Caring for the Patient

I would like to ask all of you to take a brief trip down memory lane. For some of you, these memories are more recent than others.

As a young medical student, I would be instructed to go evaluate a patient and formulate a treatment plan. I would introduce myself as a student doctor and on numerous occasions the patient would nervously look at me and say, “I sure hope you are as good as my real doctor.” Later as a resident, I would often explain to my patients that I was moving on to another rotation but that they could rest assured that they would remain in “good” hands with my replacement. This ongoing comforting communication about a “good doctor” often provoked me to think about how patients defined “good” in this context, and also how my colleagues defined “good.” After many years in practice, and the mentoring under some surgical giants, I have some pretty simple understandings to share with you.

In 1958, a group of medical school alumni formed the Alton Ochsner Surgical Society at the Tulane University School of Medicine in New Orleans. Dr. Ochsner was the revered and internationally known surgeon and professor at Tulane and past president of Southeastern Surgical Congress. In his talk to the charter meeting, he considered his work as a teacher of young surgeons to be his greatest achievement. I thought about his statement again while preparing my remarks today, and I am humbled by them. Teaching tomorrow’s physicians is of the utmost importance—and I do not take the task lightly.

Our information-packed curriculum and schedule was designed to make us understand the technology and science needed to practice medicine and surgery. There is no question that medical school curricula and residency programs are the most crowded places on the planet. Everybody is trying to get in.

Teach students and residents about diet, the nutritionists insist. Teach them ethics, another crowd says. Teach literature, demand the humanists. Teach cost containment, say the economists.

I will not join the chorus of mixed voices clamoring for inclusion in the formal learning plan. My advice to you is simple, but it is the most important thing I ever learned in medicine.

I am a rural doctor. My hospital is a 20-bed critical access facility located in Centreville, Mississippi, an area where the New Orleans gentry used to spend the summer to avoid yellow fever. In practicing my profession in a small rural community, I have learned that caring for my patients means far more than applying technology on their behalf.

It is true that we save many lives and avert many tragedies with technology and drugs developed in the last half century. But it is the time, the touch, and the tolerance we give our patients that will lead to a real healing of the wounded relationship between physician and patient.

Just one measure of how wounded and broken this time-honored relationship has become was revealed in the mid 90’s study between physicians and marketing researchers at the University of Southern California, Vanderbilt University, and the University of California, Irvine. Sixty percent of the Americans surveyed were unhappy with their doctors. Seventy percent said their doctors are not concerned about them or their families.

Some of you may have seen a recent 2021 Wall Street Journal editorial titled “The Doctor’s Office Becomes an Assembly Line. ¹ ” The author quoted a 1983 AMA study that found that 75% of physicians owned their practices and that by 2018 independent practice ownership was down to just 46%. This shift from intimate, personally controlled practice environments to big box medical centers has led to many changes, including serious injury to the essential doctor-patient relationship.

This is not news to any of us, nor is the fact that much of this tension is driven by healthcare business administrators, not primarily physicians. Yet both the blame and the responsibility to fix the problem sit on our shoulders.

The editorial really resonated with me because it pointed out that by being forced to constantly look away and peck at the electronic medical record (EMR) during a patient visit, we are committing the equivalent of texting while driving. Our patients need our full attention, and they are not getting it. They are often silently begging for us to simply look and listen. They see our distracted focus on the computer screen as de-humanizing—both for them and for us.

Sustained eye contact and meaningful listening are basic human signals of empathy. A perceived lack of empathy for our patients is an unintended consequence of the EMR innovation that is becoming so concerning that medical schools are now offering courses in empathy. While most of us would naturally assume we come to the bedside with a natural caring instinct, outside influences are steadily eroding this critical component of our connection to our patients.

Can you imagine what the doctor in Luke Fildes’ famous painting, The Doctor (1891, Tate Gallery, London), would think of our level of compassion today? A copy of the painting hung in my father’s office as long as I can remember. When he retired from active practice, I inherited it for my office where it remains today. I discovered that it was also reproduced in the 1920 Tulane School of Medicine commencement program—my grandfather’s and great uncle’s graduating class.

Fildes painted the work on the Isle of Jersey off the coast of England. It shows a sick child, a very tired physician, an anxious father, and an upset mother. Through the years, painting styles and lifestyles have changed dramatically, but the simple act of parenting has not.

We make several assumptions about each of the characters in the painting. The doctor has very likely been at the patient’s bedside for many hours. He shows signs of both physical and mental fatigue. His meager arsenal against the child’s illness consists of what appears to be a homemade remedy which might have given comfort, but surely afforded no cure.

The child probably suffers from what today would be a curable illness; perhaps pneumonia. Quite possibly, the child will die.

Based on what we know of the society and the era reflected in the painting, we can hazard a guess about the father as well. That anxious father, who no doubt loves his daughter more than life itself, will not hold the doctor responsible if the child dies. He will show that physician more respect than our patients show us even when we perform miracle cures with modern drugs and advanced technology.

This is an incredible paradox. Why have patients lost faith in their physicians at the very time in history it is most possible for their physician to cure their illnesses?

It could be that we are fighting with a double-edged sword. Technology and the extraordinary pharmacopeia of medicine today are truly the answers to alleviating much of the suffering of humankind. But technology and a surfeit of information can also serve as barriers between us and our patients. How that comes about, I am not quite sure, but I have witnessed its occurrence.

I have visited some medical schools with my father when he still was in rural practice. On one such visit to a leading Southern medical center, we saw an extraordinary cardiac procedure by a brilliant young surgeon. He and the surgical team did a masterful job guiding the patient safely through an operative repair that we did not dream was possible 25 years ago.

