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The most horrible blow to me in my medical education came in discussions
with teachers about the doctor-patient relationship.
The overwhelming majority of them emphasised the importance of professional
distance. It sounded like one should take a scientist's detachment in dealing
with patients as if they were experiments in a laboratory.
This was carried
through to the wards where doctors on rounds described patients as their
diseases - so many lab values, signs, symptoms and treatments.
I was amazed that a group of doctors could hover around the bed of a human
being, staring at them, even poking and undressing them with little more
humanity than was given to the dogs in physiology lab - nice boy, calm boy.
Most of the doctors, young and old, appeared more comfortable looking at
the monotony of the IV drip or the wise wagging of the Attending's lip.
I remember myself often apologising to the patient after the others had
left, embarrassed for my colleagues.
The teachers who were giants in my education loomed large mostly because
they obviously loved and cared for each patient.
Often, at the bedside,
they spoke to the patient directly, digressing about the person's life to
a level of a detail that bewildered many of the students present. One student
even felt that this chatter with patients obscured our goals and ate up
precious time.
In psychiatry, this distance was magnified.
In psychiatry, this distance was magnified multifold for fear of that dreaded
thing called transference.
In group discussions, we students would show
our vulnerability to our Attending or Resident by caring greatly for the
pain the patient was suffering. Whenever emotion for the patient was expressed,
this was sharply criticised as getting too involved.
And, God forbid, if we ever had the impulse to touch the patient. I remember the excitement of some of the staff who were trying to develop a computer program that would interview the patient, thus eliminating the subjective component altogether.
None of this improved in my internship.
In fact, it all got worse.
Under the intense pressure of time, the human component was reduced to single answers for extremely complex questions. One's work was summed up by their profession.
The family question informed you whether the person was married,
had children and whether the parents or grandparents were living and which
disease they had.
One's faith was listed without any indication whether
it was present in the person's life at all.
Hobbies, attitudes, passions were usually ignored.
So in essence, the person part of the patient was
completely ignored.
All this felt like the doctor-as-technician analogy
gone berserk.
As I responded to this cancer within my profession, I started to wonder
what this did to the patients so I asked them.
I heard anger, fear and depression come from their mouths in a fountain of frustration.
Rarely did their eyes twinkle for their doctor and if they did, so often it was for their prowess not their compassion.
Medicine was exhausting, draining with very few deep spiritual rewards.
Here was a very sad case of lost expectations.
I found the doctor, and to a lesser extent, the nurse likewise grossly affected.
Medicine was exhausting, draining with very few deep spiritual rewards. To this day I have not found
a happy hospital setting in twenty years of searching for one.
Medicine, you are blowing it! Transference paranoia and professional distance
be damned! For the health of the patient, the staff, and for the health
of our profession, patients and staff must strive toward friendship in the
deepest sense of the word. Bedside manner has nothing to do with information!
It is the unabashed projection of love, humour, empathy, tenderness, and
compasion for that patient.
Please, keep your scientific brilliance, it is an important tool, but it
is not the magic inherent in healing; for that, we must look to love and
caring. If this science could keep everyone alive, healthy and vibrant forever,
it could join the pantheon of subjective therapeutics, but even when it
tries to, it fails miserably. Psychotropic medication and death bed heroics
are just two glaring examples where science's outcome falls embarrassingly
short of its goals.
Friendship is great medicine for the patient.
Friendship is great medicine for the patient. It overcomes all the inadequacies
of the healing profession. In friendship is the potential for you to be
yourself without fear of misunderstanding. The patient can feel the same
way. There is no taboo subject and no withheld information. As a friend,
you can be the imperfect doctor with the imperfect patient, so forgiveness
is implied in all actions. And what comfort to the patient in knowing that
a friend is on the case, a chance to feel special. That feeling alone is
good medicine.
In the current climate of litigation, the health professional can, too,
feel great comfort in entering a patient's room knowing that, at least here,
they can feel safe. Even more important to the doctor, who has to be around
human suffering every day with such inadequate tools and solutions, this
patient's/friend's love comforts, and can bring peace to him or her.
Transference in inevitable. Every object has some kind of impact on another.
Don't we want that in the doctor-patient relationship? Some studies have
shown that just the doctor's presence can have a positive impact on the
patient's health. It goes without saying that the deeper the friendship,
the deeper the effect.
So often in my practice there have been patients who craved love from some
other person (parent, lover or friend) - felt incomplete without it. So
I would love them. As I loved them so, too, they would love me.
This is good stuff because if the love is present and real, then a patient
cannot say 'I am alone', which matters greatly to them and to me. I know
how devastating loneliness can be. I feel patients (all people) need to
know love is not an issue of control but of freely giving and freely receiving.
