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Of Divinity, Retro Dynamics and Basic Edicts in Physician-Patient Relationship

The practice of medicine is probably almost as old as the human race. Just as the first human beings built homes, created communes, a few men devoted themselves to the job of diagnosing and treating the physical and mental symptoms afflicting sick members of the tribe. The first healers — call them shamans, vaids, hakims, or more generically, physicians — were held in high social esteem, despite the fact that few of their remedies actually worked! The clinical practice in those early days was bereft of any scientific basis, yet, the faith the patient harboured in the powers of his physician helped. The recipes gave relief perhaps due to a placebo effect, while the healer offered hope, encouragement, and time and space for natural healing.

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Down the ages, through intense observation, experimentation, serendipitous discoveries, and thoughtfulness, the medical men gained knowledge, and acquired new insights and skills in the delivery of healthcare. The state gave due recognition to their endeavours. They enjoyed a high standing in the social order and were well rewarded. The great French philosopher and writer, François Marie Arouet de Voltaire, wrote this regarding doctors about 250 years ago:

“Men who are occupied in the restoration of health to other men, by the joint exertion of skill and humanity, are above all the great of the earth. They even partake of divinity, since to preserve and renew is almost as noble as to create.”(1)

Wheels of Time

The wheels of time, however, have rolled on to usher in a new age. The landscape of healthcare has changed dramatically. Driven by the quick fire technical advances, which have brought imposing new machines and gadgetry to the fore, the embrace of commerce and industry has become a bear hug. Predictably, this has led to some significant improvement in the efficacy of some treatments. However, much at the same time, the basic elements of good listening, human touch, care, and humility have receded debasing the strength and esteem of the doctor-patient relationship. Physicians now have too little time and too many patients; too much focus on the diagnostic tests and lab results and too little on the person; and too much reliance on hyped medical magic, too little on Sushrutic (or Hippocratic) human caring.

The practice of medicine has allowed itself to be bogged down in modern day scientific principles, and become captive to the so-called objectivity of numbers and formulae — the “statistics game” which, as a first tenet, must assume that biological systems, pathologies, and ecosystems (despite their diversity) function in a rigid manner; obviating the plain truth that no matter how strong the medication or how advanced the surgical technique, and no matter how expertly they’re applied, their success must relate to, among other factors, first and foremost the ability of the patient’s body and mind to heal itself, and, in a major way, to the biological behaviour of the pathology, and the macrocosm the individual thrives in.

Changing Face of Medicine

Just as the tribe of family physician faces extinction, the meaning of the word “personal” has transformed considerably when applied to medicine. Today “personalized” medicine does not mean time for the doctor to better understand the individual patient. It means using more technology. The definition of “personalized medicine” as it stands today is “the application of genomic and molecular data to better target the delivery of healthcare, facilitate the discovery and clinical testing of new molecules and products, and help determine a person’s predisposition to a particular disease or condition.”

While it is true that we can never return to a simpler, slower, less technological past, nor would we want to, and that, in times to come, cancer vaccines, genomic sequencing, and stem cell research will lengthen our lives and improve the quality of our days, the modern doctor-patient relationship needs a serious relook, introspection and possibly, a retro fitment. Medicine is still about healing, and listening to the patient remains a highly therapeutic process. The founding father of medicine, Hippocrates, of the Island of Cos, said: “It is more important to know the patient who has the disease than the disease the patient has.” Though more than 2,500 years have passed since the time of Hippocrates, this simple edict remains equally true today amidst all the hype of modern medicine. The availability of effective treatments is wonderful, but they can only supplement, and, in no way, replace the magic of a healing doctor-patient relationship.

Four Fundamental Edicts

We must not reduce ourselves to becoming “biomedical mechanics”. We must work to change the way we practise medicine. Working with patients requires a special set of skills and behaviours that must be taught and encouraged in medical schools. The Sushrutas, Charaks, Jivaks, Nagarjunas, Hippocrates, Galen, and others, who gave the practitioners of medicine a coat of glory and a halo of divinity in the past, would certainly wish that the modern day medicine must not relegate the simple edicts of the yore. If these skills increase humanism, and restore the faith in the magic of a healing doctor-patient relationship, they are not without basis even if one were to be guided by the “statistics game”. Their application has been shown to consistently result in better health outcomes.(2)

Rule 1: Be a good listener. Being a good listener requires a lot of patience — practise it, it is not easy. Several clinical studies record that patients on average are given about 20 seconds to express their concerns before being cut off and redirected by the doctor.(3) However, patients who are allowed to present all their concerns in their own words cooperate more fully and show a greater improvement with medical treatment.

Rule 2: Share and acknowledge the patient’s thoughts. Every patient has his own ideas and feelings about his illness and his own goals. Most physicians, however, allot little time to this issue.(4) Being on the same page is most important, however. Unless a doctor understands the fears and concerns of his patient, well as he might treat him, he may not extract the best results. Recognizing the patient’s perspective, allaying fears, addressing concerns is vital to a treatment’s success.

Rule 3: Do not hesitate to explain. People, and this includes caregivers, have an intense need for explanation about their disease. Most physicians, however, are content to treat the disease. Patients want to know how they came to be sick, what to expect from the illness and what they can do to relieve symptoms or hasten recovery. The amount of information given by physicians correlates with the degree of satisfaction patients express concerning the treatment they have received. Yet studies show that doctors consistently underestimate the amount of information patients want and grossly overestimate the amount of information they actually give.

Rule 4: Encourage self-care. It enhances a patient’s confidence in his ability to recover. If a patient actively participates in his therapeutic plan, his satisfaction, cooperation and level of activity improves. This can work magic in a wide range of chronic diseases.

The practice of medicine is intricately complex. Falling prey to fallacies and foibles of modern medical technology (take benefits of it while being pragmatic), being buoyed by numbers that may have no meaning for a particular person, letting dogmatism prevail over common sense, and yielding ground to arrogance instead of humility are a definite recipe to failure.

References:
1. François M A de Voltaire. “Physicians” In Philosophical Dictionary, 1st edition, 1764. http://ebooks.adelaide.edu.au/ v/voltaire/dictionary/chapter363.html
2. Lorig KR, Mazonson PD, Holman HR. Evidence suggesting that health education for self-management in patients with chronic arthritis has sustained health benefits while reducing health care costs. Arthritis and Rheumatism 1993; 36: 439-446.
3. Roter DL, Hall JA. Physician interviewing styles and medical information obtained from patients. Journal of General Internal Medicine 1987; 2: 325-329.
4. Sanchez-Menegay C, Stalder M. Do physicians take into account patients’ perspectives? Journal of General Internal Medicine 1994; 9: 404-406.

Dr Yatish Agarwal is a professor and consultant at the department of diagnostic radiology and imaging, Safdarjung Hospital and Vardhman Mahavir Medical College, New Delhi. Dr Bipin Batra is executive director of the National Board of Examinations (NBE).

Note: This article first appeared in Astrocyte.

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