Blog | Tuesday, February 21, 2012

Think like a doctor, part II


In part I we discussed the history of medicine as a science. This is part II in a series.

It is during a surgery rotation when a medical student perhaps feels least competent. Not only is there an enormous amount of book learning, there are the physical skills that take years to develop. Most of the time you pull on a retractor and answer questions, record vitals and pull out drains. My instructor, who in the OR hurled Spanish invectives like scalpels and called every med student, "Pullgoddamyou," was gentle as a kitten with conscious patients.

When I was in his office an elderly woman came in for a superficial biopsy. He had treated her for years and she trusted him. After spending time talking to her and calming her, he numbed up the area and went to work. But the patient was tearful, from the pain and also from the knowledge that the biopsy was not going to give her good news. I reached up and took her hand, then quickly released it, uncomfortable with my spontaneous act of intimacy. Dr. Gruff looked at me and said, "No! Hold her hand! That is compassion; that is being a doctor!"

Compassion can be learned, or at least a simulacrum of it. Hopefully it comes naturally to most doctors, but for those who it does not, and cannot be taught, there are specialties that don't involve much patient care. Radiology, pathology, and a few others involve very little patient interaction, but are essential to the modern practice of medicine. While the surgeon waits, hands folded in the OR, the pathologist quickly prepares slides and calls up with an answer that can be the difference between a small biopsy or a radical cancer surgery. Sitting in the barber's chair one day, the barber asked me to take a bottle of wine to a radiologist. His wife had gone in for minor surgery and the radiologist had discovered an early cancer on a routine X-ray, saving the woman's life.

I'd guess that most people, when thinking of a doctor, think of their own doctor, a primary care physician or an OB/GYN. Hopefully this is someone they've come to trust, someone who can give them the tools to stay as healthy as possible and to treat them with compassion when they fall ill. This part of medicine: this rapport, this compassion, is essential to good patient care. A patient who likes you, and who you in turn like, is more likely to trust in and benefit from your advice.

But compassion is not enough. In medicine, compassion unguided by science can be dangerous. When you have strep throat, do you seek out a compassionate clergy or friend with no medical knowledge, or a doctor? The doctor knows that untreated, strep can lead to abscesses, rheumatic fever, and can (but does not usually) cause permanent damage. She knows that strep is easily killed by certain antibiotics and not by others. She knows when the sore throat is more likely to be a virus and should be treated with hot tea and chicken soup rather than drugs.

Physicians are daily witnesses to the power of compassion, and like any power, compassion can corrupt. A compassionate act often has immediate and satisfying results. Treating hypertension gives neither the physician nor the patient immediate satisfaction. It is the reduction of the risk of heart attack and stroke, a benefit that accrues over time, that makes treatment worthwhile. But doctors like anyone else would love to see an immediate reaction, something unlikely in a patient with a disease without symptoms. Patients are rightly skeptical about treating a disease which causes no discomfort. It is up to the physician to work with the patient to help them understand the importance of treatment, to use their rapport to help the patient understand the benefit.

Sometimes the doctor and the patient unconsciously conspire to gain immediate satisfaction where none should medically exist. Of the two, the physician should know better. When doctors recommend unproven or implausible treatments with the idea that it may make the patient feel better, they enter a folie a deux. We know how to treat high blood pressure with diet, exercise, and medication. It might not make you feel better immediately but it will save your life. Compassion will help bring the patient around.

But how about adding on some hypnosis or acupuncture? These feel more "real" to the doctor and the patient, but are no more real than a sugar pill. If there is any benefit to these, it is through the same mechanism the doctor uses in the exam room: a hand on the shoulder, a cocked ear, a smile. It is compassion without the benefit of actually treating the disease.

There is nothing wrong with compassion. In fact it is necessary to get the most benefit out of the patient-doctor collaboration. But it is not, in itself, powerful enough to cure infection, to prevent strokes and heart attacks. Compassion plus medical science is good doctoring. Compassion plus no science is charlatanism.

In part III, I'll examine how to spot the difference.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog, White Coat Underground. The blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.