Friday, August 16, 2013
I was naive when I decided to enter medicine. My impressions then were that doctors always "did" stuff--for patients, and to patients. We would do stuff to you (examinations, blood tests, scans, surgeries) in order to help you.
A lot of time and education later, I've learned that that straightforward paradigm is far from the only way that doctors help people. In fact, following that mostly simple formula (you come to us, we do stuff to you) is sometimes more harmful than helpful.
Good doctoring involves understanding the limits of medicine's capabilities. It involves being able to reckon with uncertainty, to be able to put one's self in patients' shoes, to see that sometimes doing nothing is the best medicine.
This is challenging for all of us. People, as patients, want answers. We want stuff done. It's part of American culture to expect results. On a fundamental level, the doctor-patient relationship has a transactional nature: You want help, we provide expertise, you (or your health insurance) pay us. Somehow, there's a sense of non-value when "nothing" is given in return for your visit.
A wise mentor once taught me something that has stuck with me over many years. Sometimes there is nothing we can do for patients. Times when we simply have no more tools to offer. Rather than see this as failure, he suggested, see this as profound help: Doctors are there to bear witness.
In a "do-it-all" culture, this can seem anathema. Especially to doctors-in-training, who must grapple with finding their own limits after years in training being taught the state of the art in many fields—always with the implicit message of doing, doing, doing in every phase. It creates cognitive dissonance.
When I was an intern and faced this barrier ("There's so much I can't do," I felt, dejectedly), I thought very hard about switching fields. That wise mentorship helped me to re-frame the sense of powerlessness and vulnerability I felt.
Bearing witness is incredibly powerful. Listening to others share their stories of illness and suffering is enriching–for the subject and the listener. Generous listening is a skill in which the listener simply and humbly listens; without judgment or assessment or interjection. It's incredibly hard for physicians to engage in generous listening; we are continually taught to move toward a conclusion, to move faster, to see more patients.
I came across an example of generous listening that is so moving I feel the need to share it: Alice Dreger, a Professor of Clinical Medical Humanities and Bioethics at Northwestern, has become engaged for some time in providing what she calls pro bono medical histories, or, "Taking the History and Giving it Back." [Read her account of it here.]
To put it simply: There are many people that have been traumatized by their interactions with the health care system--made to feel abnormal, inhuman, warped, different. Dr. Dreger listens to their stories, and integrates them with 'official' medical records. She humbly uses her knowledge to let people unburden themselves, and to interpret their records in a way that people can make sense of them.
She charges nothing for her service. Of this work, she writes:
Providing these histories to individuals--work that remains almost completely invisible to the outside world--has been the most consistently satisfying aspect of my professional life.
Dr. Dreger has a PhD in the history and philosophy of science. She doesn't order CT scans or write prescriptions for the people whom she helps. But her act of bearing witness, of helping to make sense of individual's trauma, is profoundly moving for her and her pro bono clients. How does she know it's helpful?
"... [M]aybe this work helps just because I'm somebody (anybody "outside") taking seriously the harm these people have experienced. Maybe what's going on is partly just a validation, a witnessin--saying, essentially, "I believe you. And yes, this really did happen to you." (Some people have told me that they keep handy what I've written for them, so that when they have one of those moments of uncertainty, they can pull it out and say, "Yeah, that really did happen.")
"In any case, I'm convinced it does help people. The "thank you's" these people have given me are like no others in tone and depth. The gratitude feels so deep that I find myself engulfed in my own sense of profound gratitude."
Just knowing about work like Dr. Dreger's nourishes my soul.
This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
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Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
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Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
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Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
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The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.