixed it.  We asked the girls if they knew anything about early rock and roll - they didn't - or rotary phones, or stick shifts.  We talked about popping the clutch and speed shifting.  I knew more about 50's rock and oll than she did because she was born in 1953, she said. I told her I loved my car especially since my wife had picked it out for me as we shopped together, and how she had died, and the lady asked me how long we were married and I said over 40 years and I said I always let Ann pick out my cars for me and I teared up a little and she said that's a long time and I played channel 72 on Sirius XM coming back home, 50's music, rock and role and Patti Page and even Doris Day, and when it was the rock and roll I teared up again and even sobbed a little, and I thought it was really about Ann; I told the lady that she was my girl.  Then I picked up Lola and took her to her guitar lesson on Lakeshore in Oakland and somehow the car and rock and roll of the 50's - Lloyd Price, even - and having my car and having my housekeeping and gardening couple, Antonia and José here, somehow it got me together.

So let's keep the Pacers-Celtics game in its place.  I still have to root against the Celtics.  It's on the list of essentials.

Which reminds me that Karim Emil Bitar, one of my friends on Twitter, Lebanese in Paris, expert in foreign policy and Lebanese politics, said that WiFi access had to be on the new list of Maslow essentials, maybe near eating and breathing.  So life goes on.


Budd Shenkin

Sunday, April 21, 2024

Elite College Campuses Erupt - What To Do?

 

Elite college campuses erupt. Administrators and fund-raisers, known as “presidents,” largely don't know what to do. It's really not that hard, fellas and gals, or it shouldn't be.

Based on what we learned in the 1960's and 70's, what should we think about this? I have a bunch of thoughts, not yet congealed. One thing for sure – don't let it fester. If you do, general reaction will be to elect Nixon and Reagan. Letting it fester, without guiding the flow of the stream and just letting it overflow, would be malpractice.

It's interesting that the outrage over probable war crimes against the Gaza population has quickly metamorphosed into cries to wipe out Israel.  I guess that's the way these things go, especially in the spring.   A lot of Arabs among the university population is probably responsible for a lot of that.  It's par for the course worldwide for many lefty faculty to have delusions of sainthood. Idealism is a good thing. But fanaticism is a bad thing. Enforcing laws can help to tell the difference.

It is such a shame that so many administrators are inept.  They should offer alternative, acceptable ways for students and faculty to express themselves - set up places where they can give their talks, let those come who want to.  Think of their presentations as teach-ins, provide safety for all who come, no to counter-demonstrations, but yes to counter teach-ins.  If there are to be direct person to person confrontations, they need to be supervised. You say universities are about the search for truth? Make it so. Use your words. If they don't work, you'll have to use your monopoly on violence – meaning expulsion, fining, incarceration. Indulgence doesn't stop contagions.

In other words, just saying "not this" is not enough; they have to offer the alternative and say, "not that, but this."  And then enforce it.  Letting things go and hoping they will burn themselves out is stupid; they don't, or at least not for a long time.  The specific penalties and enforcement means can vary.  Certainly, anyone from outside the campus needs to be prosecuted if they make trouble.

While I deeply disagree with the sentiments of the protestors, it is just elementary to say that they need to be able to express themselves.  If they want to practice civil disobedience, they should not be physically harmed, but they should be prosecuted; civil disobedience contemplates this consequence. No blocking of the ordinary business of the university, no canceling of classes, no intimidation. If they feel deeply enough to be expelled and arrested, trusting that they will be proved right by time, they can do that. Personally, I think they will regret it, but then, I was careful not to get arrested in 1969 when I marched in the streets of DC. I don't go nuts.

The incompetent leaders of these universities need to remember that the spread of student uprisings in 1968 obeyed the epidemiologic rules of contagious spread.  Prevention needs to be practiced. When student uprisings occur, reaction is just around the corner.  Although, as a friend pointed out, 2024 is far from 1968.  The country is divided, but not on fire.  Still, as a householder who had the Oakland fire come within three blocks of his house, I'm convinced that making sure fires are well put out is a good practice.

What should Jews do?  Unlike the Jewish fascist government in Israel -- Netanyahu, Ben-Gvir and Smoltrich are basically the Killers of the Jewish Dream -- righteous American Jews should call for debate, call for civilized discourse, positively acknowledge the right to free speech, and at the same time call for enforcement of law, and express their own willingness to let the law be enforced. They should also tell the administrators that if they don't enforce the law properly, they will be forcing Jews once again the protect themselves, and any blood will be on the hands of the administrators. Jews will not be bullied. You do it, or we will. Schmucks.


