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