Pneumonochrome

In the May 28th issue of JAMA the “A Piece of My Mind” feature is titled “In Defense of Phobias“. Rosenbaum concludes with the following:

I hope that you all experience many times the opportunity to participate in an action or a decision that could do harm to a patient. These activities are an unavoidable component of medical care. And if you fear that participation, do not lose your fear. Instead, remember that our profession seeks to extend the quality and quantity of life, but the effort to conquer illness will always bear inherent risk. Be afraid, because that fear makes you more human, and greater humanity makes you a better physician. Be not so afraid that you cannot take action, but not so confident that you forget the potential consequences of that action.

This really rang true for me. I’ve commented before on the awe that I believe a physician should maintain for the trust extended to him by his patients, but I really don’t think enough can be said about it. At least, I never feel like I’ve completely come to terms with it myself.

Rosenberg uses as an example in the article the unease, or fear, that a physician may feel just before inserting a needle into a patient’s eye to administer treatment. Even if that treatment is the best hope of saving the patient’s vision, even if it is the two-thousandth time the physician has done it, doing this should give a person pause. The fear should be felt by the physician because it is likely being felt in a much greater degree by his patient. The ability to sense that fear, to feel it a little with the patient helps us to keep proper perspective as we attempt to help our patients solve the problems they bring to us.

That fear will help us avoid arrogance. It will help us maintain humanism in our relationship to our patients. That discomfort that we feel when considering if the potential benefits of a treatment justify the risks will help us remember that our patients are considering the same balance, though usually without the specific education and experience the physician will have to inform that decision.

I understand that not every patient we see will need a treatment that is really risky, most of them won’t. Not feeling fear when working with those patients is fine, because the patient probably isn’t feeling much fear.

I have no delusions that every decision I make as a physician will be earth-shattering in some way, but I hope I never forget that some decisions I make will be earth shattering, and that I’ll feel a little of the shudder.

I attended a lunch-time talk at the medical school on Tuesday. The Topic was “Becoming a Physician”. Specifically, the speaker said that there’s more to doctoring than learning basic sciences, applying them to a set of symptoms to determine their cause and knowing the appropriate treatment. He said those things are all important, but if that concludes our qualifications for medical practice, we’ll never really be physicians.

He said that to become a physician, we need to develop personality traits such as empathy, compassion, respect, and communication. Even learning to recognize the appropriate times to show these characteristics, and learning how to show them isn’t enough, in the end. We must be empathetic, compassionate, respectful, and communicative. Those things must be a part of our natures, not just a product we can produce and deliver, if we are to deliver patient-centered care and be fulfilled in our practice.

These things, he said, cannot be taught in didactic sessions, by PowerPoint presentations, or learned from texts. We may learn why they are important, or appropriate ways to express those traits in such settings, but we can only develop character traits within ourselves by continually practicing them, by opening ourselves up to our patients, and perhaps by making some mistakes and getting hurt in one way or another.

A related point that comes to mind is that we cannot forget the experience of being ill while we are on the other side of the doctor-patient relationship. Remembering our own experiences with illness, and the experiences our past patients have had with illness will help us to understand current and future patients, help us to connect to them and show compassion to them in ways they can benefit from it. And it show our authentic concern and care for our patients, which will help them to feel more comfortable with us, trust us more, and open up to us as completely as possible.

But all of this requires that we undertake the process of becoming a Physician, because it is a process, and it is the process that creates the necessary nature within us when nothing else can.

“There’s a right that’s given to us as physicians to do things to patients that would be criminal for anyone else to do.”

That was part of the closing remark in one of my classes today, and I can’t think of many things that would be more important for a doctor to realize. Physicians are given permission to have contact with patients that would be considered criminal contact coming from almost anyone else. The amount of trust that must exist between physician and patient for the patient to be comfortable with this arrangement is unimaginable to me, and I think it helps me understand why “medical professionalism” is so very important.

While many patients may give that trust to a physician because of his credentials and white coat, and others may give that trust to a physician because they trust the person who referred them to the physician, no patient should ever be expected to give that trust to someone, including a physician, who has not earned it through profession, respectful behavior toward the patient.

Really think about that. Surgeons cut into their patients. They inflict wounds that could very well be fatal, and in any other circumstance probably would be fatal. How could I, if I pursue a career in surgery expect a patient just to trust me, without any effort at building a trusting relationship from me, to bring them well within the reach of death, and to bring them back again?

How can a physician expect a patient to whom he has not shown compassion and respect to be comfortable revealing what may be the most intimate details of his life? And yet, in many cases, exactly those most intimate details are the ones necessary to determine the correct diagnosis, and effectively administer the right treatment?

It was very sobering to me to hear that said today, and I think it helped impress upon me the responsibility that I am taking on along with the privilege of having the opportunity to see people in the humble, vulnerable, and fearful moments of their lives, the privilege of being able to help them find some relief from their fears and their pains. That is why I’m going into medicine, but I think it is a very serious thing the remember that those privileges come with some heavy responsibilities as well.