Later in the day, making rounds with the young surgeon, we went into the intensive care unit to see how the patient was doing postoperatively. He checked all the monitors as he explained them all to us. Every possible function was measured and digitized. Every organ had its own flashing light. One device even told the surgeon he or she “must re-explore if blood loss becomes excessive”—advice I am not sure I would take from a machine.

The patient still had his endotracheal tube in place so he could not speak, but he was certainly awake. It was obvious to us that he was listening intently to what his doctor was telling us.

The young surgeon completed his explanation of the machines which performed their sentry duties in a businesslike manner. But never once did the young surgeon acknowledge his patient. He did not look at him. He made no effort to reassure him. He never touched him.

My father always taught me to touch a patient, something as simple as a hand on a shoulder. This was one of the clearest cases I ever witnessed of the need for the human touch. In short, the young physician was intolerant of his patient. He had saved his life, but he was not willing to spend a few minutes in his patient’s shoes to get an inkling of the fear and confusion his patient felt.

When I first went into private practice, my dad called me into his office to give me some advice about Dr. Smith (not his real name), a local family physician on the hospital staff. I had only known Dr. Smith peripherally in my adult years at home but knew of his reputation as a beloved and admired physician.

My dad advised me to be patient with Dr. Smith and not to speak critically of him. If I became frustrated with my interactions with him, I was to see my dad first so I could vent.

I found this whole conversation puzzling but went back to work.

Soon consults appeared from Dr. Smith which were appreciated and then the phone calls with management questions. It did not take me long to realize that Dr. Smith’s pool of medical knowledge was very shallow. This made me wonder how he had been elevated to such a lofty position as a beloved physician.

Being young and naïve it took me a while to figure out the reason Dr. Smith was so well respected. It final dawned on me: because his medical knowledge was limited, he spent a long time in each patient’s room trying to figure out what the problem was and how to treat the diagnosis.

Patients did not perceive this as a lack of knowledge, as I had, but as concern and caring.

Michael Crichton, author of many best-selling novels, is a graduate of Harvard Medical School. In a televised interview with Diane Sawyer, he made this astute observation. “The most common thing that people want from their doctors is time. … Why do they want the time? What does the time mean? They want the time. They want to talk. … That’s a kind of healing. ² ”

In the old days, like in the painting, time was about all a physician had to offer many patients. With no antibiotics, no cancer specific drugs, no means of precisely locating a lesion, and primitive anesthesiology, many diseases so routinely treated today were death notices.

Yet, in an era when physicians could do very little to battle the diseases people dreaded most, patients had a tremendous respect for the profession.

Dr. Lewis Thomas, former dean of Yale Medical School, director emeritus of the Sloan Kettering Memorial Research Center, and well-known essayist, described the practice of medicine as an art in his book, The Youngest Science. ³ It was an art, he said because there was little science to it.

In this book, he relates the story about a Mississippi doctor. It was during the 1950s and 1960s when Dr. Thomas was on the faculty at Tulane where he was “totally involved,” he said, with the “science of medicine.”

He was asked to deliver an address on antibiotics at the annual meeting of a county medical society in Mississippi. His host was to be the newly elected president of the society, a successful physician in his forties whose career was to be capped that evening after the banquet by his inauguration. It was to be a great honor.

But during the meal, Dr. Thomas’ host was called away to the phone. He came back to the head table to apologize. He had an emergency call to make. The program went on as planned. Dr. Thomas spoke. And the president’s induction was conducted in his absence.

The doctor arrived just as everyone else was leaving, having completely missed the occasion which was planned largely to honor him. Dr. Thomas asked him about the call. He told Dr. Thomas that one of his patients had died. He had looked after her for years and he knew the family would be distressed and would need him.

He said he was sorry he missed the evening. He had been looking forward to it all year, but some things can’t be helped, he said.

Dr. Thomas called the 1950s and the 1960s the decades when medicine was learning to be a science. In the Mississippi story, however, he saw a vestige of the old medicine, practiced as an art.

I do not blame physicians entirely for the widening distance between them and their patients. Physicians are people, after all, responding to society as every other human responds to it.

I am suggesting that—just as we have learned the science of our profession—we should perhaps re-learn some of the old art. We should be instruments of our patient’s emotional healing as well as tools in their physical cure. And we should forever forsake the notion that personal contact with the patient is solely the province of the social worker.

Winston Churchill, England’s great prime minister during World War II, was asked to give the commencement address at Harrow in October 1941, a time when Britain stood alone against the Nazis and the survival of the country was still in doubt. After a well-deserved introduction, he rose with great dignity, walked to the lectern, and gave a commencement address that was brief but memorable for a simple line that became one of his most famous quotations: “This is the lesson: never give in, never give in, never, never, never, never in nothing, great or small, large or petty—never give in except to convictions of honor and good sense. ⁴ ”

I would like to paraphrase Churchill in asking that you make the fullest use possible of the wonderful technology and pharmaceuticals available to physicians today for the benefit of our patients. Practice the science of medicine, but learn the art of medicine, too. Do not give your patients up to technology, EMR, social services, or allied health personnel. They are our patients and are ultimately our responsibility as doctors.

“Never give them up”

I would like to leave you with one final but extremely important thought. What is the secret of being a good doctor in taking care of your patients?

The answer is provided to us by Dr. Francis Peabody in a 1927 article in the Journal of the American Medical Association. ⁵

“The secret of the care of the patient is in caring for the patient.”