Budd Shenkin


Sunday, April 14, 2024

Humanistic Medicine -- Definition and Importance

 

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


Narrative medicine

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

Saturday, March 16, 2024

Israel, Anti-Semitism, And Our Dilemma

 

A friend of mine sent me this disturbing, unbalanced expression of discontent by Joel Kotkin from The Claremont Institute. > https://americanmind.org/salvo/golden-land/. Imagine, unbalanced right-wing distraught expression of alarm from the Claremont Institute, who'd a thunk it.

Before the war, last February, in an acclaimed blog post, I set out what I thought US policy should be toward the increasingly illiberal leaning Israel. I said basically that much of what had drawn us toward Israel for decades, before the Likud-Netanyahu-extreme religious right descent, had disappeared. So we had to start regarding Israel as an ally of convenience more than an ally of conviction.

http://buddshenkin.blogspot.com/2023/02/on-israel-and-american-policy-toward.html.

Now, of course, our dilemma is even more acute. If Israel makes it difficult to support them, Hamas of course makes support of them totally impossible – except they are getting it. But I'm getting ahead of myself.

In reading the Claremont article, which bemoans what he identifies as rising anti-Semitism and insufficient public opposition to anti-Semitism, I find some agreement. I, too, am appalled at the support given to the lefty teachings.  I am appalled at the pro-Hamas virulence, and the lack of arrests and expulsions when they cross the line.  Lefty faculties are appalling.

But, once again, there is the problem of anti-Israel vs. anti-Semitism.  They are not the same.  I think much of what Israel has done, has been, and continues to be appalling, and it has spawned ever more Israel isolation in world politics.  i find too many Jewish organizations saying, either you're pro-Israel totally, or you're anti-Semitic.  Israel would have a lot more supporters if their politics and West Bank actions and declarations of intent to wipe out all Palestinians were not so dreadful.  Netanyahu and colleagues have squandered the ethical high ground that Jews have occupied previously.  There is a reason so many American Jews, and others who would be friendly, hesitate in their support of Israel.  Most people feel, I think, that Israel has a right and a necessity to exist, but not a right to oppress.  Not to whitewash the dreck of Palestinian and other Arab and Iranian organizations, and not to whitewash the ignorant anti-Semitism of the unwashed left here and abroad.  And certainly not to whitewash all the anti-Semitism exported from Arab countries.  I wish they would all return to where they came from and see how they like living under Assad and other friendly murderers.

Likud and the Israeli right wingnuts have put Jews worldwide in an impossible position. How do you support liberal values and the existence and need for safety for Israel, when the state of Israel's policies are so difficult to support?  It's so difficult to say one hates the government and its policies and that some of its leaders belong in the Hague, but we need to give all our support to Israel and let them do and say whatever they want, when so much of what they want is heinous.  We just have to wait out the crisis, I guess, and hope Netanyahu goes to jail soon, while strongly resisting and calling out anti-Semitism.  Jews need to be judicious -- strong but reasonable, and not exerting wealth and power tools on the universities so prominently, which fuels paranoia and anti-Semitism. Being judicious in these circumstances is really hard.   

One of my friends read the piece and was disturbed. He is dissatisfied, as Kotkin is, with the Democrats – Progressives support for Hamas is really appalling and surprisingly widespread, but he is dissatisfied with the rest of the Democrats as well. He wishes for a moderate third party messiah. I had to say, friend, ain't gonna happen, can't happen, all third parties are destructive -- although I think Kennedy could drain some votes from Trump.  I'm hoping that the security community drops its non-partisan stance and says, we are partisan for democracy and the continuation of American leadership of the free world, and therefore, even though we are predominantly Republican privately, we are dropping our reticence and urging everyone to vote for Biden, or else we as a country are doomed.  Maybe that would help.  The Democratic party, which is not a stronghold of anti-Semitism at all, and which has good policies basically in so many areas, although there are certainly anti- Semites in their Left wing -- is the only hope.  And anyone who thinks that Biden hasn't given enough support to Israel - at great political cost to himself - is mistaken. He is giving more than they have a right to expect.

Anyway. As I used to hear on CBS when it was reputable, That's the way it is.

Budd Shenkin