I realise that all the hang-ups and anxiety over sex have played a role
in keeping this distance, but we have reinforced it's power and thrown the
baby (love and friendship) out with the bath water (sex).
All this seems similar to me with what Arab men do with their women. Because
the men know how insanely hungry men are for sex, they decide that, rather
than bring it out and deal with it, let's just make the woman cover everything
up.
Patients will fall in love with doctors and vice versa. These experiences
weather the storms much easier in a friendship (the most open forum for
communication) context. Others will show a concern for dependency on the
part of the patient in such an alienated, addicted society. Who is surprised
if a person has been a friend to many? Then they have developed the skills
to nip adoration in the bud. Without the kind of close friendship how could
I possibly feel comfortable massaging or housecalling the patient?
Friendship is a fabulous tool for the doctor.
Friendship is a fabulous tool for the doctor but don't enter this playground
causally - go only if human intimacy beckons, and you are willing to learn
the skills necessary to handle whatever happens.
There would also be a tremendous positive medicinal effect on the patients
and staff if health professionals, in their respective settings, put great
effort into eliminating the hierarchical nature of hospital (or clinical)
staffs and instead chose to be friends with the whole team. Membership alone
does not make team effort. A true group effort is learned by groups being
with each other both professionally and recreationally. The hope here is
to have a staff like each other so much that simply riding to work, or walking
down the hall and saying 'hello' to a co-worker, is a delight. A bubbliness
among staff can have dramatic healing effects, so even if a loving, friendly
staff is not affected, the patient sure is.
I believe such a vibrancy in a hospital would affect visitors - traditionally
anxious, depressed and restrained - in an enlivening way which in turn would
have a wonderful effect on patients. We're looking to erase that frequent
refrain, I hate going to the hospital (or the doctor's) and replace it with
I had such a refreshing time in the hospital.
This intimacy in doctor-patient relationships can certainly affect the malpractice
issue. Studies have shown that the least sued physicians are those who are
closest to their patients. What a glorious gift friendship is that can lift
eh spectre of defensive medicine. With a friend you can be the most honest.
A potential for even a much deeper insurance.
I believe there is a potential for even a much deeper insurance with a community
of friends as patients. I'm speaking of an insurance of survival. If you
have been wholesomely kind in your medicine, then, if you ever have any
needs, you can reach out to your patients because your health and needs
mutually benefit you both. All the old autobiographies of country doctors
tell such touching tales.
Finally, let's connect this important relationship with the needs of our
society. If we are to survive as a species we must heal our society. Boredom,
loneliness and fear have a devastating stranglehold on our society, exemplified
by rampant crime of every description. A much-loved and respected physician
has the potential for great leverage on the three horsemen of the apocalypse.
We must replace an ethic that worships power and wealth with one that values
love and community. So let us love our patients, give them hugs and see
how great it feels.
The entire design of our pilot practice and of the hospital we are building
is influenced by the desire to enhance the deepening friendships. By being
a communal structure of many friends working and playing together, raising
our children in mutual support is our way of exploring depths of closeness
with each other and being an example for those who visit. Living with our
families in the hospital, giving up a private life, and being ultimately
vulnerable to any who come as patients could only feel safe in the context
of friendship. Not charging fees and refusing to carry malpractice puts
all our trust for survival in the power of friendship. We will not even
hire a custodial staff, but rather will rely on the mutual effort of staff
and patients working together for our mutual survival.
The integration of medicine with arts and crafts, agriculture, recreation,
nature, social service and so on, is an attempt to provide infinite possibilities
for people to get together in work, learning and fun.
On the personal level, my initial interviews with patients have been three
to four hours long, but only of their health needs but to explore everything
about them. Every day this exchange deepens, both through conversation,
play, walks, messages, and so on. I encourage them to bring their family
so our families can get to know one another. The goal is to strive for lifelong
friendship. We engage each other's interests, celebrate each other's highs
and weep over the lows. We hug each other not just as a greeting but to
'charge each other up'. I encourage them to call, write or come back anytime.
In fact, I suggest that doing so creates a greater sense of continuity.
Not every patient wants such closeness, some will even be frightened or
suspicious of it. This must be taken in stride. Hopefully, if I'm not the
right person for that patient, then one of the other staff members will
be. All one can really offer is the heartfelt attempt.
It's important to emphasise that one does not need to go to this extreme
to have fabulous friendships in their medical practice. I simply mention
it as a style to stimulate (or reinforce) others to dream and act as they
dream. Whatever your style is, as a health professional, you can make room
for friendship - make it a big room.
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