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

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