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
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Patient relations |
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Understanding how and when to employ the various models of the doctor-patient relationship |
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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 |
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Being able to empathize with patients, learned from study, experience and practice, knowing how to communicate empathy appropriately in different circumstances |
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Understanding and adhering to boundaries of patient relations |
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Being able to adapt to different patient needs of relationships and caring style |
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Knowing how to integrate professional demeanor with personal and professional authenticity |
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Knowing how to elicit and communicate information effectively and sensitively |
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Understanding the power relations between doctor and patients, and not using it inappropriately |
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Treating patients with respect, as a patient with disease, not “the thyroid in 208,” not “a fascinoma” |
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Understanding the power of projection, how patients need to feel they are in good hands |
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Knowing how to handle difficult and provocative patients |
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Understanding clinician anger when patients don't fulfill the sick role properly |
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Understanding how to adopt different styles for short-term and long-term patient relationships |
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Understanding both the commonality of patients, but the differences that culture and finances and other circumstances present |
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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 |
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Figure 2
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Severe Disease |
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Knowing how to and when to give bad news, such as a diagnosis of serious disease, returning cancer, untreatable condition. |
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Knowing when to stop treatment and switch to palliative care, involving and listening to the patient and family, but showing leadership |
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Understanding how to cohere in team medicine in end of life care |
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Knowing how not to shy away from very sick people |
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Knowing what to do when there is nothing to be done, how to be there with the patient |
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Knowing how to comfort families of the dying |
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Knowing the process of caring for patients by families and caregivers |
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Knowing how to process death, the family's feelings and your own |
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Understanding the natural course of life and death, and being able to accept it |
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Knowing how to adapt to belief systems and values of the patient to put life and death in perspective |
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Knowing how to employ narrative medicine to help give share a meaning for the patient’s life |
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Knowing how to integrate into present care physicians and caregivers who have treated the patient in the past, especially PCPs |
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Figure 3
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Figure 4
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Figure 5
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HM Adjunctive Tools & Perspective |
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Narrative medicine |
Use techniques of fiction to craft a story of the life and illness, make sense of it all |
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Spiritual medicine |
Understand structure of meaning to patient, putting religion, illness and life in perspective |
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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 |
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Sociology of medicine |
Understand roles (e.g., the “sick role”), expectations of attitudes and behavior in medical care relationships |
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Anthropology of medicine |
Understand how different societies understand illness, the healer role, religious processes of cure |
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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 |
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Medical payments |
Understand how payments shape behaviors, how caring has been under-recognized and underpaid |
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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 |
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